Clinical and angiographic outcome following implantation of the new Less Shortening Wallstent in aortocoronary vein grafts: introduction of a second generation stent in the clinical arena

NT-proBNP and Major Adverse Cardiovascular Events in Patients with ST-Segment Elevation Myocardial Infarction Who Received Primary Percutaneous Coronary Intervention: A Prospective Cohort Study

Background

The prognostic significance of the amino-terminal fragment of the prohormone brain-type natriuretic peptide (NT-proBNP) in patients with ST-segment elevation myocardial infarction (STEMI) after percutaneous coronary intervention (PCI) has not been fully elucidated. Major adverse cardiovascular events (MACEs) are clinically viable indicators for the accurate, rapid, and safe evaluation of patients with STEMI. This study was designed to investigate the relationship between NT-proBNP levels and the occurrence of short-term MACEs in patients with STEMI who underwent emergency PCI.

Methods

This prospective cohort study included 405 patients with STEMI aged 20–90 years who underwent emergency PCI at the First People's Hospital of Changde City from April 6, 2017, to May 31, 2019. Stent thrombosis, reinfarction, congestive heart failure, unstable angina, and cardiac death were considered as MACEs in this study. The target-independent and -dependent variables were NT-proBNP at baseline and MACE, respectively.

Results

There were 28.25% of MACEs. Age, number of implanted stents, Killip class, infarction-related artery, applied intra-aortic balloon pump (IABP), creatine kinase (CK) peak value, CK-MB peak value, TnI peak value, and ST-segment resolution were independently associated with MACE (P < 0.05). In a multivariate model, after adjusting all potential covariates, Log2 NT-proBNP levels remained significantly associated with MACE, with an inflection point of 11.66. The effect sizes and confidence intervals of the left and right sides of the inflection point were 1.07 and 0.84–1.36 (P=0.5730) and 3.47 and 2.06–5.85 (P < 0.0001), respectively.

Conclusions

In patients with STEMI who underwent PCI, Log2 NT-proBNP was positively correlated with MACE within 1 month when the Log2 NT-proBNP was >11.66 (NT-proBNP >3.236 pg/mL).

Major adverse cardiovascular events after implantation of absorb bioresorbable scaffold: One-year clinical outcomes

Background/Aim: Bioresorbable vascular scaffold (BVS) represents a novel generation of intracoronary devices designed to be fully resorbed after healing of the stented lesion, delivering antiproliferative drug to suppress restenosis, providing adequate diameter of the coronary vessel and preserving the vascular endothelial function. It was supposed that BVS will reduce neointimal proliferation and that their late bioresorption will reduce the negative effects of traditional drug-eluting stents, including the late stent thrombosis, local vessel wall inflammation, loss of coronary vasoreactivity and the need for the long-term dual antiplatelet therapy. The purpose of this research was to investigate efficacy and safety of Absorb everolimus-eluting BVS implantation and the prevalence of major adverse cardiovascular events (MACE) at the mid-term follow-up. Methods: The study encompassed 42 patients selected for BVS implantation and fulfilling inclusion criteria - 37 male and 5 female - admitted to the Dedinje Cardiovascular Institute, Belgrade, Serbia over the one-year period (from January 2015 to January 2016) for percutaneous coronary intervention (PCI). Coronary vessel patency before and after stenting was assessed by the Thrombolysis in Myocardial Infarction flow (TIMI) grades. After the index PCI procedure with BVS all patients were clinically followed by regular (prescheduled or event-driven) visits during the next 12-month period. Results: In the intention-to-treat analysis, all Absorb BVS procedures were successful, without the need for conversion to other treatment modalities. The complete reperfusion (TIMI flow grade 3) after the intervention was established in 97.6 % of patients and 100 % of them achieved the TIMI flow grade ≥ 2. The presence of angina pectoris was reduced significantly by the BVS procedure: stable angina 57.1 % to 11.9 %, (p < 0.001) and unstable angina 31 % to 0 %, respectively (p < 0.001). After the one-year follow-up, the MACE rate was 11.9 %. Myocardial infarction occurred in 4.8 % and the need for PCI reintervention in 2.4 % of cases (not influenced by the gender or the age of patients). There were 4 cases of death (all patients were older and had lower values of left ventricular ejection fraction). Conclusion: The results of the current research demonstrated a high interventional success rate of the Absorb BVS implantation, followed by the early improvement of the anginal status. However, that was not translated into the favourable mid-term clinical outcomes, opening debate about the current status of Absorb BVS and the need for future refinements of stent design and implantation techniques.

