[Show abstract][Hide abstract] ABSTRACT: This study sought to compare the initial success rate of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in a native coronary artery (NCA) in patients with and without previous coronary artery bypass grafting (CABG) and to assess predictive factors.
Landmark novel wiring techniques for CTO-PCI have contributed to improvement in the initial success of CTO-PCI. However, challenges persist in CTO-PCI in NCA in pCABG patients.
Patients who underwent CTO-PCI in an NCA were selected and classified into 2 groups: pCABG (206 PCIs in 153 patients) and nCABG (1,431 PCIs in 1,139 patients).
CTO was located more often in the left anterior descending artery (p = 0.0003), and severe calcified lesions were observed more frequently in the pCABG group (p < 0.0001). Although the retrograde attempt was tried more frequently in the pCABG group, the CTO-PCI success rate was significantly lower in the pCABG patients than in the nCABG patients (71% vs. 83%). Longer procedural time and greater radiation exposure were needed in the pCABG patients. Logistic regression analysis among the pCABG patients revealed that intravascular ultrasound use and parallel wiring were positive factors, and lesion tortuosity was a negative factor.
The initial success rate of CTO-PCI of an NCA in the pCABG group was significantly decreased compared with that in the nCABG group. Anatomic complexity and unstable hemodynamic state were unfavorable conditions. This study reveals that the issues to be overcome are lying with CTO revascularization in an NCA in pCABG patients.
[Show abstract][Hide abstract] ABSTRACT: Although lipid-lowering therapy with statin and ezetimibe has been reported to provide greater reduction in low-density lipoprotein cholesterol levels than statin monotherapy, the effect of supplemental therapy on plaque stabilization is yet to be fully elucidated. Cap thickness of fibroatheroma evaluated by optical coherence tomography (OCT) is a major determinant of vulnerable plaque. The primary objective of this study is to evaluate the effect of ezetimibe in addition to fluvastatin on the progression of coronary atherosclerotic plaque evaluated by OCT. Sixty-three patients with angina pectoris with intermediate, nonculprit, lipid-rich plaque lesions evaluated by OCT were enrolled. The patients were divided into 2 groups: ezetimibe (10 mg/day) + fluvastatin (30 mg/day), and fluvastatin (30 mg/day) alone, and serial OCT examinations were performed at baseline and 9-month follow-up. A total of 57 patients (ezetimibe + fluvastatin, n = 31; fluvastatin alone, n = 26) underwent serial OCT examinations. The change in low-density lipoprotein cholesterol level was significantly larger in the ezetimibe + fluvastatin group compared with fluvastatin-alone group (-34.0 ± 32.0 vs -8.3 ± 17.4 mg/dl, p <0.001). Fibrous cap thickness was significantly increased and the angle of the lipid plaque was significantly decreased in both groups. The change in the fibrous cap thickness was significantly greater in the ezetimibe + fluvastatin group (0.08 ± 0.08 mm vs 0.04 ± 0.06 mm, p <0.001). In conclusion, lipid-lowering therapy by ezetimibe + fluvastatin could increase the fibrous cap thickness of lipid-rich plaque compared with fluvastatin monotherapy.
The American journal of cardiology 11/2013; 113(4). DOI:10.1016/j.amjcard.2013.10.038 · 3.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES: The aim of this study was to evaluate the relationship between cholesterol metabolism and coronary plaque vulnerability. BACKGROUND: Cholesterol homeostasis, defined as the balance between absorption and synthesis, influences the progression of coronary atherosclerosis. METHODS: Consecutive stable angina pectoris patients (N = 80) not receiving any lipid-lowering therapy were divided into 2 groups based on the presence of in vivo thin cap fibroatheroma (TCFA) in de novo target vessels assessed by the combined use of virtual histology intravascular ultrasound and optical coherence tomography. RESULTS: Patients with in vivo TCFA (n = 42) showed a higher campesterol-to-lathosterol ratio (3.36 [interquartile range, 2.10 to 4.26] vs. 1.50 [1.20 to 2.50], p < 0.0001). The campesterol-to-lathosterol ratio, low-density lipoprotein (LDL) cholesterol, and high-sensitivity C-reactive protein (hsCRP) were positively correlated with the percentage of necrotic core volume (r = 0.520, p < 0.0001; r = 0.520, p < 0.0001; and r = 0.539, p < 0.0001, respectively) and negatively correlated with thinnest fibrous cap thickness (r = -0.566, p < 0.0001; r = -0.530, p < 0.0001; and r = -0.358, p = 0.007, respectively) . The independent predictors of the incidence of TCFA were the campesterol-to-lathosterol ratio (odds ratio: 3.989, 95% confidence interval: 1.688 to 9.428; p = 0.002), LDL cholesterol (odds ratio: 1.425, 95% confidence interval: 1.023 to 1.985; p = 0.03), hsCRP (odds ratio: 1.025, 95% confidence interval: 1.003 to 1.047; p = 0.02), and the percentage of necrotic core volume (odds ratio:1.084, 95% confidence interval: 1.012 to 1.161; p = 0.02). CONCLUSIONS: Enhanced absorption and reduced synthesis of cholesterol may be related to coronary plaque vulnerability.
