Impact of diabetes mellitus on clinical outcomes after first episode in-stent restenosis PCI: Results from a large registry

BACKGROUND

Diabetes mellitus (DM) is associated with a high rate of major adverse cardiac events (MACE) after de novo coronary artery percutaneous coronary intervention (PCI). Whether patients with DM undergoing PCI for in-stent restenosis (ISR) experience a similar heightened risk of MACE is not known. Hence, we sought to compare the clinical outcomes of patients with and without DM undergoing PCI for ISR.

METHODS

Patients undergoing first episode ISR PCI between January 2015 and December 2021 were included. The primary outcome of interest was MACE (all-cause death, myocardial infarction [MI], and target lesion revascularization [TVR]) at 1-year.

RESULTS

A total of 3156 patients (56.7% with DM) underwent PCI for ISR during the study period. Patients with DM were younger, more likely to be female, and had a higher prevalence of comorbidities. At 1-year follow-up, DM was associated with a higher rate of MACE (22.4% vs. 18.7%, unadjusted HR 2.03, 95%CI(1.27-3.25), p = 0.003). All-cause mortality and MI were significantly more frequent among people with DM at 1-year follow-up. The rate of TVR was similar in both groups (17.9% vs. 16.0%, unadjusted HR 1.14, 95%CI (0.94-1.37), p = 0.180). On adjusted analysis, there was no significant difference in the rate of MACE (AHR 1.07, 95%CI(0.90 - -1.29), p = 0.444), all-cause death (AHR 1.54, 95%CI(0.93-2.54), p = 0.095) or MI (AHR 1.10, 95%CI(0.74-1.63), p = 0.652).

CONCLUSION

ISR PCI in patients with DM was associated with a higher rate of MACE at 1-year follow-up. However, this increased risk was no longer significant after adjusting for baseline characteristics.

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.

Implantable Self-Reporting Stents for Detecting In-Stent Restenosis and Cardiac Functional Dynamics

Despite the increasing number of stents implanted each year worldwide, patients remain at high risk for developing in-stent restenosis. Various self-reporting stents have been developed to address this challenge, but their practical utility has been limited by low sensitivity and limited data collection. Herein, we propose a next-generation self-reporting stent that can monitor blood pressure and blood flow inside the blood arteries. This proposed self-reporting stent utilizes a larger inductor coil encapsulated on the entire surface of the stent strut, resulting in a 2-fold increase in the sensing resolution and coupling distance between the sensor and external antenna. The dual-pressure sensors enable the detection of blood flow in situ. The feasibility of the proposed self-reporting stent is successfully demonstrated through in vivo analysis in rats, verifying its biocompatibility and multifunctional utilities. This multifunctional self-reporting stent has the potential to greatly improve cardiovascular care by providing real-time monitoring and unprecedented insight into the functional dynamics of the heart.

Integrative bioinformatics analysis identifies APOB as a critical biomarker in coronary in-stent restenosis

Aim: Coronary artery disease (CAD) is a major contributor to the worldwide prevalence of cardiovascular disease. In-stent restenosis (ISR) is a common complication which can lead to stent implantation failure, necessitating repeated intervention and presenting a significant obstacle for CAD management. Methods: To accurately assess and determine the hub genes associated with ISR, CAD databases from the Gene Expression Omnibus were utilized and weighted gene coexpression network analysis was employed to identify key genes in blood samples. Results: APOB was identified as a risk gene for ISR occurrence. Subsequent correlation analysis of APOB demonstrated a positive association with ISR. Clinical validation further confirmed the predictive value of APOB in ISR detection. Conclusion: We have identified APOB as a critical predictive biomarker for ISR in CAD patients.

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.

Long-term clinical outcomes of excimer laser coronary atherectomy for the management of recurrent in-stent restenosis

BACKGROUND

Recurrent in-stent restenosis (ISR) remains a serious problem. Optimal modification of the underlying mechanism during index percutaneous coronary intervention (PCI) is key to prevent ISR. Excimer laser coronary atherectomy (ELCA) has its own indications and is among others used in recurrent ISR in case of stent underexpansion and/or diffuse neointimal hyperplasia. We aimed to assess the long-term clinical outcomes of ELCA for the management of recurrent ISR.

