Recurrent coronary artery dissection of left main trunk initially presented with normal coronary angiography

Although spontaneous coronary artery dissection (SCAD) is usually diagnosed by coronary angiography, diagnosis may be missed because of various presentations and imperfections of coronary angiography. We report a case of a 41-year-old female with pregnancy-related SCAD who presented with cardiac arrest. Initial coronary angiography was normal without intimal flap. Unexpectedly, 4 days after admission, SCAD in left main trunk was revealed with recurrent myocardial infarction. Intimal flap was sealed at the time of first angiography and this is an interesting point that made us report this case. SCAD is a rare but not negligible cause of not only acute myocardial infarction but also sudden cardiac arrest even if first coronary angiography is normal. <Learning objective: In a case of a young post-partum woman with resuscitated sudden cardiac arrest who has normal coronary artery, intensive observation is needed. We should be aware that spontaneous coronary artery dissection is a rare but not negligible cause even if initial coronary angiography is normal.>.

Intravascular Ultrasound-Derived Stent Dimensions as Predictors of Angiographic Restenosis Following Nitinol Stent Implantation in the Superficial Femoral Artery

PURPOSE

To identify intravascular ultrasound (IVUS) measurements that can predict angiographic in-stent restenosis (ISR) following nitinol stent implantation in superficial femoral artery (SFA) lesions.

METHODS

A retrospective review was conducted of 97 patients (mean age 72.9±8.9 years; 63 men) who underwent IVUS examination during endovascular treatment of 112 de novo SFA lesions between July 2012 and December 2014. Self-expanding bare stents were implanted in 46 lesions and paclitaxel-eluting stents in 39 lesions. Six months after stenting, follow-up angiography was conducted to assess stent patency. The primary endpoint was angiographic ISR determined by quantitative vascular angiography analysis at the 6-month follow-up. Variables associated with restenosis were sought in multivariate analysis; the results are presented as the odds ratio (OR) and 95% confidence interval (CI).

RESULTS

At follow-up, 27 (31.8%) angiographic ISR lesions were recorded. The lesions treated with uncoated stents were more prevalent in the ISR group compared with the no restenosis group (74.1% vs 44.8%, p=0.02). Lesion length was longer (154.4±79.5 vs 109.0±89.3 mm, p=0.03) and postprocedure minimum stent area (MSA) measured by IVUS was smaller (13.9±2.8 vs 16.3±1.6 mm(2), p<0.001) in the ISR group. Multivariate analysis revealed that bare stent use (OR 7.11, 95% CI 1.70 to 29.80, p<0.01) and longer lesion length (OR 1.08, 95% CI 1.01 to 1.16, p=0.04) were predictors of ISR, while increasing postprocedure MSA (OR 0.58, 95% CI 0.41 to 0.82, p<0.01) was associated with lower risk of ISR. Receiver operating characteristic analysis identified a MSA of 15.5 mm(2) as the optimal cutpoint below which the incidence of restenosis increased (area under the curve 0.769).

CONCLUSION

Postprocedure MSA can predict ISR in SFA lesions, which suggests that adequate stent enlargement during angioplasty might be required for superior patency.

Correlation between S-1 treatment outcome and expression of biomarkers for refractory thymic carcinoma

BACKGROUND

Thymic carcinoma is a rare cancer with minimal evidence of a survival benefit following chemotherapy. An oral fluoropyrimidine of S-1, however, is the recommended active cytotoxic chemotherapy agent for refractory thymic carcinoma based on a case series, whereas sunitinib or everolimus are recommended as molecular-targeted agents based on Phase II trials. We retrospectively investigated the efficacy of S-1 for refractory thymic carcinoma and performed a biomarker analysis.

METHODS

We assessed the clinicopathological variables of 14 consecutive patients who underwent S-1 for refractory thymic carcinoma and correlated the clinical outcomes with potential biomarkers using paraffin-embedded cancer tissues of eight patients in the cohort.