Chinese primary knee osteoarthritis progression cohort (CPKOPC) to evaluate the progression of knee osteoarthritis in the Beijing population: a prospective cohort study protocol

INTRODUCTION

Millions of patients are currently suffering from pain and dysfunction caused by osteoarthritis (OA), and billions of dollars have been invested into treatment. Because there is no effective treatment that can reverse the progression of knee OA, it is important to determine the risk factors that may influence the progression. However, although there are many studies that examine risk factors for progression, there are only a few that specifically focus on the impact of each risk factor for predicting progression of knee OA. This study aimed to develop a cohort of patients with primary knee OA in the Beijing area to establish models that identify the influence of each risk factor on the prediction of knee OA progression.

METHODS AND ANALYSIS

This is a prospective, multicentre, hospital-based cohort study. The study population comprises 2000 patients with primary knee OA from the Beijing area. The recruitment and baseline visits started in December 2017 and will finish in November 2018. After baseline visits, the patients will be followed for 3 years or until the occurrence of primary outcomes. Demographic variables will be collected during the baseline visit. Influencing factors including occupational exposures, family history and treatment will be collected at baseline and each follow-up visit. The primary outcome measure is a comprehensive index which will be combined with clinical WOMAC score, imaging K-L grade and clinical outcomes. These data will also be collected at baseline and each follow-up visit.

ETHICS AND DISSEMINATION

This study protocol has been approved by Peking University Third Hospital Medical Science Research Ethics Committee. All the eligible participants will give written informed consent. The findings will be published in peer-reviewed journals and presented at national or international conferences. Besides, the results will be disseminated to all participants via the social software 'WeChat'.

TRIAL REGISTRATION NUMBER

ChiCTR-ROC-17013790; preresults.

Major Adverse Cardiovascular Events: An Inevitable Outcome of ST-elevation myocardial infarction? A Literature Review

Major adverse cardiovascular events (MACE) remain the major cause of mortality and morbidity in patients with STEMI (ST-elevation myocardial infarction). The current literature is aimed to analyze the occurrence of MACE following STEMI irrespective of treatment provided, and follow up after the first diagnosis of STEMI. A PubMed search for Studies of STEMI identified 24,244 articles. After applying our inclusion/exclusion criteria, we found out 75 articles of relevance wherein MACE and its components were considered to be the primary endpoint. These 75 articles included eight Cohort Studies, 13 clinical trials including five randomized controlled trials (RCT), one case-control Study, one cross-sectional study, one review article, and 51 other observational studies. Our analysis shows that MACE remains one of the strongest adverse outcomes among STEMI patients. The current literature review found out the incidence of MACE was 4.2 % to 51% irrespective of the mode of treatment, and follow-ups lasting up to 10 years from the time of STEMI diagnosis.

The Comparison between Self-Expanding and Balloon Expandable Stent Results in Left Anterior Descending Artery