METHODS

A multicenter, retrospective observational study was conducted. Patients with recurrent ISR who were additionally treated with ELCA were included. The primary outcome was major adverse cardiac events (MACE) defined as a composite of cardiovascular death, myocardial infarction, stroke, target lesion revascularization at 12 months, and longer term.

RESULTS

Between 2014 and 2022, 51 patients underwent PCI with the additional use ELCA for recurrent ISR. Primary outcome occurred in 6 patients (11.8%) at 12 months and in 12 patients (23.5%) at a median follow-up of 4 (1-6) years. Technical and procedural success were achieved in 92% and 90% of cases, respectively. Coronary perforation occurred in 2 patients as a result of distal wire perforation, but was not ELCA-related. There were no in-hospital MACE.

CONCLUSIONS

ELCA appears to be a safe method with acceptable long-term results for the management of recurrent ISR.

Drug-coated balloon in the treatment of coronary bifurcation lesions: A hope or hype?

When compared to non-bifurcation lesions, percutaneous coronary intervention in coronary bifurcation lesions is technically demanding and has historically been limited by lower procedural success rates and inferior clinical results. Following the development of drug-eluting stents, dramatically better results have been demonstrated. In most of the bifurcation lesions, the provisional technique of implanting a single stent in the main branch (MB) remains the default approach. However, some cases require more complex two-stent techniques which carry the risk of side branch (SB) restenosis. The concept of leaving no permanent implant behind is appealing because of the complexity of bifurcation anatomy with significant size mismatch between proximal and distal MB which may drive rates of in-stent restenosis and the potential impact of MB stenting affecting SB coronary flow dynamics. With the perspective of leaving lower metallic burden, a drug-coated balloon (DCB) has been utilized to treat bifurcations in both the MB and SB. The author gives an overview of the existing state of knowledge and prospects for the future for using DCB to treat bifurcation lesions.

An Impedance Sensor for Pathologically Relevant Detection of In-Stent Restenosis In Vitro

Cardiovascular disease (CVD) is the biggest cause of death globally. CVD is caused by atherosclerosis which is the accumulation of fatty deposits, often within the fine arteries of the heart or brain. These blockages reduce blood flow and lead to oxygen starvation (ischemia) which can lead to heart attacks and strokes. To treat blocked arteries an implantable device called a stent re-opens the artery to reinstate blood flow to the organ. The stent itself can become blocked over time by cell growth (intimal hyperplasia) which is characterised by excessive smooth muscle cell proliferation. Sensors based on electrical impedance spectroscopy (EIS) embedded in a stent could detect this re-blocking to allow for early intervention. Using platinum interdigitated electrodes on silicon sensor wafers we were able to co-culture different ratios of mouse smooth muscle cells and mouse endothelial cells on these sensors. This mimics the complex, multicellular environment which a stent is found in vivo when undergoing neo-intimal hyperplasia. Trends in the cell impedances were then characterised using the detection frequency and the gradient of change between populations over time which we termed 'Peak Cumulative Gradients (PCG). PCGs were calculated to successfully discriminate each cell type. This work moves towards a sensor that may help guide clinician's decision-making in a disease that is historically silent and difficult to detect. Clinical Relevance-This moves towards an early warning system for the detection of neo intimal hyperplasia ultimately leading to a reduction in stent complications.

In-hospital and 1-Year Outcomes of Repeated Percutaneous Coronary Intervention for In-stent Restenosis With Acute Coronary Syndrome Presentation

BACKGROUND

In-stent restenosis (ISR) is the Achilles' heel of percutaneous coronary intervention (PCI). There have been controversial data about outcomes of repeated PCI (redo-PCI) for ISR. This study aims to determine the predictors of major adverse cardiac events (MACE) in patients underwent redo-PCI for ISR.

METHODS

In this retrospective study, all patients with acute coronary syndrome who were underwent successful PCI for ISR at Tehran Herat Center (between 2004 and 2019) were eligible for inclusion. Patients with moderate to severe valvular heart disease and/or hematological disorders were excluded. Participants were divided into 2 groups based on the occurrence of the MACE [composite of cardiovascular death, myocardial infarction (MI), coronary artery bypass grafting, target vessel revascularization, and target lesion revascularization]; then, the study variables were compared between the 2 groups. Finally, the predictors of MACE were identified using Cox regression analysis.

