Current treatment of in-stent restenosis. J Am Coll Cardiol. 2014;63:2659-2673. [PMID: 24632282 DOI: 10.1016/j.jacc.2014.02.545]

Exosomes: the next-generation therapeutic platform for ischemic stroke

Current therapeutic strategies for ischemic stroke fall short of the desired objective of neurological functional recovery. Therefore, there is an urgent need to develop new methods for the treatment of this condition. Exosomes are natural cell-derived vesicles that mediate signal transduction between cells under physiological and pathological conditions. They have low immunogenicity, good stability, high delivery efficiency, and the ability to cross the blood-brain barrier. These physiological properties of exosomes have the potential to lead to new breakthroughs in the treatment of ischemic stroke. The rapid development of nanotechnology has advanced the application of engineered exosomes, which can effectively improve targeting ability, enhance therapeutic efficacy, and minimize the dosages needed. Advances in technology have also driven clinical translational research on exosomes. In this review, we describe the therapeutic effects of exosomes and their positive roles in current treatment strategies for ischemic stroke, including their anti-inflammation, anti-apoptosis, autophagy-regulation, angiogenesis, neurogenesis, and glial scar formation reduction effects. However, it is worth noting that, despite their significant therapeutic potential, there remains a dearth of standardized characterization methods and efficient isolation techniques capable of producing highly purified exosomes. Future optimization strategies should prioritize the exploration of suitable isolation techniques and the establishment of unified workflows to effectively harness exosomes for diagnostic or therapeutic applications in ischemic stroke. Ultimately, our review aims to summarize our understanding of exosome-based treatment prospects in ischemic stroke and foster innovative ideas for the development of exosome-based therapies.

First-in-man study of a novel everolimus-coated balloon for the treatment of coronary in-stent restenosis

BACKGROUND

Treatment of patients with in-stent restenosis (ISR) remains challenging. In this setting the use of drug-coated balloons (DCB) represents an attractive approach to avoid adding another metal layer to the coronary wall.

AIMS

The Chansu Vascular Technologies (CVT)-ISR trial aimed to evaluate the safety and efficacy of a novel everolimus-DCB (CVT-DCB) using a new coating formulation and crystalline everolimus.

METHODS

The CVT-ISR trial was a prospective, multicenter, open, single-arm, first-in-man (FIM) study. A total of 51 patients (mean age 69.2 years, 74.5% male) with single ISR coronary lesions (≤24 mm in length) were enrolled at nine sites in Europe.

RESULTS

The primary safety endpoint, freedom from target lesion failure (TLF) at 180 days, was 92.2%, with the lower bound of the 95% confidence interval (81.1%), above the protocol-defined objective performance criterion (OPC) (65% for conventional balloon angioplasty, P  < 0.05). At 1 year freedom from TLF was 90.2%. The primary efficacy endpoint, in-stent late lumen loss at 180 days (evaluated in a predefined subgroup of 25 patients scheduled for late angiography), was 0.40 mm (median 0.30 mm), lower than the protocol-defined OPC of the plain balloon angioplasty historical control (0.80 mm, P  < 0.001).

CONCLUSION

This FIM study demonstrated the superior efficacy of the new everolimus CVT-DCB compared with conventional balloon angioplasty in the treatment of patients with ISR.

CLINICAL TRIALS REGISTRATION

NCT05731700.

Intravascular imaging and functional assessment for coronary in-stent restenosis: Current status and future directions

Despite significant advancements in drug-eluting stent technology, in-stent restenosis (ISR) still occurs in approximately 10 % of patients undergoing percutaneous coronary intervention, remaining a significant global health concern. The mechanisms underlying ISR are complex and multifactorial, yet recent innovations in intravascular imaging and functional assessment have substantially advanced our understanding, enabling more targeted and personalized therapies. This review synthesizes the latest insights into ISR, emphasizing the pivotal roles of advanced imaging modalities, such as optical coherence tomography (OCT) and intravascular ultrasound, and functional assessments like quantitative flow ratio and optical flow ratio in guiding ISR management. Additionally, we explore the clinical implications of in-stent neoatherosclerosis and calcified nodules as key pathological mechanisms influencing restenosis progression and patient outcomes. The review also highlights the significance of OCT-based ISR classifications in refining treatment approaches. By integrating these diagnostic and therapeutic advances, this work provides clinicians and researchers with an updated foundation and actionable insights for optimizing ISR management through tailored, imaging-guided strategies.

Catlet scoring system as a new predictor for in-stent restenosis in patients with chronic coronary artery disease undergoing percutaneous coronary intervention with drug-eluting stent

BACKGROUND

He's team have recently developed a new Coronary Artery Tree description and Lesion EvaluaTion (CatLet) angiographic scoring system, which is capable of accounting for the variability in coronary anatomy, and risk-stratifying patients with coronary artery disease. Preliminary studies have demonstrated its superiority over the the Synergy between percutaneous coronary intervention with Taxus and Cardiac Surgery (SYNTAX) score with respect to outcome predictions for acute myocardial infarction (AMI) patients. However, there are fewer studies on the prognostic in chronic coronary artery disease(CAD). This study aimed to clarify whether the CatLet score had a predictive value for in-stent restenosis(ISR) in patients with chronic coronary artery disease undergoing percutaneous coronary intervention with drug-eluting stent(DES).

METHODS

A total of 260 patients who were diagnosed with chronic CAD and underwent coronary DES implantation at the second affiliated Hospital of Wannan medical college in China were consecutively enrolled from January 2020 to June 2021.Finally, 164 patients underwent the second angiography after 2 years.According to whether ISR was detected at follow-up angiography, patients were divided into the ISR group (n = 26) and the non-ISR group (n = 139).

RESULTS

A total of 165 patients (46 women and 119 men) with a mean ages of 66.19 ± 10.54 years were finally enrolled in this study. Of these, ISR occurred in 26/165 chronic CAD patients (15.76%) by follow-up angiography. Univariate analysis showed that most baseline characteristics of the ISR and non-ISR group were similar. Patients in the ISR group had significantly the history of chronic obstructive pulmonary disease(COPD), adverse lesion characteristic, higher Catlet score compared with patients in the non-ISR group.The CatLet score was capable of predicting in-stent restenosis after adjustment for risk factors; The Multivariable-adjusted model showed good calibration and good discrimination (area under ROC curve = 0.7164) for ISR.

CONCLUDE

CatLet score is a new predictor of ISR in patients with chronic CAD after coronary DES implantation.

Peculiarities of in-Stent Thrombosis and Restenosis in Coronary Arteries Post-COVID-19: A Systematic Review of Clinical Cases and Case Series

Background

One of the most serious complications of coronary artery stenting is restenosis and in-stent thrombosis; their prevalence can reach 20-25%. Stent thrombosis can be acute (up to 24 hours), subacute (24 hours to 30 days), late (30 days to 1 year), and very late (> 1 year after previous stenting). In the patients with COVID-19 in intensive care units, the proportion of those with elevated troponin levels reached 25%.

Objective

Evaluation of the association between COVID-19 and the development of in-stent thrombosis and restenosis of the coronary arteries based on the analysis of clinical cases and case series.

Materials and Methods

We searched the PubMed and Scopus databases for relevant case reports and case series of stent restenosis and in-stent thrombosis associated with coronavirus infection (CVI) published between 2020 and the present. Thirty-eight full-text publications were screened and manually checked for analysis. We found 10 publications describing cases of thrombosis and restenosis of stents associated with coronavirus infection, of which only 2 were case series. In total, we analyzed 22 cases.

Results

In the structure of in-stent restenosis and thrombosis, 59.1% were very late, 9.1% were late; 18.2% were considered subacute events, and 13.6% were acute events. All cases were angiographically confirmed. The main location of restenosis or thrombosis was the left coronary artery (LAD) (51.1%), thrombosis of the right coronary artery (RCA) occurred in 27.3%, and location in circumflex artery was in 22.7%. All patients had COVID-19 confirmed by a PCR test or the presence of immunoglobulins G and M. In fourteen patients (54.5%), an X-ray examination showed the presence of bilateral polysegmental infiltration.

Conclusion

Analysis of publications demonstrates the association between restenosis and in-stent thrombosis in patients with coronary arteries disease (CAD) and coronavirus infection.

Paclitaxel-Coated Balloon for the Management of In-Stent Coronary Restenosis: An Updated Meta-Analysis and Trial Sequential Analysis

BACKGROUND

Drug-coated balloons present a potentially advantageous therapeutic approach for managing coronary in-stent restenosis (ISR). However, the comparative benefits of paclitaxel-coated balloons (PCBs) over uncoated balloons (UCBs) remain unclear.

AIMS

We conducted a systematic review and meta-analysis to evaluate and compare the clinical outcomes of patients treated with PCBs and UCBs.

METHODS

We systematically searched PubMed, Embase, and Cochrane for studies comparing PCBs and UCBs in managing coronary ISR. We used a random-effects model to pool risk ratios (RRs) and their 95% confidence intervals (CIs). Statistical analyses were conducted using Review Manager 5.4.1. Heterogeneity was assessed using I2 statistics. Quality and risk of bias were evaluated using the Cochrane Collaboration's tool.

RESULTS

We included seven randomized controlled trials with 1349 patients, of whom 840 underwent percutaneous coronary intervention with PCB. In our pooled analysis, patients treated with PCB had lower risks of target lesion revascularization (RR 0.31, 95% CI 0.18-0.52; p < 0.01), target vessel revascularization (0.53, 0.42-0.67; p < 0.01), major adverse cardiac events (MACEs) (0.25, 0.16-0.38; p < 0.01), and myocardial infarction (MI) (0.59, 0.37-0.95; p = 0.03). However, there were no significant differences in all-cause mortality (0.79, 0.37-1.70; p = 0.54), cardiac death (0.46, 0.03-8.12; p = 0.60), while tendencies for a significant difference were found for target lesion failure (0.39, 0.13-1.11; p = 0.08), or stent thrombosis (0.21, 0.03-1.35 p = 0.10).