The first Wallstent results had high thrombosis and death. It was reported that the left anterior descending (LAD) artery was the vessel implicated in major complications that occurred in patients who received a Wallstent. Subsequently, Wallstent applications were refrained from with LAD lesions. However, the promising results of second-generation self-expanding Magic Wallstent implantation have been reported recently. The purpose of this study is to assess the immediate and intermediate clinical outcomes of patients undergoing self-expanding Magic Wallstent implantation at the LAD site and to compare those outcomes with those of a similar group of patients undergoing balloon expandable stenting at the same site. Between 1995 and 1999, 255 consecutive patients underwent LAD stenting at our center. The study population was divided into two groups based on the mode of delivery (self-expanding versus balloon-expandable) of stent design. Group I included 97 patients in whom self-expanding Magic Wallstents were implanted. Group II included 158 patients in whom various types of balloon-expandable stents were implanted. Procedural success was defined as successful deployment of the stent in the absence of adverse cardiac events (death, acute myocardial infarction, emergency coronary bypass surgery). Clinical success was defined as the absence of adverse cardiac events (death, acute myocardial infarction, emergency coronary bypass surgery, repeat balloon angioplasty) within the first two weeks. The mean follow-up period was 8 +/- 5.3 months for Group I and 9.8 +/- 7.5 months for Group II. There was no difference in baseline characteristics between the two groups. Fourteen patients in Group I and 22 patients in Group II had bailout procedures. The number of patients with reference vessel diameter less than 3 mm was 37 in Group I and 60 in Group II. The stent length was greater in Group I than in Group II (p = 0.0003). In Group I, stenting improved minimal lumen diameter (MLD) from 0.65 +/- 0.4 mm to 2.35 +/- 0.4 and percent diameter stenosis (PDS) from 76.24 +/- 17.3 to 22.78 +/- 13.6. In Group II, stenting improved MLD from 0.73 +/- 0.4 mm to 2.49 +/- 0.5 and PDS from 76.71 +/- 15.5 to 18.99 +/- 9.6. Final MLD and final PDS improved more in Group II than Group I. Stent could not be delivered in three patients in Group I and nine in Group II. In Group II, six stents were dislocated from its delivery system. Procedural and clinical success and subacute stent thrombosis rates were 93.8%, 85.6%, and 7.2% in Group I, and 93%, 86.7%, and 5.1% in Group II, respectively. Within the first two weeks, death occurred in one patient in each group, acute myocardial infarction in four (Group I) and two (Group II) patients; coronary bypass surgery in three (Group I) and five (Group II) patients, and balloon angioplasty in two (Group I) and four (Group II) patients, respectively. In Group I, following the first two weeks, no patients died, two patients had nonfatal myocardial infarction, and coronary bypass surgery and target vessel repeat balloon angioplasty was required in five and ten patients, respectively. In Group II, one patient died in the follow-up period, there was no nonfatal myocardial infarction, and bypass surgery and target vessel repeat balloon angioplasties were required in three and eleven patients, respectively. None of these differences in clinical events was statically significant. We found that self-expanding Magic Wallstent implantation can be performed in LAD lesions and was associated with a rate of early clinical results and intermediate term clinical results similar to that of balloon-expandable stents in LAD arteries. In conclusion, the Magic Wallstent may confidently be used for LAD lesions. </hea

Retrograde embolization during saphenous vein graft angioplasty

Angioplasty of degenerated saphenous vein grafts is not infrequently complicated by distal embolization of atheromatous debris. We describe an uncommon case in which balloon angioplasty of an old vein graft to a second diagonal branch of the left anterior descending coronary artery was followed by distal embolization. However, the embolization occurred in a retrograde fashion distal to the anastomotic site, resulting in occlusion of the upstream first diagonal branch. The reasons for its occurrence are discussed, together with suggestions for its recognition.

Coronary wallstents show significant late, postprocedural expansion despite implantation with adjunct high-pressure balloon inflations

