Rotational Atherectomy Combined with Drug Coated-Balloons for in-Stent Restenosis

Long-Term Outcomes and Clinical Predictors of Mortality Following Occurrence of Stent Thrombosis

Background Stent thrombosis (ST) remains a significant medical issue. In particular, longer-term mortality and clinical predictors after ST occurrence have yet to be elucidated. Methods and Results This was a multicenter, retrospective, observational study. A total of 187 definite ST cases from January 2008 to December 2017 were enrolled, and the long-term clinical outcomes were investigated. The primary outcome measure was the cumulative mortality after ST occurrence. In addition, independent predictors of mortality were assessed. Among the stent types causing ST, bare-metal stent, first-generation drug-eluting stent, second-generation drug-eluting stent, and third-generation drug-eluting stent comprised 31.0%, 19.3%, 36.9%, and 6.4% of cases, respectively. Median duration from stent implantation to ST was 680.5 (interquartile range, 33.8-2450.5) days. Cumulative mortality was 14.6%, 17.4%, 21.2%, 24.4%, and 33.8% at 1, 2, 3, 5 and 10 years, respectively. The cumulative mortality did not significantly differ by type of stent, and mortality of late ST was higher than that of early ST and very late ST; however, it did not reach statistical significance after the multivariate analysis. Independent predictors of mortality were hemodialysis (hazard ratio [HR], 7.80; 95% CI, 3.07-19.81; P<0.001), culprit lesions in the left main trunk (HR, 8.14; 95% CI, 1.71-38.75; P=0.008), culprit lesions in the left coronary artery (HR, 2.77; 95% CI, 1.10-6.96; P=0.030), and peak creatine kinase (HR, 1.017; 95% CI, 1.011-1.022; P<0.001). Conclusions The 10-year cumulative mortality after ST reached 33.8%. Close follow-up is thus mandatory for patients with ST, especially with hemodialysis, culprit lesions in the left main trunk and left coronary artery, and high peak creatine kinase.

Additional ablation effect of low-speed rotational atherectomy following high-speed rotational atherectomy on early calcified in-stent restenosis: A case report

Optical frequency domain imaging-guided additional low-speed rotational atherectomy following sufficient high-speed rotational atherectomy for early calcified in-stent restenosis might be a safe and useful option for achieving additional large lumen gains and stent expansion.

How Should I Get Prepared for and Treat Rota Burr Entrapment in a Focally Underexpanded and Restenosed Stent: A Case Report

Although high-speed rotational atherectomy has been successfully used in selected cases of stent underexpansion secondary to heavy peri-stent calcification, a higher risk of burr entrapment demands extreme caution and surgical back-up on site. The main cause of this complication is the lack of diamond dust on the back end of the burr, which prevents backward ablation of tissues when retracted. To date, only few reports of successful burr retrieval using percutaneous bailout techniques have been published. We report a case of burr entrapment within a previously implanted left circumflex artery stent which was successfully recaptured using the dual catheter technique; following the retrieval the patient underwent routine percutaneous coronary intervention.

Inhibition of the Ras/ERK1/2 pathway contributes to the protective effect of ginsenoside Re against intimal hyperplasia

Neointimal hyperplasia is the major cause of carotid stenosis after vascular injury, which restricts the long-term efficacy of endovascular treatment and endarterectomy in preventing stenosis. Ginsenoside Re (Re) is a major active ingredient of ginseng having multifaceted pharmacological effects on the cardiovascular system, and is a potential treatment for restenosis. In this study, we demonstrated that Re treatment significantly inhibited vascular injury-induced neointimal thickening, reduced the intimal area and intima/media (I/M) ratio, increased the lumen area, and inhibited pro-inflammatory cytokines. In cultured A7R5 cells, Re inhibited LPS-induced proliferation and migration as evidenced by suppressed colony formation and shortened migration distance, accompanied by the downregulated expression of pro-inflammatory cytokines. Re promoted VSMC apoptosis induced by balloon injury in vivo and LPS challenge in vitro. Moreover, Re inhibited autophagy in VSMCs evoked by balloon injury and LPS as supported by reduced LC3II and increased p62 expressions. Suppression of autophagy with the specific autophagy inhibitor spautin-1 efficiently inhibited LPS-induced cell proliferation and inflammation and promoted caspase-3/7 activities. Mechanistically, we found that Re attenuated Ras/ERK1/2 expression in VSMCs in vivo and in vitro. The MEK1/2 inhibitor PD98059 showed similar effects to Re on cell proliferation, migration, apoptosis, and the levels of autophagy and cytokines. In conclusion, we provided significant evidence that Re inhibited vascular injury-induced neointimal thickening probably by promoting VSMC apoptosis and inhibiting autophagy via suppression of the Ras/MEK/ERK1/2 signaling pathway.

Rotational Atherectomy: A Contemporary Appraisal

Rotational atherectomy (RA) is an atheroablative technology that enables percutaneous coronary intervention for complex, calcified coronary lesions. RA works on the principle of 'differential cutting' and preferentially ablates hard, inelastic, calcified plaque. The objective of RA use has evolved from plaque debulking to plaque modification to enable balloon angioplasty and optimal stent expansion. The clinical experience over the past 30 years has informed the current best practices for RA with use of smaller burr sizes, short ablation runs a 'pecking' motion, and avoidance of sudden decelerations. This has led to significant improvements in procedural safety and a reduced rate of associated complications. This article reviews the principles, clinical indications, contemporary evidence, technical considerations and complications associated with the use of RA.