CONCLUSION

These findings suggest that PCBs are superior to UCBs regarding the occurrence of target lesion revascularization, target vessel revascularization, MACEs, and MI, but they do not differ in all-cause mortality, and cardiac death, while trends to significant differences favoring PCB were found to stent thrombosis and target lesion failure.

Recurrent drug eluting stent, in-stent restenosis (DES-ISR): Epidemiology, pathophysiology & treatment

Coronary artery in-stent restenosis (ISR) is driven by neointimal hyperplasia and neo-atherosclerosis in previously placed stents. Drug eluting stents (DES) have been adopted as first line therapy for the initial episode of ISR. However, recurrent ISR has limited durable salvage options. In this article we review the pathophysiology, incidence, and management options of recurrent DES- ISR.

Impact of Obstructive Sleep Apnea on In-Stent Restenosis in Coronary Heart Disease Patients after Elective Drug-Eluting Stenting

Background

Extensive research has established obstructive sleep apnea (OSA) as a contributing factor to numerous cardiovascular and cerebrovascular diseases. However, whether OSA affects in-stent restenosis (ISR) after elective drug-eluting stenting is unclear. Therefore, the objective of this study was to examine the impact of OSA on ISR in patients with coronary heart disease (CHD) who underwent successful elective drug-eluting stent (DES) implantation.

Methods

This study retrospectively analyzed CHD patients who successfully underwent elective coronary stent implantation and overnight sleep breathing monitoring and were readmitted for coronary angiography due to symptoms of CHD at 12 to 26 months after percutaneous coronary intervention (PCI). OSA was diagnosed when the apnea-hypopnea index (AHI) was ≥5 events/hour. ISR was defined as >50% restenosis of the vessel diameter in which the DES was implanted. To explore the association between OSA and ISR among patients with CHD, multivariate logistic regression models were developed and utilized.

Results

This study enrolled 206 individuals who were diagnosed with CHD, with a mean age of 62.01 ± 10.27 years, and males constituted 76.2% of the patient population. After a median follow-up period of 15 months following DES implantation, there was a significant increase in the incidence of ISR among patients with moderate to severe OSA, increasing from 10.9% to 31.3% (p < 0.001). According to the fully adjusted model, the occurrence of ISR was found to be independently associated with the presence of OSA (OR: 3.247, 95% CI: 1.373-7.677, p = 0.007).

Conclusions

In individuals who underwent elective drug-eluting stenting, OSA is an independent risk factor for ISR.

Monocyte to high-density lipoprotein cholesterol ratio predicts restenosis of drug-eluting stents in patients with unstable angina pectoris

Several studies have shown that the monocyte count to high-density lipoprotein cholesterol ratio (MHR) serves as a predictive marker for in-stent restenosis (ISR) of bare-metal stents (BMSs). However, the ability of the MHR to predict ISR in patients with drug-eluting stents (DESs) remains uncertain. This study aimed to investigate the predictive value of the MHR for ISR in patients with unstable angina pectoris who have undergone primary DES implantation. A total of 474 consecutive patients with unstable angina pectoris who underwent successful DES-based percutaneous coronary intervention (PCI) from 01-12-2014 to 01-12-2022 were enrolled in the study. Patients were divided into the ISR group and the non-ISR group on the basis of the follow-up results of coronary angiography. The demographic and clinical characteristics of the patients were documented. The MHR was calculated via the following formula: [Formula: see text]. Multivariate logistic regression models were developed to evaluate the predictive value of the MHR for DES-ISR. The baseline MHR was notably greater in the ISR group than in the non-ISR group (P < 0.001). After adjusting for confounding factors, the MHR emerged as an independent predictor of ISR (OR = 1.244; 95%CI 1.171-1.321). Receiver operating characteristic (ROC) curve analysis revealed that MHR for predicting ISR had an AUC of 0.752 (95% CI 0.708-0.796). For a MHR > 7.32, the sensitivity was estimated to be 59.8% (95% CI 47.2-66.5%) and the specificity was 81.2% (95% CI 71.2-86.4%). Including the MHR in the predictive model for ISR improved the area under the curve (0.698 vs. 0.782, P < 0.001), categorical net reclassification improvement (0.703; 95%CI 0.536-0.871), and integrated discrimination improvement (0.121; 95%CI 0.092-0.151). The MHR can be used to predict DES-ISR in patients with unstable angina pectoris, indicating that the MHR may serve as a valuable marker for risk stratification and prognosis in individuals undergoing DES implantation.

Recent Advances in the Treatment of Coronary In-Stent Restenosis

In-stent restenosis (ISR) remains the predominant cause of stent failure and the most common indication for repeat revascularization. Despite technological advances in stent design, ISR continues to pose significant challenges, contributing to increased morbidity and mortality among patients undergoing percutaneous coronary interventions. In the last decade, intravascular imaging has emerged as an important method for identifying the mechanisms behind ISR and guiding its treatment. Treatment options for ISR have expanded to include balloon angioplasty, cutting or scoring balloons, intravascular lithotripsy, atheroablative devices, drug-eluting stents, drug-coated balloons, surgical revascularization, and intravascular brachytherapy. The aim of the current review is to describe the classification and mechanisms of ISR, provide a comprehensive and updated overview of the evidence supporting different treatment strategies, suggest a management algorithm, and present insights into future developments in the field.

Drug-coated balloons for coronary artery disease: An updated review with future perspectives

Since the advent of coronary stents, two of the most common long-term complications after percutaneous coronary intervention (PCI) are in-stent restenosis (ISR) and stent thrombosis (ST). Although the rates of ST have been nearly abolished and ISR rates have declined with the current gold-standard second-generation drug-eluting stents (DES), late ISR of DES remains a valid concern in the field of interventional cardiology. The drug-coated balloon (DCB) is a non-stent technology that relies on the concept of targeted homogeneous drug delivery from an inflated balloon to restore luminal vascularity, treat atherosclerosis, and overcome some limitations of PCI, including ISR and prolonged dual antiplatelet therapy to prevent ST by leaving nothing behind. Most clinical evidence on coronary DCBs predominantly comes from small, randomized data and registries using paclitaxel DCBs for ISR and de novo lesions in the coronary space. Since 2014, outside the United States, DCBs have been approved for the treatment of ISR, with a class I recommendation by the European Society of Cardiology. The Food and Drug Administration very recently approved the Agent DCB to treat ISR in patients with coronary artery disease in the US. Additionally, recent randomized clinical data also showed DCB's safety and efficacy for the treatment of de novo small-vessel disease and high-bleeding-risk patients, while their role for other clinical situations including acute coronary syndrome, large-vessel disease, bifurcation lesions, and long-diffuse distal lesions is currently under investigation. Herein, we review the evidence-based role of DCBs in the treatment of coronary lesions and offer future perspectives.

Drug-coated balloon angioplasty versus drug-eluting stent implantation in ACS patients with different angiographic patterns of in-stent restenosis

BACKGROUND

Drug-coated balloon (DCB) angioplasty and drug-eluting stents (DES) are two widely used treatments for in-stent restenosis (ISR). Focal and non-focal types of ISR affect the clinical outcomes. The present study aims to compare DES reimplantation versus DCB angioplasty in acute coronary syndrome (ACS) patients with focal ISR and non-focal ISR lesions.

METHODS

Patients with ISR lesions underwent percutaneous coronary intervention (PCI) were retrospectively evaluated and divided into DES group and DCB group. The primary endpoint was the incidence of target lesion failure (TLF) at 24 months follow up. Propensity score matching (PSM) was conducted to balance the baseline characteristics.

RESULTS

For focal ISR, TLF was comparable in the DES and DCB groups at 24 months of follow-up (Before PSM, hazard ratio [HR]: 0.70; 95% confidence interval [CI]: 0.39-1.27; p = 0.244; After PSM, HR: 0.83; 95% CI: 0.40-1.73; p = 0.625). For non-focal ISR, TLF was significantly decreased in DES compared with DCB group (Before PSM, HR: 0.43; 95% CI: 0.29-0.63; p < 0.001; After PSM, HR: 0.33; 95% CI: 0.19-0.59; p < 0.001), which was mainly attributed to the lower incidence of clinically indicated target lesion revascularization (CD-TLR) (Before PSM, HR: 0.39; 95% CI: 0.26-0.59; p < 0.001; After PSM, HR: 0.28; 95% CI: 0.15-0.54; p < 0.001).

CONCLUSIONS

The clinical outcomes for DES and DCB treatment are similar in focal type of ISR lesions. For non-focal ISR, the treatment of DES showed a significant decrease in TLF which was mainly attributed to a lower incidence of CD-TLR.

TRIM27 Promotes Endothelial Progenitor Cell Apoptosis in Patients with In-Stent Restenosis by Ubiquitinating TBK1

Approximately 2-10% in-stent restenosis (ISR) may occur following percutaneous coronary intervention (PCI) despite the use of modern drug-eluting stents (DES); thus, our study aimed to explore the effects of tripartite motif-containing (TRIM) 27 on ISR and the underlying mechanism. For this purpose, a total of 42 patients undergoing coronary angiography who had prior coronary angiography with DES implantation were recruited. Endothelial progenitor cells (EPCs) markers (defined as CD34 and vascular endothelial growth factoreceptor-2 (VEGFR-2)) in peripheral blood were measured to asses the circulating EPC level. The TRIM family-related gene expressions were detected by reverse transcription-quantitative polymerase chain reaction. Results suggested that ISR patients had reduced CD34+VEGFR-2+ and increased apoptosis rate of EPCs, along with upregulated TRIM27 and TRIM37 and downregulated TRIM28. TRIM27 promoted and TBK1 inhibited the apoptosis rate of EPCs. Mechanically, TRIM27 interacted with TBK1 to ubiquitinate TBK1 in in vitro study. In summary, TRIM27 promoted the progression of ISR in patients after PCI by ubiquitinating TBK1, which might provide novel ideas for the clinical treatment of ISR.