RESULTS

A total of 178 thymic malignancies were identified, of whom 14 patients included 12 cases of squamous cell carcinoma, one lymphoepithelioma-like carcinoma, and one undifferentiated carcinoma. Six patients exhibited a partial response (42.9 %: 95 % confidence interval [CI], 21.4-67.4) and the disease control rate was 85.7 % (60.0-96.0 %). After a median follow-up of 24.2 months, the median progression-free survival was 8.1 months (range, 2.6-12.2 months), and median overall survival was 30.0 months (range, 6.2-41.9 months). No significant correlation between biomarker expression and response was noted. However, thymidine synthase (TS)/dihydropyrimidine dehydrogenase and TS/orotate phosphoribosyltransferase were observed.

CONCLUSIONS

S-1 for refractory thymic carcinoma offered clinical activity and achieved an 85 % disease control rate. Although the biomarkers did not correlate with clinical outcome, the study results showed efficacy of S-1 as a cytotoxic chemotherapy for refractory thymic carcinoma, which warrants future investigation.

Charged particle flows in the beam extraction region of a negative ion source for NBI

Experiments by a four-pin probe and photodetachment technique were carried out to investigate the charged particle flows in the beam extraction region of a negative hydrogen ion source for neutral beam injector. Electron and positive ion flows were obtained from the polar distribution of the probe saturation current. Negative hydrogen ion flow velocity and temperature were obtained by comparing the recovery times of the photodetachment signals at opposite probe tips. Electron and positive ions flows are dominated by crossed field drift and ambipolar diffusion. Negative hydrogen ion temperature is evaluated to be 0.12 eV.

Feasibility study of docetaxel plus bevacizumab as first line therapy for elderly patients with advanced non-small-cell lung cancer: Thoracic Oncology Research Group (TORG) 1014

Background

Docetaxel monotherapy is one of the standard treatments for non-small-cell lung cancer in elderly patients. The addition of bevacizumab to docetaxel seems promising; however, the feasibility of this combination has not been investigated in such patients.

Methods

Patients with advanced non-squamous non-small-cell lung cancer aged 70 years or older who had not previously received cytotoxic chemotherapy were enrolled. Patients in the Level 0 cohort received docetaxel 60 mg/m² and bevacizumab 15 mg/kg, whereas those in the Level-1 cohort received docetaxel 50 mg/m² and bevacizumab 15 mg/kg. Chemotherapy was repeated 3 weekly for six cycles. The primary endpoint was toxicity and the secondary endpoints were response rate, progression-free survival, overall survival, and proportion of patients who underwent three or more cycles of chemotherapy.

Results

Twenty-one patients were enrolled from December 2010 to September 2012 at six institutes. Of the nine patients enrolled in Level 0, two experienced dose-limiting toxicity (febrile neutropenia and prolonged Grade 4 neutropenia in one patient, and Grade 3 infection in another patient) during the first cycle. Enrollment to the Level 0 cohort was terminated because two patients developed Grade 4 sepsis during later cycles. The remaining 12 patients were enrolled in the Level-1 cohort, in which two dose-limiting toxicities (prolonged Grade 4 neutropenia and Grade 3 increased aminotransferase level) were observed. No patient in the Level-1 cohort experienced Grade 4 nonhematologic toxicity. Grade 4 neutropenia occurred in 89 % of Level 0 patients and 50 % of Level-1 patients. The proportion of patients who experienced Grade 3/4 infection, febrile neutropenia or sepsis was 44 % in the Level 0 cohort, and 8 % in the Level-1 cohort. The overall response rate to chemotherapy and progression-free survival were 29 % (95 % CI, 11–52 %) and 5.9 months (95 % CI, 3.6–9.1 months), respectively. Efficacy outcomes did not differ significantly between the cohorts.

Conclusions

Toxicities were tolerable in level-1 cohort. The recommended dose of combination chemotherapy with docetaxel and bevacizumab for elderly patients was determined as 50 mg/m² of docetaxel and 15 mg/kg of bevacizumab and toxicities were tolerable. Further studies are warranted.

Trial registration

UMIN Clinical Trial Registry; UMIN000004240.