RESULTS

Of 748 redo-PCI patients (mean age: 65.2 ± 10.1; 71.0% males), 631 patients had met the inclusion criteria. Fifty-four patients (9.8%) developed MACE within a 1-year follow-up period. Multivessel disease, primary PCI, Ad-hoc PCI, history of non-ST-segment elevation MI, and diabetes mellitus were independent predictors for MACE. In a subgroup analysis, 30 patients who experienced third PCI (target lesion revascularization/target vessel revascularization) were followed more as 1-year MACE. Among these patients, 14 MACEs were observed during the last follow-up (till June 2020).

CONCLUSIONS

Multivessel disease, primary PCI, and history of non-ST-segment elevation MI were the predictors of higher 1-year MACE, whereas Ad-hoc PCI and diabetes mellitus had a protective effect on MACE.

Rapidly Progressive Stenosis of the Left Main Trunk Ostium Starting 21 Months After Stent Implantation

Rapidly progressive in-stent restenosis (ISR) after stent deployment from the left main trunk (LMT) to the left anterior descending artery (LAD) without plaque at the LMT ostium has not been reported. A 60-year-old Japanese man with a history of scleroderma, pulmonary fibrosis, and type 2 diabetes developed acute myocardial infarction of the right coronary artery (RCA) and was treated by emergency percutaneous coronary intervention (PCI) for RCA. Nine days later he underwent PCI from the LMT to the LAD. Follow-up coronary angiography (CAG) at 9 and 21 months post-PCI did not reveal ISR in any lesion, but the patient experienced cardiac arrest at 25 months post-PCI. Emergency CAG after resuscitation revealed ISR of the LMT ostium; emergency PCI was conducted. The development of ISR at the ostium of the LMT although the patient was free of plaque 4 months before is extremely unusual. This rare ISR of the LMT ostium progressed rapidly after follow-up CAG revealed no ISR at 21 months post-stent implantation.

Healed neointima of in-stent restenosis lesions in patients with stable angina pectoris: an intracoronary optical coherence tomography study

The phenomenon to heal neointimal rupture or thrombus after coronary stenting occurs as well as in native coronary artery. We investigated clinical characteristics and neointimal vulnerability of healed neointima by optical coherence tomography (OCT). We treated 67 lesions by percutaneous coronary intervention for in-stent restenosis (ISR) and conducted OCT examinations. Healed neointima was defined as neointima having one or more layers with different optical densities and a clear demarcation from underlying components. ISR with healed neointima was found in 49% (33/67) of the lesions. Compared to ISR without healed neointima, ISR with healed neointima showed significantly longer stent age (102 ± 72 vs. 31 ± 39 months, P < 0.001), lower frequency of dual antiplatelet therapy [42% (14/33) vs. 74% (25/34), P = 0.017], lower use of angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (ACE-I or ARB) [61% (20/33) vs. 91% (31/34), P = 0.028], lower usage of second-generation drug-eluting stents (DESs) [36% (12/33) vs. 63% (22/34), P = 0.029], higher usage of thick-strut stents [42% (14/33) vs. 15% (5/34), P = 0.012], larger neointimal area (6.8 ± 2.6 vs. 5.2 ± 1.8 mm², P = 0.005), higher incidence of thin-cap fibroatheroma [58% (19/33) vs. 21% (7/34), P = 0.002], neointimal rupture [45% (15/33) vs. 9% (3/34), P = 0.001], and lower incidence of stent underexpansion [15% (5/33) vs. 44% (15/34), P = 0.010]. In conclusions, ISR with healed neointima was associated with neointimal vulnerability, stent age, stent type, stent strut thickness, stent expansion, antiplatelet therapy, and use of ACE-I or ARB.

In-Stent Restenosis in Saphenous Vein Grafts (from the DIVA Trial)

Saphenous vein grafts (SVGs) have high rates of in-stent restenosis (ISR). We compared the baseline clinical and angiographic characteristics of patients and lesions that did develop ISR with those who did not develop ISR during a median follow-up of 2.7 years in the DIVA study (NCT01121224). We also examined the ISR types using the Mehran classification. ISR developed in 119 out of the 575 DIVA patients (21%), with similar incidence among patients with drug-eluting stents and bare-metal stents (BMS) (21% vs 21%, p = 0.957). Patients in the ISR group were younger (67 ± 7 vs 69 ± 8 years, p = 0.04) and less likely to have heart failure (27% vs 38%, p = 0.03) and SVG lesions with Thrombolysis In Myocardial Infarction 3 flow before the intervention (77% vs 83%, p <0.01), but had a higher number of target SVG lesions (1.33 ± 0.64 vs 1.16 ± 0.42, p <0.01), more stents implanted in the target SVG lesions (1.52 ± 0.80 vs 1.31 ± 0.66, p <0.01), and longer total stent length (31.37 ± 22.11 vs 25.64 ± 17.42 mm, p = 0.01). The incidence of diffuse ISR was similar in patients who received drug-eluting-stents and BMS (57% vs 54%, p = 0.94), but BMS patients were more likely to develop occlusive restenosis (17% vs 33%, p = 0.05).

