Isolated coronary ostial stenosis associated with coronary vasospasm

String-sign in left internal thoracic artery is associated with regression in left main trunk stenosis after coronary artery bypass

The left internal thoracic artery (LITA) is the conduit of choice for coronary artery bypass (CABG) due to favorable long-term patency. Uncommonly, diffuse narrowing like a string without significant stenosis of an anastomosis is observed in the LITA graft (called "string sign"). Isolated left main trunk (LMT) diseases were reported to regress in some cases. However, the relationship between "string sign" and the regression of solitary LMT disease remains unknown.We retrospectively studied 40 consecutive patients with isolated LMT stenosis who underwent CABG using LITA and who underwent angiography before and after operation (31 males, 9 females, mean age, 65.0 years). The patients were divided into 2 groups according to the postoperative angiographic outcomes of the LITA graft: one group included patients with "string sign" (6 patients), the other group consisted of patients with a patent LITA graft (34 patients).There were no significant differences in clinical backgrounds between the two groups. The 2 groups showed similar quantitative % coronary artery stenosis of the LMT before operation (77.5% versus 76.8%) and the observation period was similar in both groups. Coronary angiography after CABG revealed that % stenosis of the LMT in patients with "string sign" was significantly less than that in patients with a patent LITA graft (41.7 ± 26% versus 82.5 ± 11%, P < 0.001). Regression in LMT was significantly more frequently observed in the "string sign group". Furthermore, ostial stenosis was more frequent in patients with "string sign". "String phenomenon" of the LITA graft is one of the signs related to the regression of LMT stenosis, and especially in ostial stenosis of the LMT.

Long-term clinical and angiographic follow-up in patients with isolated ostial stenosis of the left coronary artery

BACKGROUND

Isolated ostial stenosis (IOS) of the left coronary artery is a rare disease of unknown etiology, and the long-term prognosis and angiographic characteristics of affected patients have not been fully studied.

METHODS AND RESULTS

The present study investigated 57 patients with stenosis of the left main trunk (LMT) who underwent coronary artery bypass grafting (CABG). They were categorized into 3 groups, based on the angiographic findings: Group I comprised 9 patients with IOS; Group II comprised 12 patients with left coronary ostial stenosis in the presence of distal vessel obstructions; Group III comprised 36 patients with stenosis of LMT excluding ostial stenosis and associated with distal vessel obstruction. The patients underwent serial angiography at 1, 5, and 10 years after CABG. Middle aged women with fewer coronary risk factors were more common in Group I compared with Groups II and III (P<0.01). The patency rate of the internal thoracic artery grafts was significantly higher in Groups II and III than in Group I (P<0.05). In Group I, the percentage stenosis of LMT lesions decreased significantly (P<0.05), but there was no difference in the other groups.

CONCLUSIONS

IOS had clinical characteristics and time course distinct from those of atherosclerotic LMT disease.

Localized versus systemic vasculitis: diagnosis and management

Localized vasculitis restricted to a specific anatomic site or organ is often histologically indistinguishable from more severe, systemic forms of vasculitis. By definition, localized vasculitis involves blood vessels within a confined vascular distribution or single organ without clinical evidence of generalized inflammation. Important factors that determine treatment and prognosis, in what appears initially to be a localized process, include histopathologic type, organ site, and the presence of systemic inflammatory markers and symptoms. The major issue is whether single organ vasculitis is actually an isolated form of the disease in which case surgical excision is curative, or whether the single organ involvement is simply a precursor of more threatening systemic vasculitis. The Birmingham Vasculitis Activity Score is a valuable tool to identify those patients with concurrent systemic involvement. The physician's recognition of a localized versus systemic vasculitic process is important in terms of making the correct diagnosis, prescribing treatment, and arranging appropriate clinical follow-up.

Comparison of cutting balloon vs stenting alone in small branch ostial lesions of native coronary arteries

Angioplasty of small vessels is associated with a higher rate of restenosis, even in the ostium. The present study compared the acute, late results of cutting balloon vs those of stenting alone in small branch ostial lesions of native coronary arteries and the effect on the parent vessel. The study group comprised 61 patients with successful angioplasty of smaller branch ostial lesions in native coronary arteries. The reference vessel diameter was between 2.5 and 3.0 mm. Patients were divided into 2 groups: group I (cutting balloon, n=30) and group II (stenting alone, n=31). After intervention, patients in group II achieved significant acute lumen gain, larger minimal lumen diameter (MLD) and less diameter stenosis. At 3-month follow-up, the MLD and diameter stenosis of the 2 groups were almost identical; however, late loss was lower in group I. At the 6-month follow up, the cumulative restenosis rate was 41% (11/27) in group I compared with 63% (19/31) in group II (p=0.05), and the target lesion revascularization was also lower in the cutting balloon group [29% (8/27) vs 53% (16/30) p=0.05]. In group 1, the MLD of the parent vessel did not change before, after cutting balloon or at follow-up. In contrast, there were significant reductions in parent vessel MLD following stenting alone and at follow-up. Plaque shift did not occur in the cutting balloon group. Cutting balloon angioplasty is a feasible approach for the treatment of small branch ostial lesions and does not cause significant narrowing of the parent vessel.