Unprotected left main bifurcation restenosis treated with a 2-stent technique

The present case report refers to the percutaneous treatment of severe left main stem stenosis as a consequence of proliferative in-stent restenosis of left circumflex coronary with retrograde involvement. A reverse mini-crush technique with 2 stents was described.

Tissue coverage and neointimal hyperplasia in overlap versus nonoverlap segments of drug-eluting stents 9 to 13 months after implantation: in vivo assessment with optical coherence tomography

BACKGROUND

Histologic experimental studies have reported incomplete neointimal healing in overlapping with respect to nonoverlapping segments in drug-eluting stents (DESs), but these observations have not been confirmed in human coronary arteries hitherto. On the contrary, angiographic and optical coherence tomography studies suggest that DES overlap elicits rather an exaggerated than an incomplete neointimal reaction.

METHODS

Optical coherence tomography studies from 2 randomized trials including sirolimus-eluting, biolimus-eluting, everolimus-eluting, and zotarolimus-eluting stents were analyzed at 9- to 13-month follow-up. Coverage in overlapping segments was compared versus the corresponding nonoverlapping segments of the same stents, using statistical pooled analysis.

RESULTS

Forty-two overlaps were found in 31 patients: 11 in sirolimus-eluting stents, 3 in biolimus-eluting stents, 17 in everolimus-eluting stents, and 11 in zotarolimus-eluting stents. The risk ratio of incomplete coverage was 2.35 (95% CI 1.86-2.98) in overlapping versus nonoverlapping segments. Thickness of coverage in overlaps was only 85% (95% CI 81%-90%) of the thickness in nonoverlaps. Significant heterogeneity of the effect was observed, especially pronounced in the comparison of thickness of coverage (I(2) = 90.31).

CONCLUSIONS

The effect of overlapping DES on neointimal inhibition is markedly heterogeneous: on average, DES overlap is associated with more incomplete and thinner coverage, but in some cases, the overlap elicits an exaggerated neointimal reaction, thicker than in the corresponding nonoverlapping segments. These results might help to understand why overlapping DES is associated with worse clinical outcomes, both in terms of thrombotic phenomena and in terms of restenosis and revascularization.

In-stent thrombosis due to neoatherosclerosis: insight from optical coherence tomography

Neoatherosclerosis is one of the multiple mechanisms that cause stent thrombosis, which is one of the rare but severe complications of drug-eluting stent implantation. This case study highlights the use of optical coherence tomography in identifying the precise mechanism of the stent thrombosis, which helped guide the appropriate intervention.

Angiographic findings of everolimus-eluting as compared to sirolimus-eluting stents: angiographic sub-study from the Randomized Evaluation of Sirolimus-eluting versus Everolimus-eluting stent Trial (RESET)

Several recent randomized trials comparing everolimus-eluting stent (EES) and sirolimus-eluting stent (SES) reported similar clinical outcomes. This study was aimed to clarify the differences in the angiographic findings of EES as compared to SES. Randomized Evaluation of Sirolimus-eluting versus Everolimus-eluting stent Trial is a prospective multicenter randomized open-label trial comparing EES with SES in Japan. From February to July 2010, 3197 patients were randomly assigned to receive either EES or SES. Of these, angiographic sub-study enrolled 571 patients (EES 285 patients, SES 286 patients). Angiograms were assessed qualitatively and quantitatively at procedure and at 8-12 months in the independent core angiographic laboratory. Late loss of the proximal edges tended to be greater in the EES group than that in the SES group (0.12 ± 0.49 vs. 0.04 ± 0.43 mm, P = 0.05), although late loss in the other segments was similar between the 2 groups. Edge restenosis was mainly observed in EES group, whereas body restenosis was demonstrated in half of SES group. Stent fracture was observed only in the SES group (1.5 %), and peri-stent contrast staining (PSS) tended to be more frequently observed in the SES group than in the EES group (3.6 and 1.5 %, P = 0.18). Restenotic response in the proximal edge was more prominent in the EES group as compared to the SES group. Abnormal angiographic findings such as stent fracture and PSS tended to be more frequent in the SES group.