Adjunct high-pressure balloon inflations following the delivery of oversized self-expandable Wallstents may affect their implied late, postprocedural self-expansion. Consequently, we examined 15 "Magic" Wallstents, which were implanted following a strategy of stent oversizing and subsequent adjunct high-pressure balloon inflations (16 +/- 2 atm; all > or = 12 atm). The excellent radiographic visibility of this stent permitted reliable quantitative coronary angiographic measurement of both lumen and stent dimensions (before and after stenting, and at follow-up). At follow-up, extent and distribution of in-stent neointimal proliferation were evaluated with volumetric intravascular ultrasound. Between postintervention and follow-up examination, mean stent diameter increased from 3.7 +/- 0.4 to 4.2 +/- 0.4 mm (p <0.0001); there was no significant difference in late stent expansion between proximal, mid-, and distal stent subsegments. Late stent expansion showed a significant (reverse) relation to maximum balloon size (r = -0.56, p <0.04), but not with follow-up lumen size or late lumen loss. On average, 52 +/- 18% of the stent was filled with neointimal ingrowth; neointimal volume/cm stent length was 64 +/- 22 mm3. Both late stent expansion (r = 0.36, p <0.02) and maximum balloon pressure (r = 0.41, p <0.001) were related to neointimal volume/cm stent but not to follow-up lumen size. Thus, despite high-pressure implantation, Wallstents showed significant late self-expansion, which resulted in larger stent dimensions at follow-up that assisted in accommodating in-stent neointimal proliferation. Conversely, late stent expansion had a significant relation to the extent of in-stent neointimal ingrowth. Beneficial and disadvantageous effects of the late stent expansion appear to be balanced, because a relation to late lumen loss or follow-up lumen dimensions was not found to be present.

Coronary wallstent implantation by the transradial artery approach. A case report

The authors report the implantation of two wallstents in a patient by use of the transradial artery approach. This approach for coronary wallstent implantation allows for intensive anticoagulation therapy with less risk of bleeding.

Endovascular stents: a 'break through technology', future challenges

Coronary stents were developed to overcome the two main limitations of balloon angioplasty, acute occlusion and long term restenosis. Coronary stents can tack back intimal flaps and seal the dissected vessel wall and thereby treat acute or threatened vessel closure after unsuccessful balloon angioplasty. Following successful balloon angioplasty stents can prevent late vessel remodeling (chronic vessel recoil) by mechanically enforcing the vessel wall and resetting the vessel size resulting in a low incidence of restenosis. All currently available stents are composed of metal and the long-term effects of their implantation in the coronary arteries are still not clear. Because of the metallic surface they are also thrombogenic, therefore rigorous antiplatelet or anticoagulant therapy is theoretically required. Furthermore, they have an imperfect compromise between scaffolding properties and flexibility, resulting in an unfavourable interaction between stents and unstable or thrombus laded plaque. Finally, they still induce substantial intimal hyperplasia which may result in restenosis. Future stent can be made less thrombogenic by modifying the metallic surface, or coating it with an antithrombotic agent or a membrane eluting an antithrombotic drug. The unfavourable interaction with the unstable plaque and the thrombus burden can be overcome by covering the stent with a biological conduit such as a vein, or a biodegradable material which can be endogenous such as fibrin or exogenous such as a polymer. Finally the problem of persisting induction of intimal hyperplasia may be overcome with the use of either a radioactive stent or a stent eluting an antiproliferative drug.

Short- and long-term clinical and quantitative angiographic results with the new, less shortening Wallstent for vessel reconstruction in chronic total occlusion: a quantitative angiographic study

OBJECTIVES

This study was designed to examine whether oversized implantation of the new, less shortening Wallstent provides a more favorable long-term clinical and angiographic outcome in chronic total occlusions than does conventional coronary balloon angioplasty.

BACKGROUND

Restenosis and reocclusion remain major limitations of balloon angioplasty for chronic total occlusions. Enforced mechanical remodeling by implantation of the oversized Wallstent may prevent elastic recoil and improve accommodation of intimal hyperplasia.

METHODS

Lumen dimension was measured by a computer-based quantitative coronary angiography system (CAAS II). These measurements (before and after intervention and at 6-month follow-up) were compared between the groups with Wallstent implantation (20 lesions, 20 patients) and conventional balloon angioplasty (266 lesions, 249 patients) for treatment of chronic total occlusion. Acute gain (minimal lumen diameter after intervention minus that before intervention), late loss (minimal lumen diameter after intervention minus that at follow-up) and net gain (acute gain minus late loss) were examined.