Assessment of the Predictive Ability of the Neutrophil-to-Lymphocyte Ratio in Patients with In-Stent Restenosis after COVID-19

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) is an independent predictor of the severity of coronary heart disease and COVID-19. This study aims to assess the predictive ability of the NLR in patients with in-stent restenosis after COVID-19.

MATERIALS AND METHODS

a cross-sectional study included 931 patients who underwent repeated myocardial revascularization between May 2020 and May 2023. The 420 patients of the main group had in-stent restenosis, of which 162 patients had COVID-19 previously. The control group included 511 patients without stent restenosis (107 patients had COVID-19 previously). All reported events were verified by hospital electronic records from the Complex Medical Information System.

RESULTS

The mean values of the NLR were 2.51 and 2.68 in the study groups, respectively. A statistically significant positive relationship in both groups was found between the NLR and troponin, D-dimer, C-reactive protein, creatinine, ALT, and AST. A statistically significant positive relationship was found between NLR and myocardial infarction (MI) in patients of both groups (p = 0.004; p < 0.001, respectively) and a negative relationship with the ejection fraction (p = 0.001; p < 0.036, respectively). An evaluation of the predictive ability of the clinical and laboratory predictors of recurrent myocardial infarction shows a high degree of utility of this model. The area under the ROC curve for AUC for NLR was 0.664 with 95% CI from 0.627 to 0.700 (p < 0.001).

CONCLUSIONS

NLR is one of the significant factors for predicting the development of adverse outcomes in patients with revascularized myocardium after COVID-19.

Impact of risk factors on intervened and non-intervened coronary lesions

INTRODUCTION

In-stent restenosis (ISR) and aggravated non-intervened coronary lesions (ANL) are two pivotal aspects of disease progression in patients with coronary artery disease (CAD). Established risk factors for both include hyperlipidemia, hypertension, diabetes, chronic kidney disease, and smoking. However, there is limited research on the comparative risk factors for the progression of these two aspects of progression. The aim of this study was to analyze and compare the different impacts of identical risk factors on ISR and ANL.

METHODS

This study enrolled a total of 510 patients with multiple coronary artery lesions who underwent repeated coronary angiography (CAG). All patients had previously undergone percutaneous coronary intervention (PCI) and presented non-intervened coronary lesions in addition to the previously intervened vessels.

RESULTS

After data analysis, it was determined that HbA1c (OR 1.229, 95% CI 1.022-1.477, P=0.028) and UA (OR 1.003, 95% CI 1.000-1.005, P=0.024) were identified as independent risk factors for ISR. Furthermore, HbA1c (OR 1.215, 95% CI 1.010-1.460, P=0.039), Scr (OR 1.007, 95% CI 1.003-1.017, P=0.009), and ApoB (OR 1.017, 95% CI 1.006-1.029, P=0.004) were identified as independent risk factors for ANL. The distribution of multiple blood lipid levels differed between the ANL only group and the ISR only group. Non-HDL-C (2.17 mmol/L vs. 2.44 mmol/L, P=0.007) and ApoB (63.5 mg/dL vs. 71.0 mg/dL, P=0.011) exhibited significantly higher values in the ANL only group compared to the ISR only group.

CONCLUSIONS

Blood glucose levels and chronic kidney disease were identified as independent risk factors for both ISR and ANL, while elevated lipid levels were only significantly associated with ANL. In patients with non-intervened coronary lesions following PCI, it is crucial to assess the concentration of non-HDL-C and ApoB as they serve as significant risk factors.

Long-Term Results of Bioresorbable Vascular Scaffolds in Patients With In-Stent Restenosis: The RIBS VI Study

BACKGROUND

In patients with in-stent restenosis (ISR) bioresorbable vascular scaffolds (BVS) provide similar results to drug-coated balloons (DCBs) but are inferior to drug-eluting stents (DES) at 1 year. However, the long-term efficacy of BVS in these patients remains unknown.

OBJECTIVES

This study sought to assess the long-term safety and efficacy of BVS in patients with ISR.

METHODS

RIBS VI (Restenosis Intrastent: Bioresorbable Vascular Scaffolds Treatment; NCT02672878) and RIBS VI Scoring (Restenosis Intrastent: Bioresorbable Vascular Scaffolds Treatment With Scoring Balloon; NTC03069066) are prospective multicenter studies designed to evaluate the results of BVS in patients with ISR (N = 220). The inclusion and exclusion criteria were identical to those used in the RIBS IV (ISR of DES) (Restenosis Intra-stent of Drug-eluting Stents: Drug-eluting Balloon vs Everolimus-eluting Stent; NCT01239940) and RIBS V (ISR of bare-metal stents) (Restenosis Intra-stent of Bare Metal Stents: Paclitaxel-eluting Balloon vs Everolimus-eluting Stent; NCT01239953) randomized trials (including 249 ISR patients treated with DCBs and 249 ISR patients treated with DES). A prespecified comparison of the long-term results obtained with these treatment modalities (ie, DES, DCBs, and BVS) was performed.

RESULTS

Clinical follow-up at 3 years was obtained in all (100%) 718 patients. The 3-year target lesion revascularization rate after BVS was 14.1% (vs 12.9% after DCBs [not significant], and 5.2% after DES [HR: 2.80; 95% CI: 1.47-5.36; P = 0.001]). In a landmark analysis (>1 year), the target lesion revascularization rate after BVS was higher than after DES (adjusted HR: 3.41; 95% CI: 1.15-10.08) and DCBs (adjusted HR: 3.33; 95% CI: 1.14-9.70). Very late vessel thrombosis was also more frequent with BVS (BVS: 1.8%, DCBs: 0.4%, DES: 0%; P = 0.03).

CONCLUSIONS

In patients with ISR, late clinical results of DES are superior to those obtained with DCBs and BVS. Beyond the first year, DCBs are safer and more effective than BVS.

Using XGBoost for Predicting In-Stent Restenosis Post-DES Implantation: Role of Lymphocyte-to-Monocyte Ratio and Residual Cholesterol

Objective

This study aims to investigate their correlation and predictive utility for in-stent restenosis (ISR) in patients with acute coronary syndrome (ACS) following percutaneous coronary intervention (PCI).

Methods

We collected medical records of 668 patients who underwent PCI treatment from January 2022 to December 2022. Based on follow-up results (ISR defined as luminal narrowing ≥ 50% on angiography), all participants were divided into ISR and non-ISR groups. The XGBoost machine learning (ML) model was employed to identify the optimal predictive variables from a set of 31 variables. Discriminatory ability was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC), while calibration and performance of the prediction models were assessed using the Hosmer-Lemeshow (HL) test and calibration plots. Clinical utility of each model was evaluated using decision curve analysis (DCA).

Results

In the XGBoost importance ranking of predictive factors, LMR and RC ranked first and fourth, respectively. The AUC of the entire XGBoost ML model was 0.8098, whereas the model using traditional stepwise backward regression, comprising five predictive factors, had an AUC of 0.706. The XGBoost model showed superior predictive performance with a higher AUC, indicating better discrimination and predictive accuracy for ISR compared to traditional methods.

Conclusion

LMR and RC are identified as cost-effective and reliable biomarkers for predicting ISR risk in ACS patients following drug-eluting stent (DES) implantation. LMR and RC represent cost-effective and reliable biomarkers for predicting ISR risk in ACS patients following drug-eluting stent implantation. Enhances the accuracy and clinical utility of ISR prediction models, offering clinicians a robust tool for risk stratification and personalized patient management.

Usefulness of the Systemic Inflammation Response Index and the Systemic Immune Inflammation Index in Predicting Restenosis After Stent Implantation

Purpose

The systemic inflammation response index (SIRI) and the systemic immune inflammation index (SII) are indicators that reflect the body's overall systemic inflammatory response. Inflammation plays an important role in the pathogenesis of in-stent restenosis (ISR). The aim of this study was to investigate the predictive value of preoperative SIRI and SII for the occurrence of ISR in patients undergoing coronary stent implantation.

Materials and Methods

We retrospectively analyzed the clinical, hematological, and angiographic data of 387 patients who underwent coronary angiography for recurrent angina after coronary stent implantation at Qilu Hospital of Shandong University. Receiver operating characteristic curve (ROC) analysis was used to determine the optimal cutoff values for SIRI and SII to predict ISR. Based on the optimal cutoff values for SIRI and SII, patients were categorized into high-SIRI, low-SIRI, high-SII, and low-SII groups. Multivariate logistic regression models were constructed to assess the predictive value of SIRI and SII for ISR >50% and ISR >70%.

Results

This study included a total of 387 patients who underwent coronary angiography and follow-up at Qilu Hospital of Shandong University. Patients in the high-SIRI group had a higher incidence of ISR than those in the low-SIRI group (ISR >50%: 44.8% vs 30.7%, p = 0.018; ISR >70%: 41.5% vs 4.5%, p < 0.001). In addition, ISR occurred more frequently in patients with a higher SII than in patients with a lower SII (ISR >50%: 52.6% vs 35.7%, p = 0.001; ISR >70%: 51.9% vs 23%, p < 0.001). In multivariate logistic regression analysis, SIRI and SII were found to be independent predictive factors for ISR, both as continuous and categorical variables. In the ROC analysis, the optimal cutoff value for SIRI was set at 0.54 (sensitivity: 84.5%, specificity: 27%), and the optimal cutoff value for SII was set at 545.29 (sensitivity: 44.1%, specificity: 71.7%).

Conclusion

Elevated preoperative SIRI and SII values help predict ISR and may serve as a useful screening tool to perform interventional procedures based on the patient's risk of ISR after stent implantation.

BOOM: A novel bifurcation stent technique using optical coherence tomography co-registration

BACKGROUND/PURPOSE

Bifurcation lesions comprise 20 % of percutaneous coronary interventions (PCI) and are associated with worse long-term outcomes. With an increasing percentage of patients presenting with complex anatomy, including bifurcation disease, there is a need for treatment strategies to optimize PCI outcomes.