A randomized multicenter comparison of hybrid sirolimus-eluting stents with bioresorbable polymer versus everolimus-eluting stents with durable polymer in total coronary occlusion: rationale and design of the Primary Stenting of Occluded Native Coronary Arteries IV study

BACKGROUND

Percutaneous recanalization of total coronary occlusion (TCO) was historically hampered by high rates of restenosis and reocclusions. The PRISON II trial demonstrated a significant restenosis reduction in patients treated with sirolimus-eluting stents compared with bare metal stents for TCO. Similar reductions in restenosis were observed with the second-generation zotarolimus-eluting stent and everolimus-eluting stent. Despite favorable anti-restenotic efficacy, safety concerns evolved after identifying an increased rate of very late stent thrombosis (VLST) with drug-eluting stents (DES) for the treatment of TCO. Late malapposition caused by hypersensitivity reactions and chronic inflammation was suggested as a probable cause of these VLST. New DES with bioresorbable polymer coatings were developed to address these safety concerns. No randomized trials have evaluated the efficacy and safety of the new-generation DES with bioresorbable polymers in patients treated for TCO.

METHODS/DESIGN

The prospective, randomized, single-blinded, multicenter, non-inferiority PRISON IV trial was designed to evaluate the safety, efficacy, and angiographic outcome of hybrid sirolimus-eluting stents with bioresorbable polymers (Orsiro; Biotronik, Berlin, Germany) compared with everolimus-eluting stents with durable polymers (Xience Prime/Xpedition; Abbott Vascular, Santa Clara, CA, USA) in patients with successfully recanalized TCOs. In total, 330 patients have been randomly allocated to each treatment arm. Patients are eligible with estimated duration of TCO ≥4 weeks with evidence of ischemia in the supply area of the TCO. The primary endpoint is in-segment late luminal loss at 9-month follow-up angiography. Secondary angiographic endpoints include in-stent late luminal loss, minimal luminal diameter, percentage of diameter stenosis, in-stent and in-segment binary restenosis and reocclusions at 9-month follow-up. Additionally, optical coherence tomography is performed in the first 60 randomized patients at 9 months to assess neointima thickness, percentage of neointima coverage, and stent strut malapposition and coverage. Personnel blinded to the allocated treatment will review all angiographic and optical coherence assessments. Secondary clinical endpoints include major adverse cardiac events, clinically driven target vessel revascularization, target vessel failure and stent thrombosis to 5-year clinical follow-up. An independent clinical event committee blinded to the allocated treatment will review all clinical events.

TRIAL REGISTRATION

Clinical Trials.gov: NCT01516723. Patient recruitment started in February 2012.

Optical coherence tomography: from research to clinical application

Optical coherence tomography (OCT) has revolutionized intracoronary imaging. The unprecedented spatial resolution of this technique (15 μm) provides unique insights on the microstructure of the coronary wall. Currently, OCT is increasingly used in clinical practice and also constitutes an emerging, highly robust, research tool. OCT allows detailed visualization of atherosclerotic plaques and provides reliable information on plaque composition (lipid, fibrous, calcified) although its limited tissue penetration usually precludes a comprehensive analysis of the total plaque burden. OCT is the only technique allowing accurate measurements of the thickness of the fibrous cap, a classical marker of plaque vulnerability, and readily detects thin-cap fibroatheromas. In patients with acute coronary syndromes, plaque ruptures, with associated red or white thrombus, are nicely identified. OCT is also valuable to assess the results of coronary interventions. Stent expansion can be easily ascertained. In addition, due to its 10-times higher resolution, OCT is superior to intravascular ultrasound in the detection of even minor degrees of strut malapposition, tissue prolapse, residual thrombus and edge dissections. Furthermore, during follow-up OCT has a unique value to unravel the presence of strut coverage and to detect mild amounts of neointimal proliferation that might represent a valid surrogate marker of drug-eluting stent safety and efficacy. Finally, OCT has been used to unravel the underlying mechanisms implicated in stent failure, namely in-stent restenosis and stent thrombosis. Therefore, OCT appears ideally suited to help to move forward our understanding on the pathophysiology of coronary artery disease and to improve clinical decision-making processes, meeting the ever-increasing demand on coronary artery anatomical information from clinicians and researchers.