RESULTS

Wallstent deployment was successful in all patients. High pressure intra-Wallstent balloon inflation (mean +/- SD 14 +/- 3 atm) was performed in all lesions. Although vessel size did not differ between the Wallstent and balloon angioplasty groups, acute gain was significantly greater in the Wallstent group (2.96 +/- 0.55 vs. 1.61 +/- 0.34 mm, p < 0.0001). Although late loss was also significantly larger in the Wallstent group (0.81 +/- 0.95 vs. 0.43 +/- 0.68 mm, p < 0.05), net gain was still significantly greater in this group (2.27 +/- 1.00 vs. 1.18 +/- 0.69 mm, p < 0.0001). Angiographic restenosis (> or = 50% diameter stenosis) occurred at 6 months in 29% of lesions in the Wallstent group and in 45% of those in the balloon angioplasty group (p = 0.5150).

CONCLUSIONS

Implantation of the oversized Wallstent, with full coverage of the lesion length, ensures resetting of the vessel size to its original caliber before disease and allows greater accommodation of intimal hyperplasia and chronic vessel recoil. Wallstent implantation provides a more favorable short- and long-term clinical and angiographic outcome than does conventional balloon angioplasty for chronic total occlusions.

Long-term clinical outcome after stent implantation in saphenous vein grafts

OBJECTIVES

We sought to determine the role of stent implantation in vein grafts by evaluating the long-term clinical outcome and estimated event-free survival at 5 years in 62 patients and by comparing our data with those of other treatment modalities previously reported.

BACKGROUND

Patients with recurrent angina after coronary artery bypass graft surgery pose a problem. Stent implantation has been advocated in an effort to avoid repeat operation and to address the limitations of balloon angioplasty.

METHODS

Patients undergoing stenting of a vein graft were entered into a dedicated data base. They were screened for death, infarction, bypass surgery and repeat angioplasty. Procedure-related events were included in the follow-up analysis. Survival and event-free survival curves were constructed by the Kaplan Meier method.

RESULTS

A total of 93 stents (84 Wallstent and 9 Palmaz-Shatz) were implanted in 62 patients. During the in-hospital period seven patients (11%) sustained a major cardiac event: two deaths (3%), two myocardial infarctions (3%) and three urgent bypass surgeries (5%). The clinical success rate, therefore, was 89%. During the follow-up period (median 2.5 years, range 0 to 5.9), another five patients (8%) died, 14 (23%) sustained a myocardial infarction, 12 (20%) underwent bypass surgery, and 14 (23%) underwent angioplasty. The estimated 5-year survival and event-free survival rates (free from infarction, repeat surgery and repeat angioplasty) were (mean +/- SD) 83 +/- 5% (95% confidence interval [CI] 73% to 93%) and 30 +/- 7% (95% CI 16% to 44%), respectively.

CONCLUSIONS

The in-hospital outcome of patients who underwent stent implantation in a vein graft is acceptable, but the long-term clinical outcome is poor. It is unlikely that mechanical intervention alone will provide a satisfactory or definite answer for the patient with graft sclerosis over the long term.

Six-month clinical and angiographic outcome of the new, less shortening Wallstent in native coronary arteries

BACKGROUND

The new, less shortening, self-expanding Wallstent is characterized by longitudinal flexibility, a protective membrane, a low profile, and a customized range of diameters (3.5 to 6.0 mm). The recent modification of the braiding angle of the Wallstent has resulted in a new device with less shortening on expansion and a concomitant reduction in radial force. We hypothesized that the enforced mechanical remodeling produced by the selection of an oversized Wallstent might result in improved accommodation of subsequent reactive intimal hyperplasia and prevention of chronic recoil of the vessel.