Paclitaxel Drug-Coated Balloon for the Treatment of De Novo Small-Vessel and Restenotic Coronary Artery Lesions: 12-Month Results of the Prospective, Multicenter, Single-Arm PREVAIL Study

OBJECTIVES

The PREVAIL study evaluated the safety and effectiveness of a paclitaxel-coated percutaneous transluminal coronary angioplasty balloon catheter for the treatment of coronary de novo and in-stent restenosis (ISR) lesions in patients with symptomatic ischemic heart disease.

METHODS

PREVAIL was a prospective, multicenter, single-arm study that enrolled patients with clinical evidence of ischemia who had coronary lesions (de novo or first ISR) amenable to treatment with a drug-coated balloon (DCB). The study included 50 subjects (53 target lesions) who were treated with a Prevail DCB (Medtronic) during the index procedure and followed for 12 months. Mean lesion length was 14.5 ± 7.6 mm. The primary endpoint was in-stent (in-balloon) late lumen loss (LLL) by quantitative coronary angiography at 6 months post procedure. If the mean in-stent (in-balloon) LLL was less than the maximum acceptance rate of 0.50 mm at 6 months, then the study was considered successful.

RESULTS

Mean in-stent (in-balloon) LLL was 0.05 ± 0.44 mm at 6 months post procedure. There were no deaths, myocardial infarctions, or stent (lesion) thrombosis events within 12 months. The incidence of clinically driven target-lesion revascularization was 6.0% at 12 months and clinically driven target-vessel revascularization was 10.0%.

CONCLUSIONS

Paclitaxel DCB treatment of coronary de novo and first ISR lesions led to low LLL at 6 months and low rates of revascularization and safety events through 12 months.

One-year performance of thin-strut cobalt chromium sirolimus-eluting stent versus thicker strut stainless steel biolimus-eluting coronary stent: a propensity-matched analysis of two international all-comers registries

OBJECTIVES

Recent improvements in coronary stent design have focussed on thinner struts, different alloys and architecture, more biocompatible polymers, and shorter drug absorption times. This study evaluates safety and efficacy of a newer generation thin-strut cobalt chromium sirolimus-eluting coronary stent (SES, Ultimaster) in comparison with a second-generation thicker strut stainless steel biolimus-eluting stent (BES, Nobori) in percutaneous coronary intervention (PCI) practice.

METHODS

A propensity score analysis was performed to adjust for differences in baseline characteristics of 8137 SES patients and 2738 BES patients of two PCI registries (e-Ultimaster and NOBORI 2). An independent clinical event committee adjudicated all endpoint-related adverse events.

RESULTS

The use of SES, as compared with BES was associated with a significantly lower rate of myocardial infarction (MI) (1.2% vs 2.2%; P = 0.0006) and target vessel-related MI (1.1% vs 1.8%; P = 0.002) at 1 year. One-year composite endpoints of all predefined endpoints were lower in patients undergoing SES implantation (target lesion failure: 3.2% vs 4.1%; P = 0.03, target vessel failure: 3.7% vs 5.0%; P = 0.003, patient-oriented composite endpoint 5.7% vs 6.8%; P = 0.03). No significant differences between SES and BES were observed in all-cause death (2.0% vs 1.6%; P = 0.19), cardiac death (1.2% vs 1.2%; P = 0.76) or stent thrombosis (0.6% vs 0.8%; P = 0.43).

CONCLUSIONS

These findings suggest an improved clinical safety and efficacy of a newer generation thin-strut SES as compared with a second-generation thicker strut BES.

First report of intravascular ultrasound-guided intravascular lithotripsy to treat an underexpanded stent in the superficial femoral artery

BACKGROUND/OBJECTIVE

To evaluate the safety and utility of a new in Europe intravascular ultrasound (IVUS) catheter in a case of peripheral arterial disease caused by in-stent restenosis of the superficial femoral artery.