Stress imaging use and repeat revascularization among medicare patients with high-risk coronary artery disease

The optimal use of stress testing after coronary revascularization remains unclear, and overuse of stress testing might increase the rates of repeat revascularization. We analyzed the association at both the patient and regional level between the use of stress testing and repeat revascularization for a cohort of Medicare beneficiaries receiving revascularization within 30 days of an admission for symptomatic coronary artery disease. The sample consisted of 219,748 Medicare beneficiaries aged >65 years who received percutaneous coronary intervention or cardiac bypass artery grafting after hospital admission for symptomatic coronary artery disease in 2003 to 2004. Medicare claims data through 2008 identified the use of stress testing and repeat revascularization. The associations between the cumulative incidence of stress testing and repeat revascularization were analyzed using linear regression analysis. Within 6 years of the initial revascularization, the cumulative incidence of events was 0.61 for stress testing and 0.23 for repeat revascularization. Most (53.1%) repeat revascularizations were preceded by a stress test. Only 10.3% of repeat revascularization procedures were preceded by myocardial infarction. The 4-year cumulative incidence of repeat revascularization and stress testing varied between the Hospital Referral Regions represented by the sample, and the positive correlation between the rates by the health referral region accounted for only a small portion of the total health referral region variation in revascularization rates. In conclusion, stress testing is commonly performed among Medicare patients after the initial revascularization, and most repeat procedures are performed for stable coronary artery disease. The variation in stress testing patterns only explained a modest fraction of the regional variation in the repeat revascularization rates.

Treatment of in-stent restenosis involving a bifurcation lesion with a dedicated bifurcation device in combination with drug-eluting balloons

It can be difficult to find a good treatment strategy in cases with in-stent restenosis with involvement of a bifurcation lesion. To avoid multiple stent layers and to treat the bifurcation lesion properly, the patient described in this case report was treated with a Tryton side branch stent and drug-eluting balloons. Angiographic follow-up at 8 months showed an excellent result.

Percutaneous coronary intervention in patients with anomalous origin of coronary artery

Percutaneous coronary intervention in patients with anomalous origin of right coronary artery from left sinus of Valsalva was performed in Central Chest Institute during 2005-2009. The diagnosis of this type of congenital anomaly is always difficult, since it requires high operator's consideration and experience. Standard catheter curve desired for general coronary angiography is also not suitable for the abnormal origin of artery, especially when coronary intervention is to be performed. The authors report a series of these anomalous coronary patients with atherosclerotic disease who underwent transcatheter coronary intervention using Extra Backup left coronary guiding catheters, which help cannulation of the anomalous ostium and enhance the operation success.

Diagnostic accuracy of 64-slice multidetector computed tomography in evaluation of post-coronary artery bypass grafts in correlation with invasive coronary angiography

64-slice multidetector computed tomography (MDCT) allows more reliable and non-invasive evaluation of the coronary artery bypass grafts for occlusion or stenosis both in symptomatic and asymptomatic patients and also progression of disease in native coronary vessels.

Diagnostic accuracy and its affecting factors of dual-source CT for assessment of coronary stents patency and in-stent restenosis

BACKGROUND

In-stent restenosis is a common complication after stent implantation. However, the assessment of stent lumen in computed tomography (CT) coronary angiography is limited by multiple factors. Our study aimed to evaluate the accuracy and the suspected affecting factors in diagnosing coronary in-stent restenosis by dual-source CT (DSCT) compared with coronary angiography.

METHODS

One hundred and fifteen stents in 50 patients were evaluated with DSCT before coronary angiography for the detection of coronary in-stent restenosis (≥ 50% luminal narrowing). Patency of each stent was analyzed by two independent expert radiologists blinded to the results of coronary angiography. The relationship between diagnostic accuracy and the suspected factors including age, body mass index (BMI), heart rate, variation of heart rate, radiation dose, image quality, location and stent characteristics (type, material, diameter, length and strut thickness) was assessed with both univariate and multivariate analysis. The fitting of a Logistic regression model was evaluated using a receiver operating characteristic (ROC) curve.