METHODS/MATERIALS

We retrospectively analyzed 48 patients undergoing OCT guided bifurcation PCI using the 'Bifurcation and Ostial OCT Mapping' (BOOM) technique. The primary efficacy variable studied was stent precision following deployment, defined as the distance of the most proximal stent strut from the true ostium of the target vessel. Additionally, targeted follow-up occurred by phone at 6- and 12-months post procedure, where the frequency of myocardial infarction, target lesion revascularization, target vessel and non-target vessel revascularization, and mortality were collected.

RESULTS

A total of 40 (83.3 %) had an ostial lesion that required treatment while the remaining patients had true bifurcation disease. Most target lesions were in either the LAD or its branches (29 lesions (60.3 %)). With respect to stent positioning, the median absolute geographic miss, (i.e., stent protrusion into the main branch or lack of complete ostial stent coverage), was 0.75 mm. At 6 months, one patient required target lesion revascularization with no additional patients at 12 months.

CONCLUSIONS

BOOM is a safe and simple strategy that can be a useful technique to optimize precise stent placement for ostial and bifurcation lesions.

A risk score for predicting in-stent restenosis in patients with premature acute myocardial infarction undergoing percutaneous coronary intervention with drug-eluting stent

Background

This study aimed at developing and validating a risk score to predict in-stent restenosis (ISR) in patients with premature acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) with drug-eluting stent (DES).

Methods

This was a two-center retrospective study. A total of 2185 patients firstly diagnosed with premature AMI (age ≥18 years and <55 years in men, <65 years in women) from Xinjiang cohort were retrospectively analyzed. After filtering by exclusion criteria, patients were randomly divided into training cohort (n = 434) and internal validation cohort (n = 186) at a 7:3 ratio. Several candidate variables associated with ISR in the training cohort were assessed by the least absolute shrinkage and selection operator and logistic regression analysis. The ISR risk nomogram score based on the superior predictors was finally developed, and then validated in the internal validation cohort and in an independent Chengdu external validation cohort (n = 192). The higher total nomogram score, the greater the ISR risk.

Results

The eight variables in the final risk nomogram score, cardiovascular-kidney-metabolic (CKM) score included age, diabetes mellitus (DM), body mass index (BMI), systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDLC), estimated glomerular filtration rate (eGFR), stent in left anterior descending coronary artery, minimum stent diameter <3 mm. The areas under the curve (AUC) and C-statistics [training cohort: 0.834 (95%CI: 0.787 to 0.882); internal validation cohort: 0.852 (95%CI: 0.784 to 0.921); Chengdu external validation cohort: 0.787 (95%CI: 0.692 to 0.882), respectively)] demonstrated the good discrimination of the CKM score. The Hosmer-Lemeshow test (χ2 = 7.86, P = 0.448; χ2 = 5.17, P = 0.740; χ2 = 6.35, P = 0.608, respectively) and the calibration curve confirmed the good calibration of the CKM score. Decision curve analysis (DCA) testified the clinical net benefit of the CKM score in the training and validation cohort.

Conclusion

This study provided a well-developed and validated risk nomogram score, the CKM score to predict ISR in patients with premature AMI undergoing PCI with DES. Given that these variables are readily available and practical, the CKM score should be widely adopted for individualized assessment and management of premature AMI.

Targeted Delivery of Nanoparticles to Blood Vessels for the Treatment of Atherosclerosis

Atherosclerosis is a common form of cardiovascular disease, which is one of the most prevalent causes of death worldwide, particularly among older individuals. Surgery is the mainstay of treatment for severe stenotic lesions, though the rate of restenosis remains relatively high. Current medication therapy for atherosclerosis has limited efficacy in reversing the formation of atherosclerotic plaques. The search for new drug treatment options is imminent. Some potent medications have shown surprising therapeutic benefits in inhibiting inflammation and endothelial proliferation in plaques. Unfortunately, their use is restricted due to notable dose-dependent systemic side effects or degradation. Nevertheless, with advances in nanotechnology, an increasing number of nano-related medical applications are emerging, such as nano-drug delivery, nano-imaging, nanorobots, and so forth, which allow for restrictions on the use of novel atherosclerotic drugs to be lifted. This paper reviews new perspectives on the targeted delivery of nanoparticles to blood vessels for the treatment of atherosclerosis in both systemic and local drug delivery. In systemic drug delivery, nanoparticles inhibit drug degradation and reduce systemic toxicity through passive and active pathways. To further enhance the precise release of drugs, the localized delivery of nanoparticles can also be accomplished through blood vessel wall injection or using endovascular interventional devices coated with nanoparticles. Overall, nanotechnology holds boundless potential for the diagnosis and treatment of atherosclerotic diseases in the future.

Fifteen-Year Clinical Outcomes After Sirolimus-Eluting Stent Implantation

BACKGROUND

Clinical outcomes after percutaneous coronary intervention have improved with the use of drug-eluting stents, but data beyond 10 years are limited. The purpose of this study was to evaluate the clinical outcomes of patients undergoing sirolimus-eluting stent implantation with follow-up beyond 10 years and to determine the impact of clinical and angiographic characteristics on long-term prognosis.

METHODS AND RESULTS

The clinical outcomes of 885 patients who had undergone sirolimus-eluting stent implantation at a single institution were retrospectively reviewed. Primary endpoints included in the analysis were clinically driven target lesion revascularization (cTLR) and target lesion revascularization (TLR). Univariate and multivariate nominal logistic regression was used for data analysis. The incidence rates of cTLR and TLR beyond 10 years after sirolimus-eluting stent implantation were 16.4% and 36.8%, respectively, with cTLR tending to decrease beyond 10 years. Acute coronary syndrome was a predominant trigger for cTLR. Age, statin use, and stent restenosis emerged as predictors of cTLR within 10 years, but no significant predictors other than age were identified beyond 10 years.

CONCLUSIONS

Events continue to occur beyond 10 years after sirolimus-eluting stent implantation, with a trend toward an increase in acute coronary syndromes. It is important to be vigilant about the occurrence of acute coronary syndromes during long-term follow-up.

Current Management of In-Stent Restenosis

In-stent restenosis (ISR) remains the primary cause of target lesion failure following percutaneous coronary intervention (PCI), resulting in 10-year incidences of target lesion revascularization at a rate of approximately 20%. The treatment of ISR is challenging due to its inherent propensity for recurrence and varying susceptibility to available strategies, influenced by a complex interplay between clinical and lesion-specific conditions. Given the multiple mechanisms contributing to the development of ISR, proper identification of the underlying substrate, especially by using intravascular imaging, becomes pivotal as it can indicate distinct therapeutic requirements. Among standalone treatments, drug-coated balloon (DCB) angioplasty and drug-eluting stent (DES) implantation have been the most effective. The main advantage of a DCB-based approach is the avoidance of an additional metallic layer, which may otherwise enhance neointimal hyperplasia, provide the substratum for developing neoatherosclerosis, and expose the patient to a persistently higher risk of coronary ischemic events. On the other hand, target vessel scaffolding by DES implantation confers relevant mechanical advantages over DCB angioplasty, generally resulting in larger luminal gain, while drug elution from the stent surface ensures the inhibition of neointimal hyperplasia. Nevertheless, repeat stenting with DES also implies an additional permanent metallic layer that may reiterate and promote the mechanisms leading to ISR. Against this background, the selection of either DCB or DES on a patient- and lesion-specific basis as well as the implementation of adjuvant treatments, including cutting/scoring balloons, intravascular lithotripsy, and rotational atherectomy, hold the potential to improve the effectiveness of ISR treatment over time. In this review, we comprehensively assessed the available evidence from randomized trials to define contemporary interventional treatment of ISR and provide insights for future directions.

Vascular stent with immobilized anti-inflammatory chemerin 15 peptides mitigates neointimal hyperplasia and accelerates vascular healing

Endovascular stenting is a safer alternative to open surgery for use in treating cerebral arterial stenosis and significantly reduces the recurrence of ischemic stroke, but the widely used bare-metal stents (BMSs) often result in in-stent restenosis (ISR). Although evidence suggests that drug-eluting stents are superior to BMSs in the short term, their long-term performances remain unknown. Herein, we propose a potential vascular stent modified by immobilizing clickable chemerin 15 (C15) peptides on the stent surface to suppress coagulation and restenosis. Various characterization techniques and an animal model were used to evaluate the surface properties of the modified stents and their effects on endothelial injury, platelet adhesion, and inflammation. The C15-immobilized stent could prevent restenosis by minimizing endothelial injury, promoting physiological healing, restraining the platelet-leukocyte-related inflammatory response, and inhibiting vascular smooth muscle cell proliferation and migration. Furthermore, in vivo studies demonstrated that the C15-immobilized stent mitigated inflammation, suppressed neointimal hyperplasia, and accelerated endothelial restoration. The use of surface-modified, anti-inflammatory, endothelium-friendly stents may be of benefit to patients with arterial stenosis. STATEMENT OF SIGNIFICANCE: Endovascular stenting is increasingly used for cerebral arterial stenosis treatment, aiming to prevent and treat ischemic stroke. But an important accompanying complication is in-stent restenosis (ISR). Persistent inflammation has been established as a hallmark of ISR and anti-inflammation strategies in stent modification proved effective. Chemerin 15, an inflammatory resolution mediator with 15-aa peptide, was active at picomolar through cell surface receptor, no need to permeate cell membrane and involved in resolution of inflammation by inhibiting inflammatory cells adhesion, modulating macrophage polarization into protective phenotype, and reducing inflammatory factors release. The implications of this study are that C15 immobilized stent favors inflammation resolution and rapid re-endothelialization, and exhibits an inhibitory role of restenosis. As such, it helps the decreased incidence of ISR.