METHOD

Pre-therapeutic computed tomographic angiography identified severe stent restenosis related to device underexpansion, which was caused by an underlying eccentric severely calcified stenosis leading to suboptimal device deployment. The OptiCross 18 (30 MHz Peripheral Imaging Catheter, Boston Scientific, USA) is a short rail imaging catheter. It consists of two main assemblies: The imaging core is composed of a hi-torque, flexible, rotating drive cable with a radial looking 30 MHz ultrasonic transducer at the distal tip. An electro-mechanical connector interface at the proximal end of the catheter makes the connection to the Motordrive Unit (MDU5 PLUSTM) Instrument. The MDU5 PLUS-catheter interface consists of an integrated mechanical drive socket and electrical connection.

RESULTS

The use of the IVUS-guided imaging revealed in-stent restenosis, fracture, and protrusion of the calcified plaque in the stent and confirmed the preoperative computed tomography angiography which showed stent compression. Use of intravascular litotripsy catheter (intravascular lithotripsy Shockwave Medical, Santa Clara, California) and drug coated balloon led to improvement in stent expansion, having minimal patent diameter of 5.77 mm. The patient's subsequent clinical course was uneventful, and clinically had palpable pulses in the foot and ankle-brachial index of 1.

CONCLUSIONS

Whether acoustic pulse application might affect device structure in the long term remains to be determined, use of the novel IVUS system demonstrated excellent visibility of the etiology of the in-stent restenosis improving the perioperative diagnostic modalities of suboptimal endovascular outcome.

Predictive value of inflammatory factors on coronary restenosis after percutaneous coronary intervention in patients with coronary heart disease: A protocol for systematic review and meta-analysis

BACKGROUND

Evidence reveals that inflammatory factors can predict coronary restenosis in patients suffering from coronary heart disease (CHD) after percutaneous coronary intervention (PCI). Perhaps, inflammatory factors are promising biomarkers for the diagnosis of coronary restenosis after PCI. However, the accuracy of inflammatory factors has not been systematically evaluated. Therefore, it is necessary to perform a meta-analysis to certify the diagnostic values of inflammatory factors on coronary restenosis after PCI.

METHODS

China National Knowledge Infrastructure (CNKI), Wanfang, VIP, China Biology Medicine disc (CBM), PubMed, EMBASE, Cochrane Library and Web of Science were searched for relevant studies to explore the potential diagnostic values of inflammatory factors on coronary restenosis after PCI from inception to January 2021. All data were extracted by 2 experienced researchers independently. The risk of bias about the meta-analysis was confirmed by the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). The data extracted were synthesized and heterogeneity was investigated as well. All of the above statistical analyses were carried out with Stata 16.0.

RESULTS

The results of this meta-analysis will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This study clarified confusions about the specificity and sensitivity of inflammatory factors on coronary restenosis after PCI, thus further guiding their promotion and application.

ETHICS AND DISSEMINATION

Ethical approval will not be necessary since this systematic review and meta-analysis will not contain any private information of participants or violate their human rights.

TRIAL REGISTRATION NUMBER

DOI 10.17605/OSF.IO/N28JX.

Comparison of rotational atherectomy and modified balloons prior to drug-eluting stent implantation for the treatment of heavily calcified coronary lesions

The optimal strategy for lesion preparation in heavily calcified coronary lesions (HCCL) prior to drug-eluting stent (DES) implantation remains debatable. This study sought to compare the performance of rotational atherectomy (RA) and modified balloon (MB)-based strategy in patients with HCCL receiving current-generation DES.This retrospective study comprised 564 consecutive patients who underwent RA (n = 229) or MB (n = 335) for HCCL at our hospital and were treated with DES. Baseline clinical and angiographic data was obtained from our database. Patients were clinically monitored for the occurrence of any adverse events during the hospitalization. One-year follow-up was conducted by either telephone contact or outpatient visits. 1:1 propensity score matching (PSM) was performed to balance the baseline covariates. After PSM, the clinical outcomes between the 2 groups were compared.After PSM, except more target lesion in right coronary artery existing in the RA group (P = .008), no significant statistical differences were shown in regard of the other angiographic and procedural characteristics of the 2 groups. Strategy success rates were all 100% in both groups. In the unadjusted Cox proportional hazard analysis, participants with RA had a significantly lower risk of target lesion revascularization (TLR) (hazard ratio, HR 0.275, 95% confidence intervals, CI 0.119-0.635, P = .003) and major adverse cardiac event (MACE) (HR 0.488, 95% 0.277-0.859, P = .013). After adjusting for potential confounding variables, RA was significantly associated with TLR (HR 0.32, 95% 0.12-0.853, P = .023), but no longer significantly associated with MACE (HR 0.674, 95% 0.329-1.381, P = .282).In patients with HCCL, lesion preparation with RA was safe and could improve strategy success rate. There was lower rate of TLR with RA, however, no significant difference was found in the MACE rate at 1-year follow-up between RA and MB-based strategy.