RESULTS

Mean stent diameter was (2.9 ± 0.4) mm. Sensitivity, specificity, positive and negative predictive values and accuracy of DSCT in detection of in-stent restenosis were 69.2%, 91.2%, 50.0%, 95.9%, and 88.7%, respectively. In a subgroup of stents with a diameter ≥ 3.0 mm, sensitivity, specificity, positive and negative predictive values and accuracy were 100.0%, 96.5%, 75.0%, 100.0%, and 96.8%, respectively. Stent diameter < 3.0 mm and poor image quality were associated with poor diagnostic accuracy (P < 0.05). The area under curve of ROC was 0.79.

CONCLUSION

DSCT can provide high accuracy for the assessment of in-stent restenosis in stents with a diameter = 3.0 mm, and can play an important role in ruling out in-stent restenosis.

Assessment of an asymmetrical coating stent with sirolimus released from ablumial matrix in porcine model

BACKGROUND

Delayed endothelialization contributes to stent thrombosis of current drug-eluting stents. The asymmetrical coating technique provides an anti-proliferative effect abluminally without affecting luminal endothelialization. Layer-by-layer self-assembled chitosan/heparin (C/H LBL) has been proved to promote re-endothelialization. A novel stent system, C/H LBL coated luminally and sirolimus released abluminally (C/H LBL-SES), was fabricated.

METHODS

Bare metal stents (BMS), traditionally circumferential sirolimus-eluting stents (SES), and C/H LBL-SES were implanted into porcine coronary arteries. At the 7, 14 and 28 days follow-up (FU), angiography, intravascular ultrasound (IVUS), vasomotor function induced by acetylcholine (Ach), scanning-electron microscopy and histopathology were performed. Remodeling index (RI) was based on IVUS and defined as cross-sectional area (CSA) of vessel at in-stent segment divided by CSA of reference vessel and expressed as a percentage with a normal range from 0.95 to 1.05.

RESULTS

Thirty-eight mini pigs were enrolled and 74 stents (BMS = 23, C/H LBL = 28, SES = 23) were implanted in this study. At 28 days after implantation, the diameter stenosis of C/H LBL-SES by quantitative coronary angiography was 18.8 ± 2.5 %, the area stenosis by histomorphometry was 24.2 ± 2.9 %, which were comparable to that of SES and superior to BMS. At 14 days, re-endothelialization of C/H LBL-SES was almost completed, while only about 50 % of surface of SES was covered by endothelium. At 7, 14 and 28 days FU, although C/H LBL-SES suffered a greater vasoconstriction induced by Ach infusion than BMS (P < 0.05), it behaved better than SES (P < 0.01). No sign of stent malapposition was detected, while RI was within the normal range by IVUS. No acute or subacute thrombotic events occurred in all three groups.

CONCLUSIONS

The asymmetrically designed C/H LBL-SES successfully inhibited neointima hyperplasia, while diminishing vasoconstriction after Ach-stress. Endothelialization of C/H LBL-SES was less affected compared with traditionally circumferentially coated SES.

Virtual histology-intravascular ultrasound assessment of lesion coverage after angiographically-guided stent implantation in patients with ST Elevation myocardial infarction undergoing primary percutaneous coronary intervention