[Show abstract][Hide abstract] ABSTRACT: The development of the retrograde approach has dramatically changed percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs), resulting in not only an increased success rate for CTO-PCI, but also a reduction in the volume of contrast media and fluoroscopy time used during prolonged procedures performed via the antegrade approach. This chapter demonstrates the intravascular ultrasound (IVUS)-guided wiring technique with the standard antegrade approach and with the more recent retrograde approach. The frequency of IVUS guided CTO-PCI procedures with the retrograde approach has increased steadily each year. Meanwhile, the use of IVUS guided CTO-PCI with the antegrade approach to penetrate from the subintimal space to the true lumen (subintimal IVUS) has decreased. These results indicate that the retrograde approach using reverse Controlled Antegrade and Retrograde subintimal Tracking (CART) with IVUS is useful and should be attempted prior to the method utilizing subintimal IVUS.
Chronic Total Occlusions, 02/2013: pages 67-77; , ISBN: 9780470658543
[Show abstract][Hide abstract] ABSTRACT: AimsRestenosis of drug-eluting stents (DESs) might be different from that of bare metal stent restenosis in diverse ways including mechanisms and time course; however, these have not been fully examined. To gain insight into the mechanisms and time course of DES restenosis, we evaluated the characteristics of restenotic lesions of first generation DES using optical coherence tomography (OCT).Methods and resultsWe compared the morphological characteristics of early in-stent restenosis (<1 year: E-ISR, n = 43), late ISR (1-3 years: L-ISR, n = 22), and very late ISR (>3 years: VL-ISR, n = 21). OCT qualitative restenotic tissue analysis included the assessment of tissue structure [homogeneous or four types of heterogeneous intima (thin-cap fibroatheroma (TCFA)-like, layered, patchy or speckled pattern)], the presence of the peri-strut low intensity area (PLIA), microvessels, disruption with cavity, and intraluminal material and was performed at every 1 mm slice of the entire stent length. In addition to a greater trend for heterogeneous intima at the later phase, TCFA-like pattern image, intra-intima microvessels were increased from the early to the very late phase. On the other hand, the speckled pattern image was decreased from the early to the very late phase.Conclusion
The OCT morphological characteristics of DES restenotic tissue varied at different time-points. OCT images in early DES ISR might be associated with delayed arterial healing, and neoatherosclerosis might contribute to late catch-up phenomenon (L-ISR and VL-ISR) after DES implantation.
[Show abstract][Hide abstract] ABSTRACT: Frequency-domain optical coherence tomography (FD-OCT) is a novel, high resolution intravascular imaging modality. Intravascular ultrasound (IVUS) is a widely used conventional imaging modality for achieving optimal stent deployment. The aim of this study was to evaluate the impact of FD-OCT guidance for coronary stent implantation compared with IVUS guidance.