The Effect of Angiotensin Receptor Blockers on In-Stent Restenosis After Stent Implantation: A Meta-Analysis

AIM

Angiotensin receptor blockers (ARBs) have been shown to inhibit restenosis in vitro and in vivo, but the evidence found in humans is inconsistent. This study aimed to evaluate the effectiveness of ARBs in preventing in-stent restenosis after percutaneous coronary intervention (PCI).

METHOD

Databases including the Cochrane Library, MEDLINE, Web of Science, EMBASE, and CNKI were searched to collect randomised controlled trials on ARBs inhibiting restenosis that were published before October 2022. A total of 1,056 patients enrolled in eight trials were included in the study.

RESULTS

The ARBs group showed lower target lesion revascularisation than the control group (RR 0.54; 95% CI 0.34-0.86; p=0.01), but the restenosis incidence between these two groups was not statistically significant (RR 0.85; 95% CI 0.65-1.11; p>0.05).

CONCLUSION

This study found that ARBs might have a potential effect on reducing target lesion revascularisation after PCI in coronary heart disease patients but has no impact on angiographic restenosis.

Isoxanthohumol reduces neointimal hyperplasia through the apelin/AKT pathway

The abnormal proliferation, migration, and inflammation of vascular smooth muscle cells (VSMCs) play crucial roles in the development of neointimal hyperplasia and restenosis. Exposure to inflammatory cytokines such as platelet-derived growth factor (PDGF)-BB and tumour necrosis factor-alpha (TNF-α) induces the transformation of contractile VSMCs into abnormal synthetic VSMCs. Isoxanthohumol (IXN) has significant anti-inflammatory, antiproliferative, and antimigratory effects. This study aimed to explore the therapeutic impact and regulatory mechanism of IXN in treating neointimal hyperplasia. The present findings indicate that IXN effectively hinders the abnormal proliferation, migration, and inflammation of VSMCs triggered by PDGF or TNF-α. This inhibition is primarily achieved through the modulation of the apelin/AKT or AKT pathway, respectively. In an in vivo model, IXN effectively reduced neointimal hyperplasia in denuded femoral arteries. These results suggest that IXN holds promise as a potential and innovative therapeutic candidate for the treatment of restenosis.

Effect of hemoglobin A1c management levels on coronary physiology evaluated by quantitative flow ratio in patients who underwent percutaneous coronary intervention

AIMS/INTRODUCTION

The coronary physiology and prognosis of patients with different hemoglobin A1c (HbA1c) levels after percutaneous coronary intervention (PCI) are currently unknown. The aim of this study was to assess the effect of different levels of HbA1c control on coronary physiology in patients who underwent PCI for coronary heart disease combined with type 2 diabetes mellitus by quantitative flow ratio (QFR).

MATERIALS AND METHODS

Patients who successfully underwent PCI and completed 1-year coronary angiographic follow up were enrolled, clinical data were collected, and QFR at immediate and 1-year follow up after PCI was retrospectively analyzed. A total of 257 patients (361 vessels) were finally enrolled and divided into the hemoglobin A1c (HbA1c)-compliance group (103 patients, 138 vessels) and non-HbA1c-compliance group (154 patients, 223 vessels) according to the HbA1c cut-off value of 7%. We compared the results of QFR analysis and clinical outcomes between the two groups.

RESULTS

At 1-year follow up after PCI, the QFR was significantly higher (0.94 ± 0.07 vs 0.92 ± 0.10, P = 0.019) and declined less (0.014 ± 0.066 vs 0.033 ± 0.095, P = 0.029) in the HbA1c-compliance group. Meanwhile, the incidence of physiological restenosis was lower in the HbA1c-compliance group (2.9% vs 8.5%, P = 0.034). Additionally, the target vessel revascularization rate was lower in the HbA1c-compliance group (6.8% vs 16.9%, P = 0.018). Furthermore, HbA1c ≥7% (OR 2.113, 95% confidence interval 1.081-4.128, P = 0.029) and QFR decline (OR 2.215, 95% confidence interval 1.147-4.277, P = 0.018) were independent risk factors for target vessel revascularization.

CONCLUSION

Patients with well-controlled HbA1c levels have better coronary physiological benefits and the incidence of adverse clinical outcome events might be reduced.

Hypercholesterolemia exacerbates in-stent restenosis in rabbits: Studies of the mitigating effect of stent surface modification with a CD47-derived peptide

BACKGROUND AND AIMS

Hypercholesterolemia (HC) has previously been shown to augment the restenotic response in animal models and humans. However, the mechanistic aspects of in-stent restenosis (ISR) on a hypercholesterolemic background, including potential augmentation of systemic and local inflammation precipitated by HC, are not completely understood. CD47 is a transmembrane protein known to abort crucial inflammatory pathways. Our studies have examined the interrelation between HC, inflammation, and ISR and investigated the therapeutic potential of stents coated with a CD47-derived peptide (pepCD47) in the hypercholesterolemic rabbit model.

METHODS

PepCD47 was immobilized on metal foils and stents using polybisphosphonate coordination chemistry and pyridyldithio/thiol conjugation. Cytokine expression in buffy coat-derived cells cultured over bare metal (BM) and pepCD47-derivatized foils demonstrated an M2/M1 macrophage shift with pepCD47 coating. HC and normocholesterolemic (NC) rabbit cohorts underwent bilateral implantation of BM and pepCD47 stents (HC) or BM stents only (NC) in the iliac location.

RESULTS

A 40 % inhibition of cell attachment to pepCD47-modified compared to BM surfaces was observed. HC increased neointimal growth at 4 weeks post BM stenting. These untoward outcomes were mitigated in hypercholesterolemic rabbits treated with pepCD47-derivatized stents. Compared to NC animals, inflammatory cytokine immunopositivity and macrophage infiltration of peri-strut areas increased in HC animals and were attenuated in HC rabbits treated with pepCD47 stents.

CONCLUSIONS

Augmented inflammatory responses underlie severe ISR morphology in hypercholesterolemic rabbits. Blockage of initial platelet and leukocyte attachment to stent struts through CD47 functionalization of stents mitigates the pro-restenotic effects of hypercholesterolemia.

Systemic immune-inflammation index and in-stent restenosis in patients with acute coronary syndrome: a single-center retrospective study

BACKGROUND

In-stent restenosis (ISR) has been shown to be correlated with inflammation. This study aimed to examine the relationship between systemic immune-inflammation index (SII, an innovative inflammatory biomarker) and ISR in acute coronary syndrome (ACS) patients after drug-eluting stent (DES) implantation.

METHODS

Subjects who were diagnosed with ACS and underwent DES implantation were enrolled retrospectively. All individuals underwent follow-up coronary angiography at six to forty-eight months after percutaneous coronary intervention (PCI). SII was defined as [(platelet count × neutrophil count)/lymphocyte count], and Ln-transformed SII (LnSII) was carried out for our analysis. Multivariate logistic regression analysis was employed to assess the association between LnSII and DES-ISR.

RESULTS

During a median follow-up period of 12 (11, 20) months, 523 ACS patients who underwent follow-up angiography were included. The incidence of DES-ISR was 11.28%, and patients in the higher LnSII tertile trended to show higher likelihoods of ISR (5.7% vs. 12.1% vs. 16.0%; P = 0.009). Moreover, each unit of increased LnSII was correlated with a 69% increased risk of DES-ISR (OR = 1.69, 95% CI 1.04-2.75). After final adjusting for confounders, a significant higher risk of DES-ISR (OR = 2.52, 95% CI 1.23-5.17) was found in participants in tertile 3 (≥ 6.7), compared with those in tertiles 1-2 (< 6.7). Subgroup analysis showed no significant dependence on age, gender, body mass index, current smoking, hypertension, and diabetes for this positive association (all P for interaction > 0.05).

CONCLUSION

High levels of SII were independently associated with an increased risk of DES-ISR in ACS patients who underwent PCI. Further prospective cohort studies are still needed to validate our findings.

Unusual effects of PCSK9 E670G (rs505151) variation in patients with in-stent restenosis: Variable effects on restenosis risk according to concomitant chronic conditions

Recent reports showing that neo-atherosclerosis formation in stented coronary artery is characterized by the accumulation of lipid-laden macrophages within the neointima has strengthened the possibility that elevated low-density lipoprotein (LDL)-cholesterol may be a risk factor for in-stent restenosis (ISR). Protein Convertase Subtilisin/Kexin-9 (PCSK9) protein plays an important role in cholesterol metabolism by degrading of LDL receptors. The gain-of-function E670G (rs505151) mutation of the PCSK9 gene is a well-known genetic risk factor for hypercholesterolemia. This study evaluated for the first time the association of the E670G variation with the serum lipids, PCSK9 levels and concomitant diseases on the ISR risk. The study included 109 ISR, and 82 Non-ISR patients, based on the results of coronary angiography. Genotypes were determined using the real-time PCR and serum PCSK9 levels were measured by ELISA technique. The rare G allele of PCSK9 E670G (p < 0.05), hyperlipidemia (HL) (p < 0.001), and type 2 diabetes (T2DM) (p < 0.01) were associated with increased risk for ISR. In hyperlipidemic conditions, the E670G-G allele was associated with hypercholesterolemia and a higher risk of ISR (p < 0.001), while the E670G-AA genotype has been associated with a high prevalence of T2DM and hypertension. In addition, diabetic ISRs had higher serum PCSK9 levels (p < 0.05) and the E670G-AA genotype was associated with increased levels of diabetes markers. Our results indicated that the unusual effects of both G allele and AA genotype of the PCSK9 E670G variation may be involved in the risk of ISR in association with concomitant metabolic diseases.

The role of optical coherence tomography in guiding percutaneous coronary interventions: is left main the final challenge?