An occlusion or severe stenosis (angiographic culprit lesion) of the infarct-related artery is frequently located at the site of the maximum thrombus burden, whereas the origin of the plaque rupture (the true culprit) can be situated proximal or distal to it. The aim of this study was to examine stent coverage of true culprit lesions in 20 patients who underwent primary percutaneous coronary intervention and had Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow restored in the infarct-related artery by angiographically guided direct stenting. Images of lesions were obtained using virtual histology-intravascular ultrasound before and after intervention (blinded to the operator). Plaque rupture sites were identified by intravascular ultrasound in 12 lesions (60%), 11 proximal and 1 distal to the minimum luminal area (MLA). Maximum necrotic core sites were found proximal to the MLA in 16 lesions, at the MLA in 3 lesions, and distal to the MLA in 1 lesion. Plaque rupture sites were fully covered by stents in 11 lesions. Virtual histology-intravascular ultrasound-derived thin-cap fibroatheroma longitudinal geographic misses were found in 10 lesions, 7 in the proximal reference segment and in 3 patients in the proximal and distal reference segments. In conclusion, in about 50% of patients who undergo primary percutaneous coronary intervention for ST-segment elevation myocardial infarction with optimal angiographic results, the stent does not fully cover the maximum necrotic core site related to the culprit lesion.

[Results of implantation of drug-eluting stents in extensive lesion of the coronary bed according to angiographic and intravascular ultrasound findings]

OBJECTIVE

To study the results after stenting extensive stenoses, the incidence of restenosis according to angiographic findings, as well as changes in endothelization and other morphological parameters in accordance with the data of intravascular ultrasound study (IVUSS).

SUBJECTS AND METHODS

The study included 220 coronary heart disease patients with extensive stenoses of the coronary bed. Double antiaggregant therapy was used in 90% of the patients during the first year and in 9.5% during the second year. Contrast-enhanced coronarography was performed in 174 and 82 patients within the first and second years following stent implantation, respectively. IVUSS was made in 26 patents by the end of the first year and in 24 patients by the end of the second year of a followup. Quantitative and qualitative analyses were done in terms of the following indicators: the mean minimal diameter of a stented segment; its mean minimal area; the number of stents with complete endothelization. RESULTS; In the first year, 1 (0.5%) patient had a fatal outcome; the development of Q-wave and non-Q-wave myocardial infarction (MI) was observed in 2 (1%) and 3 (1.5%) patients, respectively. The appearance of angina symptoms during a year was noted in 10 (4.5%) patients; coronary artery bypass grafting (CABG) was performed in 7 (3.2%) patients; 3 (1.5%) cases had endovascular reintervention. At 2-year follow-up, 6 (2.7%) patients died; 7 (3.2%) and 7 (3.2%) patients developed Q-wave and non-Q-wave MI, respectively; recurrent angina pectoris was noted in 22 (10%) patients. CABG was made in 5 (2.3%) patients; endovascular reintervention was done in 15 (6.9%) patients. The total rate of coronary events was significantly higher at 2-year follow-up (19.2% versus 7.3% at 1-year follow-up). According to coronary angiography, stented segment restenosis was 3.8 and 4.9% after one and two years, respectively. IVUSS showed that the morphological indicators characterizing late vessel luminal loss did not differ between different periods of the follow-up. Complete endothelization was observed only in 40% of endoprostheses a year after stent implantation and in 92% of endoprostheses by the end of the second year (p < 0.05).

CONCLUSION

Complete endothelization was shown by 40 and 91% of the drug-eluting stents by the end of the first and second years of the follow-up, respectively. Within the first year of the follow-up, the total number of coronary events (death + MI + recurrent angina or repeat revascularization) was significantly smaller than that within the second year.

[Intracoronary Stenting and Angiographic Results Strut Thickness Effect on Restenosis Outcome (ISAR-STEREO) Trial]

BACKGROUND

Increased thrombogenicity and smooth muscle cell proliferative response induced by the metal struts compromise the advantages of coronary stenting. The objective of this randomized, multicenter study was to ascertain whether a reduced strut thickness of a stent is associated with improved follow-up angiographic and clinical results.

METHODS AND RESULTS

The study covered 651 patients with stenosis in the native coronary arteries > 2.8 mm in diameter. They were randomly assigned to receive 1 of 2 commercially available stents of comparable design but different thickness: 326 patients to the thin-strut stent (strut thickness of 50 microm) and 325 patients to the thicker-strut stent (strut thickness of 140 microm). The primary end point was the angiographic restenosis (> or = 50% diameter luminal stenosis at follow-up angiography). The secondary end points were the incidence of reinterventions due to restenosis-induced ischemia and the total rate of death and myocardial infarctions at 1 year (a combined end point). The incidence of angiographic restenosis was 15.0% in the thin-strut group and 25.8% in the thick-strut group (relative risk, 0.58; 95% CI, 0.39 to 0.87; p = 0.003). Clinical restenosis was also significantly reduced. Reinterventions were made in 8.6% of the thin-strut patients and in 13.8% of the thick-strut patients (relative risk, 0.62; 95% CI, 0.39 to 0.99; p = 0.03). No difference was observed in the combined 1-year rate of death and myocardial infarction.