Impact of Paclitaxel Dose on Tissue Pharmacokinetics and Vascular Healing: A Comparative Drug-Coated Balloon Study in the Familial Hypercholesterolemic Swine Model of Superficial Femoral In-Stent Restenosis

OBJECTIVES

This study sought to compare the effect of paclitaxel-coated balloon (PCB) concentration on tissue levels and vascular healing using 3 different PCB technologies (In.Pact Pacific = 3 μg/mm(2), Lutonix = 2 μg/mm(2) and Ranger = 2 μg/mm(2)) in the experimental setting.

BACKGROUND

The optimal therapeutic dose for PCB use has not been determined yet.

METHODS

Paclitaxel tissue levels were measured up to 60 days following PCB inflation (Ranger and In.Pact Pacific) in the superficial femoral artery of healthy swine (18 swine, 36 vessels). The familial hypercholesterolemic swine model of superficial femoral artery in-stent restenosis (6 swine, 24 vessels) was used in the efficacy study. Two weeks following bare-metal stent implantation, each in-stent restenosis site was randomly treated with a PCB or an uncoated control balloon (Sterling). Quantitative vascular analysis and histology evaluation was performed 28 days following PCB treatment.

RESULTS

All PCB technologies displayed comparable paclitaxel tissue levels 4 h following balloon inflation. At 28 days, all PCB had achieved therapeutic tissue levels; however, the In.Pact PCB resulted in higher tissue concentrations than did the other PCB groups at all time points. Neointimal inhibition by histology was decreased in all PCB groups compared with the control group, with a greater decrease in the In.Pact group. However, the neointima was more mature and contained less peri-strut fibrin deposits in both 2-μg/mm(2) PCB groups.

CONCLUSIONS

Compared with the clinically established PCB dose, lower-dose PCB technologies achieve lower long-term tissue levels but comparable degrees of neointimal inhibition and fewer fibrin deposits. The impact of these findings in restenosis reduction and clinical outcomes needs to be further investigated.

Neurotoxicity due to prophylactic cranial irradiation for small-cell lung cancer: A retrospective analysis

Prophylactic cranial irradiation (PCI) is an established part of standard therapy for small-cell lung cancer (SCLC). However, the concerns regarding severe late neurotoxicity following PCI have not yet been systematically investigated. Therefore, the aim of this study was to investigate the neurocognitive functioning of SCLC patients treated with PCI. Limited-disease SCLC (LD-SCLC) patients (n=40) treated at Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital (Tokyo, Japan) between January, 2004 and December, 2011 were retrospectively reviewed. A total of 18 LD-SCLC patients were treated with PCI (median age, 65.5 years; range, 52-75 years), whereas 22 LD-SCLC patients did not receive PCI (median age, 65.5 years; range, 57-84 years). The median follow-up for PCI and non-PCI patients was 22 months (range, 4-85 months) and 14.5 months (range, 2-49 months), respectively. Brain metastases occurred in 6 (33%) PCI patients and 11 (50%) non-PCI patients. In the PCI group, dementia occurred in 5 of the 12 PCI patients without brain metastases (42%, 3-40 months after PCI) and in 1 of the 11 non-PCI patients without brain metastases (9%, 4 months after initial treatment). The frequency of dementia in the PCI group was significantly higher compared with that in the non-PCI group (P=0.0357). In the PCI group, all the patients who developed dementia were aged >65 years (range, 66-75 years). Gait disturbance appeared in 25% of the PCI patients without brain metastases (9-27 months after PCI); these patients were also aged >65 years. Patients aged >65 years were significantly more likely to develop dementia (P=0.0028) and gait disturbance (P=0.0291). Therefore, neurotoxicity due to PCI tends to appear more frequently in older patients.

Rupture of pseudoaneurysm of the superficial femoral artery over four years after self-expandable nitinol stent implantation