Intravascular Ultrasound-Guided Coronary Lithotripsy Treatment of In-Stent Restenosis in Saphenous Venous Graft

To the best of our knowledge, this is the first description of intravascular-ultrasound guided coronary lithotripsy on saphenous vein graft because of severely calcific in-stent restenosis, showing good result without procedural complications.

Drug-Eluting Balloon for Management of Coronary In-Stent Restenosis in a South Asian Population: Experience From a Tertiary-Care Hospital in Pakistan

BACKGROUND

Emerging evidence suggests that the South Asian (SA) population has an increased rate of in-stent stenosis (ISR) after percutaneous coronary intervention (PCI) when compared with other ethnicities. Drug-eluting balloons (DEBs) have emerged as a viable option for the treatment of ISR. However, data describing the outcomes of DEB-PCI in the SA population are limited. Since the magnitude of the problem is high in the SA population, it is essential to evaluate the outcomes of DEB-PCI for ISR.

METHODS

In this cohort study, we investigated the incidence of target-lesion revascularization (TLR) and major adverse cardiac event (MACE) after PCI with DEB for ISR at 1 year and at long-term follow-up in Pakistani patients. From January 2010 to January 2019, a total of 147 ISR lesions in 112 patients were treated with DEB-PCI at our center.

RESULTS

The incidence of clinically driven TLR and MACE after a 1-year follow-up was 15.2% and 16.1%, respectively. At mean long-term follow-up of 2.73 ± 2.14 years, the TLR and MACE rates were 26.8% and 35.7%, respectively. The major predictors for TLR were diffuse and occlusive ISR types, DEB for a recurrent restenosis lesion, and the presence of ≥3 traditional cardiovascular disease risk factors.

CONCLUSIONS

The high rates of follow-up TLR and MACE reported in this study may suggest that the outcomes of DEB-PCI for ISR in the SA population may be unsatisfactory. With the increasing use of DEBs, it is imperative to further investigate DEB-PCI outcomes in the SA population with large, prospective studies.

Intravascular Lithotripsy for the Treatment of Calcium-Mediated Coronary In-Stent Restenoses

BACKGROUND

Coronary intravascular lithotripsy (IVL) has recently been evaluated for the treatment of severely calcified native coronary lesions. Evidence for its use in in-stent restenosis is sparse and is still an off-label indication. Therefore, we aimed to evaluate the feasibility, safety, and acute and mid-term angiographic outcomes after IVL for the treatment of calcium-mediated coronary in-stent restenosis.

METHODS

A retrospective, single-center analysis was performed for 6 cases with undilatable instent restenosis due to calcium-mediated stent underexpansion and/ or calcified neointima from January to November 2019. Lesions were treated with IVL (Shockwave Medical) and subsequent drug-eluting stent or drug-coated balloon. Angiographic success was defined as residual lumen stenosis <20% and Thrombolysis in Myocardial Infarction 3 flow. Follow-up angiography was performed at a median of 141.5 days.

RESULTS

Six patients presented with symptomatic in-stent restenoses (65.8% to 87.9%) at 11 to 175 months after implantation. Intravascular and angiographic imaging detected calcium-mediated stent underexpansion (n = 2), calcified neointima (n = 2), or a combination of both (n = 2) as cause of restenosis. In-stent IVL, subsequent high-pressure balloon dilation, and drug-eluting stent or drug-coated balloon implantation were performed successfully in all cases. Acute angiographic success and angina relief were achieved in 5 of 6 cases and sustained during follow-up. No major acute cardiovascular events occurred.