CONCLUSIONS

The use of a thin-strut device is associated with a significant reduction of angiographic and clinical restenosis after coronary artery stenting. These findings may have relevant implications for the currently most widely used percutaneous coronary intervention.

Identification of vulnerable plaque in a stented coronary segment 17 years after implantation using optical coherence tomography

A patient presented with exertional chest pain two months prior to admission. Coronary angiography revealed a subocclusive stenosis within the boundaries of the stent. Optical coherence tomography showed remarkable intimal growth inside the stent, which demonstrated a heterogeneous appearance including low-intensity areas. These findings were congruent with the morphology of fibroatheroma in the native coronary artery and suggested that new atherosclerotic progression of the intima within the stent had occurred over 17 years following bare metal stent implantation. To the best of our knowledge, this is one of the most delayed instances of a bare metal stent restenosis described in the medical literature.

A randomized, multicenter, single-blinded trial comparing paclitaxel-coated balloon angioplasty with plain balloon angioplasty in drug-eluting stent restenosis: the PEPCAD-DES study

OBJECTIVES

This study sought to define the impact of paclitaxel-coated balloon angioplasty for treatment of drug-eluting stent restenosis compared with uncoated balloon angioplasty alone.

BACKGROUND

Drug-coated balloon angioplasty is associated with favorable results for treatment of bare-metal stent restenosis.

METHODS

In this prospective, single-blind, multicenter, randomized trial, the authors randomly assigned 110 patients with drug-eluting stent restenoses located in a native coronary artery to paclitaxel-coated balloon angioplasty or uncoated balloon angioplasty. Dual antiplatelet therapy was prescribed for 6 months. Angiographic follow-up was scheduled at 6 months. The primary endpoint was late lumen loss. The secondary clinical endpoint was a composite of cardiac death, myocardial infarction attributed to the target vessel, or target lesion revascularization.

RESULTS

There was no difference in patient baseline characteristics or procedural results. Angiographic follow-up rate was 91%. Treatment with paclitaxel-coated balloon was superior to balloon angioplasty alone with a late loss of 0.43 ± 0.61 mm versus 1.03 ± 0.77 mm (p < 0.001), respectively. Restenosis rate was significantly reduced from 58.1% to 17.2% (p < 0.001), and the composite clinical endpoint was significantly reduced from 50.0% to 16.7% (p < 0.001), respectively.

CONCLUSIONS

Paclitaxel-coated balloon angioplasty is superior to balloon angioplasty alone for treatment of drug-eluting stent restenosis. (PEPCAD DES-Treatment of DES-In-Stent Restenosis With SeQuent® Please Paclitaxel Eluting PTCA Catheter [PEPCAD-DES]; NCT00998439).

[The long-term results of the endovascular treatment of the ischemic heart disease]

The long-term follow-up treatment results were analyzed for 171 patients operated on the reason of multiple coronary vessels atherosclerosis. The average follow-up time was 14.85 ± 2.52 months. The complete myocardium revascularization was achieved in 63 patients; functionally adequate myocardial function was registered in 86 patients; 22 patients demonstrated noncomplete revascularization rate. Results of complete and functionally adequate revascularization were not significantly different by the myocardial infarction, repeated revascularizative manipulations and main cardio-vessel complications rates. Patients of the third group demonstrated the statistically higher rates of myocardial infarction (p=0.016) and necessity of the coronal shunting (p=0.033).

Relations between plasma von Willebrand factor or endothelin-1 and restenosis following carotid artery stenting

OBJECTIVE

This study was designed to investigate the relation between plasma von Willebrand factor (VWF) or endothelin-1 (ET-1) and post-carotid artery stenting (CAS) restenosis.