Postcatheterization pseudoaneurysm is one of the most common vascular complications of peripheral angiographic procedures. An 83-year-old male received endovascular treatment (EVT) for a total occlusion lesion of left superficial femoral artery (SFA) due to intermittent claudication. After the subintimal angioplasty procedure with implantation of three self-expandable nitinol stents, angiography revealed contrast staining outside the stent margins. Duplex ultrasonography immediately after the procedure confirmed a pseudoaneurysm of 12 mm in diameter. There was no change in the size of pseudoaneurysm during the follow-up period. Four years after the initial procedure, he was admitted to our hospital because of swelling and pain in his left thigh. The angiography showed stent fracture at the proximal shaft of the stent. Furthermore, a fractured fragment of the stent was lying within the ruptured pseudoaneurysm, and active extravasation of contrast medium was identified. Surgical repair of the pseudoaneurysm was performed. We report a case of spontaneous pseudoaneurysm rupture of the SFA that had developed because of subintimal stent placement 4 years previously. If pseudoaneurysm is confirmed after EVT with subintimal stent placement, it should be treated by surgical or percutaneous methods, regardless of its size. <Learning objective: In general, conservative observation is thought to be reasonable when the size of pseudoaneurysm is small (<20 mm) in the absence of severe pain. However, repair of pseudoaneurysm should be considered, when the pseudoaneurysm was caused by arterial wall rupture after subintimal stent placement for a totally occluded lesion of the superficial femoral artery. It has a higher risk of spontaneous rupture during the long-term period.>.

Impact of spotty calcification on long-term prediction of future revascularization: a prospective three-vessel intravascular ultrasound study

To date, there are no prospective studies on the relationship between plaque characteristics identified by 40 MHz IVUS and future adverse events. This prospective study evaluated the relationship between plaque morphology in nonculprit nonsignificant lesions, determined by 40 MHz IVUS, and long-term clinical outcomes. Consecutively, 45 patients who underwent 3-vessel intravascular ultrasound (IVUS) examinations were prospectively enrolled. Qualitative and quantitative IVUS analyses including scoring of echogenicity for assessment of plaque characterization were performed for each nonsignificant nonculprit lesion. The number, the length, the location (superficial or deep), and maximum arc were measured for each calcium deposit within plaques. Spotty calcification was defined as calcium deposits <90° and <6 mm in length. Primary end point was defined as nonsignificant nonculprit lesion-related revascularization (NNLR) during 6 years of follow-up. A total of 163 nonsignificant nonculprit lesions with mild to moderate stenosis were identified on baseline 3-vessel IVUS. Of those 163 lesions, six lesions required NNLR during the follow-up period. There were no differences in quantitative IVUS parameters including remodeling index, plaque burden, and echogenicity between lesions requiring and not requiring NNLR. However, deep spotty calcification was more frequently identified in lesions requiring NNLR than in those not requiring NNLR (33 vs. 8 %, P = 0.02). Spotty calcium deposits identified by 40 MHz IVUS predicted the need for NNLR during a 6-year follow-up period. This finding suggests that deep spotty calcium may be a surrogate marker for plaque progression and the subsequent need for revascularization in the future.

Early feasibility evaluation of thoracoscopically assisted transcatheter ventricular reconstruction in an experimental model of ischaemic heart failure with left anteroapical aneurysm

AIMS

To test the feasibility of a thoracoscopically assisted, off-pump, transcatheter ventricular reconstruction (TCVR) approach in an ovine model of left ventricular (LV) anteroapical aneurysm.

METHODS AND RESULTS

Myocardial infarction (MI) was induced by coil occlusion of the middle left anterior descending artery and diagonals. Two months after MI creation, TCVR was performed via a minimal thoracotomy in eight sheep. Under endoscopic and fluoroscopic guidance, trans-interventricular septal puncture was performed from the LV epicardial scar. A guidewire was externalised via a snare placed in the right ventricle from the external jugular vein. An internal anchor was inserted over the wire and positioned on the right ventricular septum and an external anchor was deployed on the LV anterior epicardium. Serial pairs of anchors were placed and plicated together to exclude the scar completely. Immediately after TCVR, echocardiography showed LV end-systolic volume decreased from pre-procedure 58.8±16.6 ml to 25.1±7.6 ml (p<0.01) and the ejection fraction increased from 32.0±7.3% to 52.0±7.5% (p<0.01). LV twist significantly improved (3.83±2.21 vs. pre-procedure -0.41±0.94, p=0.01) and the global peak-systolic longitudinal strain increased from -5.64% to -10.77% (p<0.05).

CONCLUSIONS

TCVR using minimally invasive access techniques on the off-pump beating heart is feasible and resulted in significant improvement in LV performance.