A total of 70 patients with de novo coronary artery lesions and either unstable or stable angina pectoris were enrolled in this randomized study (optical coherence tomography [OCT] group: n=35, IVUS group: n=35). In the OCT group, stent implantation was performed under FD-OCT guidance alone and final stent expansion was evaluated by IVUS. In the IVUS group, conventional IVUS guidance was used and final stent apposition was evaluated by FD-OCT. There were no significant differences regarding the procedural, fluoroscopy time, and contrast volume. Although device and clinical success rates also were similar, the visibility of vessel border was significantly lower in the OCT group (P<0.05). Minimum and mean stent area and focal and diffuse stent expansion were smaller (6.1±2.2 mm versus 7.1±2.1 mm, 7.5±2.5 versus 8.7±2.4 mm, 64.7±13.7% versus 80.3±13.4%, 84.2±15.8% versus 98.8±16.5%, P<0.05, respectively), and the frequency of significant residual reference segment stenosis at the proximal edge was higher in the OCT group (P<0.05). Incomplete apposed struts in both groups were similar (P=0.34).
FD-OCT guidance for stent implantation was associated with smaller stent expansion and more frequent significant residual reference segment stenosis compared with conventional IVUS guidance.
[Show abstract][Hide abstract] ABSTRACT: Conflicting data have been reported about the association between plaque composition and remodelling index (RI). The aim of this study is to evaluate the relationship between plaque morphology obtained by optical coherence tomography (OCT) and arterial remodelling.
OCT and intravascular ultrasound imaging pull back was performed at corresponding sites on 94 lesions in 47 patients. OCT plaque characteristics for lipid content, fibrous cap thickness, thin-cap fibroatheroma (TCFA), plaque rupture, thrombus, calcification and erosion were derived using validated criteria. Compared with intermediate/negative remodelling (RI<1.0), positive remodelling (RI>1.0) was associated with presence of higher lipid pool (2.86 ± 0.42 vs. 2.20 ± 0.78; p<0.001), thin fibrous cap (47.86 ± 25.43 μm vs. 74.41 ± 32.41 μm; p<0.001), TCFA>3mm (82.1% vs. 22.7%; p<0.0001), plaque rupture and thrombus (42.8% vs. 19.7%; p = 0.024), and higher plaque burden (73.70 vs. 70.70; p = 0.048). No difference was observed in the presence of calcification and plaque erosions.
Coronary lesions with positive remodelling show higher incidences of vulnerable plaque and plaque rupture across the lesion length. This potentially explains the correlation between unstable coronary syndromes and positive remodelling.
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to assess the prevalence and to quantify the thin-cap fibroatheroma (TCFA) and ruptured plaques in patients with coronary artery disease using optical coherence tomography (OCT).
TCFA lesions are the most prevalent precursors of plaque rupture, and are responsible for acute coronary syndromes (ACS). There are limited data regarding the frequency and distribution of TCFA in diseased coronary arteries.
Coronary artery OCT was performed in 78 vessels in 47 patients, with stable angina (SA) or ACS. OCT plaque characteristics were derived using criteria that had been validated earlier. TCFA was defined as rich in lipid (two or more quadrants) with thin fibrous cap (<65 μm). Comparison was made between SA and unstable angina, and culprit and nonculprit vessels.
There was a higher incidence of TCFA and plaque rupture (65 vs. 24%, P=0.003, and 40 vs. 15%, P=0.04) in ACS patients. This was reflected in a higher lipid pool (2.66 vs. 2.26 quadrants, P=0.04) and minimum fibrous cap thickness (52 vs. 74 μm, P=0.001) in ACS patients. The mean numbers of TCFA (2.5) were similar in patients with SA and ACS. However, the maximal length of TCFA (2.63 vs. 5.54 mm, P=0.026) and plaque rupture sites (P=0.046) were higher in ACS vessels. No relationship was found between baseline characteristics and TCFA incidence and plaque rupture. We identified ACS (P=0.002), higher mean lipid pool (P=0.002), longer TCFA length (P=0.007) and higher number of TCFA (P=0.02) as predictors of plaque rupture sites.
In this in-vivo study, we identified a higher incidence of longer TCFAs and plaque rupture sites associated with ACS.
[Show abstract][Hide abstract] ABSTRACT: We performed this study to investigate with optical coherence tomography (OCT) the vascular response after sirolimus-eluting stent (SES) implantation between patients with and those without diabetes mellitus (DM).
The difference in vascular response after SES implantation between patients with and those without DM has not been fully evaluated with OCT.
Optical coherence tomography was performed to examine 74 nonrestenotic SES implanted in 63 patients (32 with DM and 31 without DM) at 9 months after SES implantation. For struts showing neointimal coverage, the neointimal thickness on the luminal side of each strut section was measured, and neointimal characteristics were classified into high, low, and layered signal pattern.