MATERIALS AND METHODS

Plasma levels of VWF and ET-1 were measured in 61 patients (36 males, mean age 64.4 ± 6.8 years) before and after CAS. The mean follow-up time was 13.8 ± 1.7 months (range, 6-63). In-stent restenosis was defined as a >10% narrowing of the vascular lumen with or without ischemic symptoms following CAS.

RESULTS

In-stent restenosis was identified in 14 (23%) patients, including 3 with >50% restenosis. In the restenosis group, mean VWF and ET-1 levels at 2 weeks, 1 and 6 months after CAS were higher than the baseline levels (p < 0.05 or p < 0.01). Mean levels of VWF and ET-1 in the restenosis group were higher than in the non-restenosis group within 6 months after CAS (p < 0.05 or p < 0.01).

CONCLUSION

Persistent elevation in plasma VWF and ET-1 within the first 6 months of CAS was found in patients with in-stent restenosis.

[Multislice computed tomoangiography in assessment of coronary stent lumen]

The treatment of coronary artery stenosis has progressively shifted over the past decades from surgical (bypasses) to percutaneous (stenting). Recent introduction of drug-eluting stents further reduced the occurrence of in-stent re-stenosis (ISR). However a non-negligible number of patients need imaging tests when symptoms recur Multi-Slice computed Coronary Angiography (CT-CA) is a clinical reality for evaluation of coronary artery stenosis, but still under evaluation in the follow-up of coronary stents. Several factors may impair proper depiction of in-stent lumen even with the most recent CT equipments. In highly selected populations CT-CA may play a clinical role even though the performance requirements both from the technical standpoint (i.e., CT scanner) and from the training (i.e., operators'experience) are still very demanding. In the meantime CT technology should improve towards higher contrast, spatial and temporal resolution in order to achieve the results that may be proper for clinical implementation.

[Efficiency of medical versus endovascular treatment using drug-eluting stents in coronary heart disease patients with extensive lesion of the coronary bed]

The goal of the study was to assess the long-term results of endovascular treatment using drug-eluting stents in coronary heart disease patients with extensive coronary artery lesion. The study covered 478 patients with diffuse coronary artery lesion, including 220 patients receiving endovascular treatment and 258 having medical treatment (a comparison group). The immediate angiographic results and long-term clinical efficiency of endovascular treatment using rapamycin-eluting stents were studied. The follow-up was 2 years. Repeat follow-ups were undertaken1and 2 years later. The immediate angiographic success rate of endovascular treatment for diffuse coronary artery lesions was 89.5%. The two-year follow-up showed the efficiency and expediency of endovascular treatment for extensive coronary artery lesions: the symptoms of angina pectoris occurred significantly less frequently symptoms, the exercise endurance was higher, and the need for antianginal medications was less in the invasively treated patients.

Use of fractional flow reserve in contemporary scenarios of coronary revascularization

Fractional flow reserve (FFR), an invasive pressure-derived index of stenosis severity, can be performed easily, rapidly, and safely in patients with coronary artery disease as a surrogate of non-invasive detection of ischemia. Over the last decades, profound clinical and scientific evaluation has demonstrated that FFR is one of the few diagnostic modalities that improve patient outcome and, at the same time, are cost-effective and cost-saving. The increasing use of PCI to treat multivessel disease and complex anatomical subsets has created new demands for accurate, "per stenosis" assessment, since revascularisation should be performed only in those stenosis that are ischaemia generating. Recent studies have demonstrated that this attitude results in better patient outcomes. Altogether, current evidence clearly supports the measurement of FFR in catheterization laboratories in order to provide objective and complementary data to coronary angiography. The purpose of this review is to discuss the value of FFR in the diagnosis and treatment of patients with different anatomical subsets, including intermediate stenosis, multivessel disease, left main disease, serial stenosis, ostial and bifurcation lesions, saphenous vein graft disease and in-stent restenosis, as well as in those presenting with acute coronary syndromes.