Left main (LM) coronary artery disease is a high-risk lesion subset, with important prognostic implications for the patients. Recent advances in the field of interventional cardiology have narrowed the gap between surgical and percutaneous approach of this complex lesion setting. However, the rate of repeat revascularization remains higher in the case of percutaneous coronary intervention (PCI) on long-term follow-up. As such, the need for better stent optimization strategies has led to the development of intravascular imaging techniques, represented mainly by intravascular ultrasound (IVUS) and optical coherence tomography (OCT). These techniques are both able to provide excellent pre- and post-PCI guidance. While IVUS is an established modality in optimizing LM PCI, and is recommended by international revascularization guidelines, data and experience on the use of OCT are still limited. This review paper deeply analyzes the current role of OCT imaging in the setting of LM disease, particularly focusing on its utility in assessing plaque morphology and distribution, vessel dimensions and proper stent sizing, analyzing mechanisms of stent failure such as malapposition and underexpansion, guiding bifurcation stenting, as well as offering a direct comparison with IVUS in this critical clinical scenario, based on the most recent available data.

Risk factors for instent restenosis of sirolimus-coated stents in coronary intervention for patients with unstable angina

To investigate the instent restenosis rate of sirolimus-coated stents in percutaneous coronary intervention (PCI) and risk factors for in-stent restenosis, patients with unstable angina (UA) caused by coronary artery stenosis were enrolled, and all clinical and imaging data were analyzed. Among 143 enrolled patients with UA aged 35-83 (mean 60.9 ± 10.0) years enrolled, there were 114 (79.7%) male and 29 (20.3%) female patients. Arterial stenosis was present in one coronary artery in 6 (4.2%) patients, in two coronary arteries in 20 (14.0%) patients, in three arteries in 116 (81.1%), and in four coronary arteries in 1 (0.7%) patient. Stenting was successfully performed in all (100%) patients, and 181 stents were deployed. The quantitative flow ratio (QFR) was 0.92 ± 0.03 (range 0.84-0.96) immediately after stenting, and the TIMI was grade 3 in all patients. The diameter of the stents deployed ranged 2.25-4 mm (mean 3.04 ± 0.44) with a length ranging 10 mm to 104 mm (mean 32.73 ± 15.5). Follow-up angiography was performed in all patients with a duration of 1-92 (mean 15.0 ± 18.8) months. Instent restenosis ≥ 50% occurred in 25 (17.5%) patients. In univariate logistic regression analysis, significant (P < 0.05) risk factors for instent restenosis ≥ 50% were QFR (OR 0.036, 95% CI 0.13-0.97), stent diameter (OR 0.43, 95% CI 0.18-0.92), hypertension (OR 3.16, 95% CI 1.02-9.82), smoking (OR 0.31, 95% CI 0.11-0.89), and neutrophil count (OR 2.22, 95% CI 1.10-5.44). In multivariate analysis, QFR (OR 0.02, 95% CI 0.002-0.19), stent diameter (OR 0.06, 95% CI 0.005-0.59), hypertension (OR 6.75, 95% CI 1.83-35.72) and neutrophil count (OR 276.07, 95% CI 12.32-10,959.95) were significant (P < 0.05) independent risk factors for instent restenosis ≥ 50%. In conclusion, certain instent restenosis rates occurs after the sirolimus-eluted coronary stent deployment for the treatment of coronary artery stenosis in patients with UA, and quantitative flow ratio after stenting, stent diameter, hypertension, and neutrophil count are significant risk factors for instent restenosis of the sirolimus-coated stents in coronary intervention.

Intrastent Restenosis: A Comprehensive Review

The primary objective of this paper is to delineate and elucidate the contemporary advancements, developments, and prevailing trajectories concerning intrastent restenosis (ISR). We aim to provide a thorough overview of the most recent developments in this area, covering various aspects such as pathophysiological insights, therapeutic approaches, and new strategies for tackling the complex challenges of ISR in modern clinical settings. The authors have undertaken a study to address a relatively new medical challenge, recognizing its significant impact on the morbidity and mortality of individuals with cardiovascular diseases. This effort is driven by the need to fully understand, analyze, and possibly improve the outcomes of this emerging medical issue within the cardiovascular disease field. We acknowledge its considerable clinical implications and the necessity for innovative methods to mitigate its effects on patient outcomes. Therefore, our emphasis was directed towards elucidating the principal facets of the condition's prevalence, expounding upon the foundational mechanisms underscoring conspicuous restenosis, and delineating the risk factors relevant in shaping the contemporary landscape of diagnostic and therapeutic modalities. This thorough examination aims to provide a comprehensive understanding of the various dimensions of the condition, including epidemiological data, pathophysiological complexities, and clinical considerations critical for evaluating and enhancing current diagnostic and treatment approaches.

Value of stent boost imaging in decision making after coronary stenting

BACKGROUND

Several studies reported the comparability of digital stent enhancement techniques (including stent boost imaging) in detecting suboptimal results of coronary stenting with Intra Vascular Ultrasound and optical coherence tomography.

AIMS

to assess results of stent deployment and determine the incidence of suboptimal results requiring changing final decision using stent boost imaging.

METHODS

This cross-sectional study included 120 patients eligible for PCI were recruited during a period of one year (January 2021 to 2022) using DES.

RESULTS

Suboptimal results were found in 38% of the PCI cases with stents (angiography guided). Importantly it was found that improper lesion preparation in our practice could not help improving stent optimization. Also, angiography guided PCI has significant incidence of suboptimal results. Digital stent enhancement techniques like stent boost have significant and important value in better decision making. After adjusting for age and sex, six factors were identified as independent predictors for final decision change (stent length, LAD/RCA affection, proximal segment affection, calcification, and optical coherence tomography.

CONCLUSION

This study has confirmed the utility of stent boost for the optimization of PCI in daily practice. Stent Boost is a simple and costless technique that provides an accurate assessment of a deployed stent without extending the procedure time and without more risk. It appears to be useful for the immediate evaluation of stent expansion and optimization of PCI by additional post-dilatation, when appropriate. Future studies are needed to determine whether Stent Boost data will correlate with adverse long-term clinical outcomes in patients undergoing PCI.

Soft implantable printed bioelectronic system for wireless continuous monitoring of restenosis

Atherosclerosis is a prominent cause of coronary artery disease and broader cardiovascular diseases, the leading cause of death worldwide. Angioplasty and stenting is a common treatment, but in-stent restenosis, where the artery re-narrows, is a frequent complication. Restenosis is detected through invasive procedures and is not currently monitored frequently for patients. Here, we report an implantable vascular bioelectronic device using a newly developed miniaturized strain sensor via microneedle printing methods. A capillary-based printing system achieves high-resolution patterning of a soft, capacitive strain sensor. Ink and printing parameters are evaluated to create a fully printed sensor, while sensor design and sensing mechanism are studied to enhance sensitivity and minimize sensor size. The sensor is integrated with a wireless vascular stent, offering a biocompatible, battery-free, wireless monitoring system compatible with conventional catheterization procedures. The vascular sensing system is demonstrated in an artery model for monitoring restenosis progression. Collectively, the artery implantable bioelectronic system shows the potential for wireless, real-time monitoring of various cardiovascular diseases and stent-integrated sensing/treatments.

Fasting blood glucose predicts high risk of in-stent restenosis in patients undergoing primary percutaneous coronary intervention: a cohort study

Objectives. Studies have shown that fasting blood glucose (FBG) is closely associated with poor prognosis in patients with coronary heart disease (CHD) after percutaneous coronary intervention (PCI), but its association with in-stent restenosis (ISR) is still unclear. Therefore, this study was to explore the association between FBG with ISR in patients with CHD after PCI. Design. In this cohort study, we included 531 patients with CHD who underwent PCI. Logistic regression, receiver operating characteristic (ROC), subgroup analysis and restricted cubic spline (RCS) were used to assess the association between FBG with ISR. Results. A total of 124 (23.4%) patients had ISR. Patients with higher levels of FBG had higher incidence of ISR compared to those with lower levels of FBG (p = 0.002). In multivariable logistic regression analyses, higher levels of FBG remained strongly associated with higher risk of ISR (as a categorical variable, OR: 1.89, 95% CI: 1.21-2.94, p = 0.005; as a continuous variable, OR: 1.12, 95% CI: 1.03-1.23, p = 0.011). ROC analysis also showed that FBG might be associated with the occurrence of ISR (AUC = 0.577, 95% CI: 0.52-0.64, p = 0.013). Subgroup analyses showed the association of FBG with ISR was also stable in several subgroups (< 60 years or ≥ 60 years, male, with or without smoking, without diabetes and without hypertension). And RCS analysis showed that FBG was linearly and positively associated with the risk of ISR. Conclusions. Higher levels of FBG were closely associated with higher risk of ISR in patients with CHD after PCI.

Monocyte to high-density lipoprotein cholesterol ratio predicts poor outcomes in ischaemic heart failure patients combined with diabetes: a retrospective study

BACKGROUND

The prevalence of ischaemic heart failure (HF) continues to increase. Diabetes mellitus (DM) concomitant with ischaemic HF increases the risk of major adverse cardiovascular events (MACEs). As a promising predictor for cardiovascular diseases, the predictive value of the monocyte to high-density lipoprotein cholesterol ratio (MHR) for MACE in the ischaemic HF with DM cohort has never been investigated before.

OBJECTIVE

We aimed to investigate the MHR as a predictor for MACE in ischaemic HF patients with DM who underwent percutaneous coronary intervention (PCI).

METHODS

This observational study enrolled 1049 patients with ischaemic HF and DM undergoing PCI from June 2017 to June 2019. The baseline data were collected. MACEs, including all-cause mortality, nonfatal myocardial infarction, and any revascularization, were recorded within the 36-month follow-up. The characteristics and incidence of MACE were analysed in four groups stratified by the quartiles of MHR. The hazard ratio for MACE was analysed with Cox regression models. The incidence of MACE in the four groups was evaluated by Kaplan‒Meier survival analysis. Restricted cubic spline analysis was performed to determine the nonlinear correlation between the MHR and MACE.