Baseline patient characteristics and lesion and procedural characteristics data were similar between the 2 groups. In total, 11,422 struts were analyzed. High signal neointima was observed in 90.2 ± 13.9%, low signal neointima in 7.3 ± 10.0%, and layered neointima in 2.7 ± 5.8%/stents. There was higher incidence of low signal neointima (10.5 ± 10.3% vs. 4.5 ± 5.6%, p = 0.003), neointimal thickness was larger (median: 106.8 μm, interquartile range: 79.3 to 130.4 μm vs. median: 83.5 μm, interquartile range: 62.3 to 89.3 μm; p < 0.0001), and neointimal coverage of stent struts was higher (92.1 ± 6.2% vs. 87.2 ± 11.9%; p = 0.03) in DM patients.
High signal neointimal pattern was predominantly observed, and low or layered signal pattern was observed in some cases. In DM patients, low signal neointima was observed with high frequency. Neointimal coverage and neointimal thickness was also higher in DM patients as compared with non-DM patients.
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to examine the binary re-stenosis rates, procedural success, and in hospital outcomes following treatment of fibro-calcified coronary lesion with rotational atherectomy in drug eluting stent era.
Binary restenosis rates have remained high with the use of bare metal stents following rotational atherectomy in calcified lesions. There is limited data available following rotational atherectomy in drug eluting stent era.
We evaluated the procedural and angiographic outcomes following a consecutive series of 516 procedures treated with rotational atherectomy followed by stenting. We compared the results between Rota + Drug eluting stent (DES) and Rota + bare metal stent (BMS) groups.
Procedural success was achieved in 97.1% of the lesions with overall low in hospital adverse events (death in 1.1%, Q MI in 1.3%, Non Q MI in 5.3%, and urgent repeat PCI in 0.4%). There was significant reduction in the binary restenosis rates following Rota + DES use as compared to Rota + BMS use (11% vs. 28.1%, P < 0.001; OR = 3.17, 95% CI: 1.76-5.93) and similar reduction was seen in the target lesion revascularization (10.6% vs. 25%, P = 0.001; OR = 2.81, 95% CI: 1.53-5.14). We have identified ostial lesions, chronic total occlusion lesions, and use of bare metal stents as independent predictors of restenosis in this group of patients.
Rotational atherectomy can be performed with high success rates and low complications, and rotational atherectomy followed by drug eluting stent implantation significantly reduces binary restenosis rates in fibrocalcific lesions as compared to rotational atherectomy and bare metal stents.
[Show abstract][Hide abstract] ABSTRACT: We evaluated, using quantitative coronary angiography, the natural history of change that occurred in target lesions after successful sirolimus-eluting stent (SES) implantation.
Percutaneous coronary intervention with drug-eluting stents (DES) has significantly reduced the rate of repeated target lesion revascularization. However, early studies have raised concerns regarding the “late catch-up” phenomenon of DES.
Between June 2004 and March 2007, consecutive 217 patients with 306 lesions without restenosis at early angiographic follow-up underwent late angiographic follow-up (early follow-up: 11.2 ± 2.1 months and late follow-up: 29.4 ± 5.2 months). Predictors of late catch-up were identified with univariate and multivariate regression analyses.
Although reference vessel diameter did not significantly change during follow-up [3.15 mm (interquartile range (IQR): 2.81–3.49 mm), 3.12 mm (IQR: 2.79–3.47 mm), and 3.08 mm (IQR: 2.76–3.46 mm) at postprocedure, and early and late angiographic follow-up, respectively; P = 0.2653], late loss (LL) significantly increased during follow-up [0.05 mm (IQR: 0.00–0.13 mm) and 0.08 mm (IQR: 0.01–0.19 mm) at early and late follow-up, respectively; P < 0.0001]. Univariate analysis showed previous intervention, adjunctive use of cutting balloon, lesion length, and progression of MLD, LL, %DS at early follow-up as predictors of late catch-up. Multivariate regression analysis identified %DS at early follow-up as a predictor of late catch-up (OR 1.076, CI 1.039–1.114, P < 0.0001).
Significant and continuous progression of neointima after SES implantation was observed in the present study. Larger LL may be a sign of late catch-up phenomenon.