METHODS AND RESULTS

To prove this hypothesis, we recently implanted 44 new, less shortening Wallstents in 35 native coronary arteries in 35 patients with acute or threatened closure after balloon angioplasty, according to a strategy of oversizing of Wallstent diameter and complete coverage of the lesion length. The initial and 6-month follow-up angiograms were analyzed with a computer-based quantitative coronary angiography (QCA) system. Acute gain (minimal luminal diameter [MLD] post minus MLD pre) and late loss (MLD post minus MLD at follow-up) were examined. Stent deployment was successful in 44 of 44 attempts (100%). Nominal stent diameter used was 1.40 mm larger than the maximal vessel diameter. One patient (3%) with a dilated but unstented lesion proximal to the stented segment sustained a subacute occlusion on day 1 associated with myocardial infarction. Event-free survival at 30 days after stent implantation was 97% (34 of 35 patients). Of the 34 patients eligible for 6-month angiographic follow-up, 3 who were asymptomatic declined repeat angiography. MLD (and percent diameter stenosis [% DS]) changed from 0.83 +/- 0.50 mm (72%) pre through 3.06 +/- 0.48 mm (15%) post to 2.27 +/- 0.74 mm (28%) at follow-up. Acute gain was 2.23 +/- 0.63 mm, and late loss was 0.78 +/- 0.61 mm. Angiographic restenosis ( > 50% DS) was observed in 5 of 31 patients (16%) at 6 months, all of whom underwent repeat angioplasty. Thus, the overall event-free survival at 6-month follow-up was 83% (29 of 35 patients).

CONCLUSIONS

The oversized Wallstent implantation with complete coverage of the lesion length conveyed a favorable 6-month clinical and angiographic outcome. The large acute gain obtained by the Wallstent afforded greater accommodation of the subsequent late loss. The enforced mechanical remodeling by oversized new Wallstents may result in prevention of acute and chronic recoil of the vessel wall and subsequently a lower restenosis rate at follow-up.

Optimized expansion of the Wallstent compared with the Palmaz-Schatz stent: on-line observations with two- and three-dimensional intracoronary ultrasound after angiographic guidance

Optimized stent expansion by high-pressure inflations of oversized balloons has initially been derived from experience obtained with the Palmaz-Schatz stent, whereas there is little experience with this strategy in the Wallstent. By using this approach with quantitative coronary angiographic guidance, 20 Wallstents and 20 Palmaz-Schatz stents were implanted in 34 patients and consecutively examined by conventional two-dimensional (2D) intracoronary ultrasound (ICUS) and three-dimensional (3D) ICUS on the basis of the application of a pattern recognition algorithm. Ultrasound criteria of adequate stent expansion were defined as a complete apposition of the stent to the vessel wall, a stent symmetry index (SSI = minimum/maximum lumen diameter) > or = O.7, and a stent-reference lumen area ratio (SRR = Minimum intrastent lumen area/Average of proximal and distal reference lumen area) > or = O.8. In all cases a smooth angiographic lumen and a negative diameter stenosis, on the basis of a distal reference, was achieved. For the Wallstents ICUS showed a higher SSI (2D, 0.95 +/- 0.04 vs 0.85 +/- 0.09; p < 0.001; 3D, 0.90 +/- 0.09 vs 0.82 +/- 0.11, p < 0.05) and a lower SRR (2D, 0.66 +/- 0.12 vs 0.81 +/- 0.13, p < 0.005; 3D, 0.63 +/- 0.14 vs 0.74 +/- 0.15, p < 0.05) than for the Palmaz-Schatz stents. Ninety percent of failure in meeting these criteria resulted from a low SRR. The incidence of incomplete stent apposition (one in both stents) or SSI <0.7 was low and generally associated with an SRR <0.8. The Wallstents met the ICUS criteria less often (2D, 2(1O%) vs 10(50%), p < 0.01; 3D, 3(15%) vs 9(45%), p < 0.05), were significantly longer (35.1 +/- 7.7 mm and 14.3 +/- 3.3 mm, p < 0.0001), and generally demonstrated a larger vessel tapering, measured as proximal minus distal ICUS reference lumen area (1.33 +/- 2.91 mm2 vs 0.44 +/- 1.97 mm(2), not significant). Wallstents meeting the ICUS criteria, however, showed less vessel tapering (0.18 +/- 1.64 mm(2)). Thus optimized stent expansion was followed by excellent angiographic results for both Palmaz-Schatz and Wallstent. Although angiographic results and visual assessment of the ICUS examination suggested a good outcome, few Wallstents met the ICUS criteria in contrast to the Palmaz-Schatz stents. The low value of the SRR in the Wallstents is likely to be caused by vessel tapering, suggesting that this criterion may be unsuitable in assessing the adequacy of the expansion of relatively long stents such as the Wallstent.