RESULTS

After the 36-month follow-up, 407 patients (38.8%) experienced MACEs. The incidence of MACE was significantly higher among patients in the upper MHR quartile than among those in the lower MHR quartiles (23.4% vs. 36.0% vs. 41.4% and 54.6%; P < 0.001, respectively), which was consistent with the Kaplan‒Meier survival analyses (P < 0.0001). A multivariate Cox regression model showed that the MHR was an independent risk factor for MACE after variables were adjusted (adjusted HR: 2.11; 95% CI 1.47-3.03; P < 0.001). Its predictive effects on MACE showed no interaction with hypercholesterolemia (P > 0.05).

CONCLUSION

The MHR was a significant and independent predictor of MACEs in ischaemic HF patients with DM undergoing PCI.

Surface Engineering of Bioactive Coatings for Improved Stent Hemocompatibility: A Comprehensive Review

Cardiovascular diseases continue to be a major contributor to illness and death on a global scale, and the implementation of stents has given rise to a revolutionary transformation in the field of interventional cardiology. The thrombotic and restenosis complications associated with stent implantation pose ongoing challenges. In recent years, bioactive coatings have emerged as a promising strategy to enhance stent hemocompatibility and reduce thrombogenicity. This review article provides an overview of the surface engineering techniques employed to improve the hemocompatibility of stents and reduce thrombus formation. It explores the mechanisms underlying thrombosis and discusses the factors influencing platelet activation and fibrin formation on stent surfaces. Various bioactive coatings, including anticoagulant agents, antiplatelet agents, and surface modifications, are discussed in detail, highlighting their potential in reducing thrombogenicity. This article also highlights a multitude of surface modification techniques which can be harnessed to enhance stent hemocompatibility including plasma treatment, physical vapor deposition (PVD), chemical vapor deposition (CVD), and electrodeposition. These techniques offer precise control over surface properties such as roughness, charge, and composition. The ultimate goal is to reduce platelet adhesion, tailor wettability, or facilitate the controlled release of bioactive agents. Evaluation methods for assessing hemocompatibility and thrombogenicity are also reviewed, ranging from in vitro assays to animal models. Recent advances in the field, such as nanotechnology-based coatings and bioactive coatings with controlled drug release systems, are highlighted. Surface engineering of bioactive coatings holds great promise for enhancing the long-term outcomes of stent implantation by enhancing hemocompatibility and reducing thrombogenicity. Future research directions and potential clinical applications are discussed, underscoring the need for continued advancements in this field.

Ten-year outcomes after percutaneous coronary intervention of in-stent restenosis in saphenous vein grafts

BACKGROUND

Only few data is available for long-term outcomes of patients being treated for in-stent restenosis (ISR) in saphenous vein grafts (SVG).

AIMS

Thus, the aim of this observational, retrospective study was to close this lack of evidence.

METHODS

Between January 2007 and February 2021 a total of 163 patients with 186 ISR lesions located in SVG were treated at two large-volume centers in Munich, Germany. Endpoints of interest were all-cause mortality, target lesion revascularization (TLR) and target vessel myocardial infarction (TVMI). Furthermore, recurrent ISR were assessed. Outcomes are presented as Kaplan-Meier event rates.

RESULTS

Mean age was 72.6 ± 8.6 years, 90.8% were male, 36.8% were diabetics and 42.3% presented an acute coronary syndrome. ISR were treated with DES in 64.0% and with balloon angioplasty (BA) in 36.0%. After 10 years, the rates for all-cause mortality, TVMI and TLR were 58.2%, 15.4%, and 22.6%, respectively. No statistically relevant differences were found between the types of treatment (DES or BA) regarding all-cause mortality (55.7% vs. 63.2%, p = 0.181), TVMI (13.8% vs. 18.6%, p = 0.215) and TLR (21.8% vs. 25.0%, p = 0.764). Median time between first and recurrent ISR was 270.8 days. Recurrent ISR were treated with DES in a comparable proportion as during first ISR (p = 0.075). Independent predictor of TLR is patient age (p = 0.034). The median follow-up duration was 5.1 years (75% CI 2.8; 8.5).

CONCLUSIONS

Clinical event rates after intervention of ISR located in SVG are high without statistically relevant differences regarding the type of treatment. However, further studies are needed.

A Simple Predictor for Long-Term Mortality After Percutaneous Iliac Artery Intervention: Systemic Immune Inflammatory Index

BACKGROUND

Peripheral arterial disease is a common disease all over the world. Medical treatment, percutaneous invasive treatment, and operation are the considerable options. Percutaneous treatment is a valid option with a higher patency rate. Systemic immune-inflammatory index (SII) is a formula which is calculated as neutrophil count to platelet count divided into lymphocyte count. This formula demonstrates the active inflammatory state. In our study, we aimed to demonstrate the relationship with SII and the mortality, major cardiovascular events, and success rates of percutaneous treatment of iliac artery disease.

METHODS

A total of 600 patients underwent percutaneous intervention due to iliac artery disease were enrolled. The primary end point was mortality and the secondary end points were in-hospital thrombosis, restenosis, residual stenosis, and postintervention complications. The best cut-off value of SII to predict mortality was determined and the patients were divided into 2 groups, as those with higher SII values (1,073.782 <) and as those with lower SII values (1,073.782 >). Each group was evaluated in terms of clinical, laboratory, and technical aspects.

RESULTS

After exclusion criteria were applied, 417 patients were enrolled into the study. Patients with high SII values had higher rates of in-hospital thrombosis [0 (0%); 3 (2.2%), P = 0.037] and mortality [38 (13.7%); 46 (33.1%), P < 0.001]. In multivariate logistic regression analysis, chronic kidney disease [odds ratio: 4.104, 95 0.5 confidence interval: 2.250-7.487, P < 0.001] and SII [odds ratio: 3.346, 95 0.5 confidence interval: 1.982-5.649, P < 0.001] were found to be independent risk factors for mortality.

CONCLUSIONS

SII is a relatively new, simple, and effective mortality risk predictor in patients with iliac artery disease who underwent percutaneous intervention. To the best of our knowledge, our study is the first study which uses SII to predict mortality in such patient group.

Myocardial revascularization failure among patients requiring cardiac catheterization and secondary revascularization in contemporary clinical practice: Results of the REVASEC multicenter registry

BACKGROUND

Myocardial revascularization failure (MRF) and Secondary revascularization (SR) are contemporary interventional cardiology challenges.

AIM

To investigate the characteristics, management, and prognosis of patients with myocardial revascularization failure (MRF) and need for secondary revascularization (SR) in contemporary practice.

METHODS

The REVASEC study is a prospective registry (NCT03349385), which recruited patients with prior revascularization referred for coronary angiography at 19 centers. The primary endpoint is a patient-oriented composite (POCE) at 1 year, including death, myocardial infarction, or repeat revascularization.

RESULTS

A total of 869 patients previously revascularized by percutaneous intervention (83%) or surgery (17%) were recruited. MRF was found in 83.7% (41.1% stent/graft failure, 32.1% progression of coronary disease, and 10.5% residual disease). SR was performed in 70.1%, preferably by percutaneous intervention (95%). The POCE rate at 1 year was 14% in the overall cohort, with 6.4% all-cause death. In the multivariate analysis, lower POCE rates were found in the groups without MRF (9.4%) and with disease progression (11%) compared with graft/stent failure (17%) and residual disease (18%), hazard ratio 0.67 (95% confidence interval: 0.45-0.99), p = 0.043. At 1 year, the SR group had less chronic persistent angina (19% vs. 34%, p < 0.001), but a higher rate of repeat revascularization (9% vs. 2.9%, p < 0.001).

CONCLUSION

MRF was found in 84% of patients with prior revascularization referred for coronary angiography. Stent/graft failure and residual coronary disease were associated with a worse prognosis. SR provided better symptom control at the expense of a higher rate of new revascularization.

High on-aspirin treatment platelet reactivity and restenosis after percutaneous coronary intervention: results of the Intracoronary Stenting and Antithrombotic Regimen-ASpirin and Platelet Inhibition (ISAR-ASPI) Registry

OBJECTIVE

The aim of this study was to assess the association between high on-aspirin treatment platelet reactivity (HAPR) and the subsequent risk of restenosis after percutaneous coronary intervention (PCI) with predominantly drug-eluting stents.

BACKGROUND

The association between HAPR and subsequent risk of restenosis after PCI is unclear.

METHODS

This study included 4839 patients undergoing PCI (02/2007-12/2011) in the setting of the Intracoronary Stenting and Antithrombotic Regimen-ASpirin and Platelet Inhibition (ISAR-ASPI) registry. Platelet function was assessed with impedance aggregometry using the multi-plate analyzer immediately before PCI and after intravenous administration of aspirin (500 mg). The primary outcome was clinical restenosis, defined as target lesion revascularization at 1 year. Secondary outcomes included binary angiographic restenosis and late lumen loss at 6- to 8-month angiography.

RESULTS

The upper quintile cut-off of platelet reactivity measurements (191 AU × min) was used to categorize patients into a group with HAPR (platelet reactivity > 191 AU × min; n = 952) and a group without HAPR (platelet reactivity ≤ 191 AU × min; n = 3887). The primary outcome occurred in 94 patients in the HAPR group and 405 patients without HAPR (cumulative incidence, 9.9% and 10.4%; HR = 0.96, 95% CI 0.77-1.19; P = 0.70). Follow-up angiography was performed in 73.2% of patients. There was no difference in binary restenosis (15.2% vs. 14.9%; P = 0.79) or late lumen loss (0.32 ± 0.57 vs. 0.32 ± 0.59 mm; P = 0.93) between patients with HAPR versus those without HAPR.

CONCLUSIONS

This study did not find an association between HAPR, measured at the time of PCI, and clinical restenosis at 1 year after PCI.

Association of ACE gene polymorphisms with in-stent restenosis by stent type (biomime, supraflex, xience)

INTRODUCTION

Angiotensin Converting Enzyme or ACE is an exo-peptidase that causes the conversion of angiotensin I to angiotensin II, vasoconstriction, and aldosterone production. ACE gene polymorphism (I/D) affects enzyme activity and the risk of coronary artery disease or CAD.

AIMS

To examine the role of ACE (I/D) Gene Polymorphisms by Stent Types (Biomime, Supraflex, Xience) the Ace gene allele and genotype frequencies were determined in patients who underwent angioplasty.

MATERIAL & METHODS

Patients with in-stent restenosis (ISR+) (N = 53) and patients as non-ISR group (ISR-) (N = 68) have been enrolled in this study based on follow-up angiography > 1 year after PCI. Frequencies of allele and genotypes of the ACE (I/D) variant were determined using polymerase chain reaction (PCR).

RESULTS

The genotypes and allele frequencies were not significantly different between the studied populations (p-Values > 0.05). However, there was a significant difference between people with a history of Clopidogrel use in the ISR- and ISR + groups observed (p-Values > 0.005).

CONCLUSION

In the present study, there was no statistically significant relationship between ACE (I/D) gene polymorphism and the incidence of restenosis in patients who underwent repeat angiography. The results showed that the number of patients who received Clopidogrel in the ISR + group was significantly less than the ISR- group. This issue can indicate the inhibitory effect of Clopidogrel in the recurrence of stenosis.

SCAI Expert Consensus Statement on Management of In-Stent Restenosis and Stent Thrombosis

Stent failure remains the major drawback to the use of coronary stents as a revascularization strategy. Recent advances in imaging have substantially improved our understanding of the mechanisms underlying these occurrences, which have in common numerous clinical risk factors and mechanical elements at the time of stent implantation. In-stent restenosis remains a common clinical problem despite numerous improvements in-stent design and polymer coatings over the past 2 decades. It generates significant health care cost and is associated with an increased risk of death and rehospitalization. Stent thrombosis causes abrupt closure of the stented artery and therefore carries a high risk of myocardial infarction and death. This Society for Cardiovascular Angiography & Interventions (SCAI) Expert Consensus Statement suggests updated practical algorithmic approaches to in-stent restenosis and stent thrombosis. A pragmatic outline of assessment and management of patients presenting with stent failure is presented. A new SCAI classification that is time-sensitive with mechanistic implications of in-stent restenosis is proposed. Emphasis is placed on frequent use of intracoronary imaging and assessment of timing to determine the precise etiology because that information is crucial to guide selection of the best treatment option. SCAI recommends image-guided coronary stenting at the time of initial implantation to minimize the occurrence of stent failure. When in-stent restenosis and stent thrombosis are encountered, imaging should be strongly considered to optimize the subsequent approach.

Challenges and chances coexist: A visualized analysis and bibliometric study of research on bioresorbable vascular scaffolds from 2000 to 2022

BACKGROUND

Bioresorbable scaffolds (BVS) provide a transient supporting force for blocked vessels and allow them to return to previous physiological characteristics. After verification with twists and turns, it has been acknowledged as an emerging revolution in percutaneous coronary intervention that expresses the current concept of intervention without placement. Through this bibliometric study, we organized the knowledge structure of bioresorbable scaffolds and attempted to predict future research hotspots in this field.

METHODS

seven thousand sixty-three articles were retrieved from the web of science core collection database from 2000 to 2022. Then, we utilize CiteSpace 6.1.R2, Biblioshiny and VOS viewer 1.6.18 to analyze the data visually.

RESULTS

First, according to the spatial analysis, the number of annual publications has shown an approximately increasing trend over the past 2 decades. The USA, the People's Republic of China, and GERMANY published the most articles on bioresorbable scaffolds. Second, SERRUYS P ranked first for his most prolific work and highest cited frequency in this domain. Third, the hotspots in this field can be inferred from the keyword distribution; they were the fabrication technique based on tissue engineering; the factors to be optimized for bioresorbable scaffolds, such as mechanical property, degradation, and implantation; and the common adverse effects of bioresorbable scaffolds, such as thrombosis. Most importantly, in terms of burst detection, we could speculate that cutting-edge technology for manufacturing scaffolds represented by 3D printing constitutes the future hotspots in bioresorbable scaffold development.

CONCLUSION

In the first visualized bibliometric analysis of BVS, we attempt to provide a panoramic view. By enrolling extensive literature, we review the growing trend of BVSs. Since its first introduction, it has been through periods of early prosperity, questioned safety subsequently and the resultantly advanced techniques in recent years. In future, the research should focus on utilizing novel techniques to consummate the manufacturing quality and assure the safety of BVSs.

Dynamic assessment of the left main-left circumflex bending angle: Implications for ostial left circumflex artery in-stent restenosis after successful two-stent PCI

BACKGROUND

Two-stent techniques for percutaneous coronary intervention (PCI) on left main (LM) bifurcation (LMB) lesions are associated with an increased risk of in-stent restenosis (ISR) at left circumflex artery (LCx) ostium but the underlying mechanisms are incompletely understood. This study sought to investigate the association between cyclic change of LM-LCx bending angle (BA_LM-LCx) and the risk of ostial LCx ISR following two-stent techniques.

METHODS

In a retrospective cohort of patients undergoing two-stent PCI for LMB lesions, BA_LM-LCx and distal bifurcation angle (DBA) were computed with 3-dimensional angiographic reconstruction. The analysis was performed both at end-diastole and end-systole, and the angulation change throughout the cardiac cycle was defined as the cardiac motion-induced angulation change (∆_CAngle).

RESULTS

A total of 101 patients were included. The mean pre-procedural BA_LM-LCx was 66.8 ± 16.1° at end-diastole and 54.1 ± 13.3° at end-systole with a range of 13.0 ± 7.7°. Pre-procedural ∆_CBA_LM-LCx > 16.4° was the most relevant predictor of ostial LCx ISR (adjusted OR 11.58, 95% CI 4.04-33.19; p < 0.001). Post-procedural ∆_CBA_LM-LCx > 9.8° and stent-induced diastolic BA_LM-LCx change > 11.6° were also related with ostial LCx ISR. DBA was positively correlated with BA_LM-LCx and showed a weaker association of pre-procedural ∆_CDBA > 14.5° with ostial LCx ISR (adjusted OR 6.87, 95% CI 2.57-18.37; p < 0.001).

CONCLUSIONS

Three-dimensional angiographic bending angle is a feasible and reproducible novel method for LMB angulation measurement. A large pre-procedural cyclic change of BA_LM-LCx was associated with an increased risk of ostial LCx ISR following two-stent techniques.

Long-term Outcomes for Drug-eluting Balloons versus Drug-eluting Stents in the Treatment of Small Vessel Coronary Artery Disease: A Systematic Review and Meta-analysis

Background: This systematic review and meta-analysis compares long-term outcomes follow-up data comparing drug-eluting balloons (DEBs) and drug-eluting stents (DESs) in interventional treatment of small coronary artery disease (<3 mm). Methods: A systematic review was undertaken along with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome was 1-3-year performance of DEB versus DES in major adverse cardiac events. Secondary outcomes include all-cause mortality, MI, cardiac death, vessel thrombosis, major bleeding, target vessel revascularisation and target lesion revascularisation. Two independent reviewers extracted data. All outcomes used the Mantel-Haenszel and random effects models. ORs are presented with a 95% CI. Results: Of 4,661 articles, four randomised control trials were included (1,414 patients). DEBs demonstrated reduced rates of non-fatal MI at 1 year (OR 0.44; 95% CI [0.2-0.94]), and BASKET-SMALL 2 reported a significant reduction in 2-year bleeding rates (OR 0.3; 95% CI [0.1-0.91]). There was no significant difference in all other outcomes. Conclusion: Long-term follow-up of DEB and DES use in small coronary arteries demonstrates DEBs be comparable with DESs in all outcomes at 1, 2 and 3 years of follow-up. A significant reduction was found in rates of non-fatal MI at 1 year in the DEB arm, and a reduction in major bleeding episodes at 2 years in the BASKET-SMALL 2 trial. These data highlight the potential long-term utility of novel DEBs in small coronary artery disease revascularisation.

Myocardial Work Evaluation-A Useful Non-Invasive Method to Predict Coronary Artery Sub-Occlusion in a Patient with Unstable Angina and Multiple Myocardial Revascularization Interventions

BACKGROUND

While lifestyle changes, management of coronary artery disease (CAD) risk factors, myocardial revascularization procedures, and medication can improve a patient's prognosis, de novo native coronary lesions and in-stent restenosis (ISR) remain significant clinical concerns. ISR is more frequent with a bare-metal stent than with a drug-eluting stent and has been documented in around 12% of DES patients. Acute coronary syndrome (ACS) manifests as unstable angina in about 30% to 60% of ISR patients. Myocardial work imaging is a modern, non-invasive technique able to identify individuals with critical coronary artery lesions with high sensitivity and specificity.

CASE REPORT

We present the case of a 72-year-old Caucasian gentleman with multiple cardiovascular risk factors, admitted to the Cardiology Clinic of Timișoara Municipal Hospital with unstable angina. From 1999 to 2021, the patient experienced two myocardial infarctions, a double aortocoronary bypass graft, and multiple percutaneous coronary interventions with 11 stent implantations, including 6 for ISR. Using two-dimensional speckle-tracking echocardiography and myocardial work assessment, we detected that the lateral wall of the left ventricle had a severely impaired deformation pattern. Angio-coronarography was performed, and sub-occlusion of the posterolateral branch of the right coronary artery was found. Angioplasty was performed and a DES was inserted, with a good final angiographic result and complete release of symptoms.

CONCLUSION

In patients with a history of multiple myocardial revascularization interventions and ISR, it is challenging to identify the critical ischemia region by non-invasive methods. Myocardial work imaging was beneficial in the detection of the altered deformation patterns indicating significant ischemia, its accuracy being superior to that of LV strain, as proven by coronary angiography. Urgent coronary angiography followed by angioplasty and stent implantation resolved the issue.