CONCLUSIONS

The application of IVL for the treatment of calcium-mediated coronary in-stent restenosis was feasible and safe, and yielded promising short- and mid-term results in the majority of cases.

Percutaneous Coronary Intervention With the Agent Paclitaxel-Coated Balloon: A Real-World Multicenter Experience

BACKGROUND

The Agent paclitaxel-coated balloon is a new drug-coated balloon (DCB) with few available real-world data. Our study sought to assess the safety and efficacy of the Agent DCB during percutaneous coronary intervention (PCI) in different coronary lesion types in a prospective registry.

METHODS AND RESULTS

All patients undergoing PCI with the Agent DCB at three Italian centers between September 2014 and March 2018 were included in this registry. Major adverse cardiac event (MACE) rate was defined as the composite of cardiac death, recurrent non-fatal myocardial infarction (MI), and target-lesion revascularization (TLR). Procedural success was also evaluated. Among the 354 patients included in the registry (450 lesions treated with 508 DCBs), Agent DCBs were used for the treatment of in-stent restenosis (ISR) in 34%, small-vessel disease (SVD) in 29%, bifurcation lesions in 26%, and "stent-like result" (SLR) lesions obtained after balloon predilation in 11%. The implantation of Agent DCBs was safe and had a high DCB lesion success rate of 92%. One-year MACE rate was 5.7% in the overall population. A higher MACE rate was observed in the ISR group (8.3%) vs the SVD group (3.6%; P=.03), with a trend toward higher event rates vs both BL (3.7%; P=.09) and SLR patients (5.5%; P=.54).

CONCLUSIONS

The use of Agent DCBs during PCI appears safe and effective in a large real-world registry. These results were maintained in all subgroups, with a slightly higher trend of events rates in the ISR setting, consistent with the higher-risk nature of this patient subset.

Impact of Side-Branch Predilation on Angiographic Outcomes in Non-Left Main Coronary Bifurcation Lesions

BACKGROUND

Despite the high prevalence of coronary bifurcation lesions in routine interventional cardiology practice, the best strategy for managing this challenging lesion subset remains debatable. Due to potential for complications, the routine practice of side-branch (SB) predilation is controversial.

METHODS

An electronic search was performed of online databases up until April 2018 for studies reporting periprocedural angiographic outcomes comparing provisional main-branch stenting with and without SB predilation. Random-effects model odds ratios (ORs) were calculated.

RESULTS

Eight studies were selected for a qualitative review, with 47.3% (1367/2890) of included subjects having angiographic outcomes following SB predilation reported. Of these, four studies included details of periangiographic outcomes comparing two groups. Bifurcation lesions stented without SB predilation demonstrated lower odds of requiring further SB intervention compared with lesions receiving upfront SB predilation (OR, 2.44; 95% confidence interval [CI], 1.71-3.47; I²=21%; P<.001). No difference was demonstrated regarding final SB TIMI flow <3, SB dissection, or intraprocedural SB occlusion. Although the odds of performing final kissing-balloon inflation were in favor of the group without SB predilation (OR, 1.62; 95% CI, 1.11-2.37; I²=61%; P=.01), there was no statistical difference in long-term major cardiovascular outcome (MACE) between the two groups (risk ratio, 1.29; 95% CI, 0.94-1.75; I²=11%; P=.33).

CONCLUSION

SB predilation during coronary bifurcation percutaneous coronary intervention did not alter overall procedural angiographic outcomes. However, SB predilation is associated with increased SB intervention, including increased requirement for SB stenting, without demonstrable long-term MACE benefit, compared with a standard strategy without SB predilation.

Longitudinal Stent Deformation: Precise Diagnosis With Optical Coherence Tomography

Longitudinal stent deformation is a recognized complication of coronary angioplasty; however, it is difficult to detect angiographically. This case illustrates the value of OCT to identify and correctly diagnose longitudinal stent deformation.

Coronary Stent Fracture: Still a Cause of Stent Failure

In the present case, multimodality images facilitated our understanding of the mechanism behind the patient's restenosis; a technique using optical coherence tomography with three-dimensional reconstruction allowed the clear identification and extent of stent fracture as well as its subsequent optimal treatment.

A Long-Term Single-Center Registry of 6893 Patients Undergoing Elective Percutaneous Coronary Intervention With the Xience Everolimus-Eluting Stent

BACKGROUND

The safety and effectiveness of the everolimus-eluting stent (EES) have been previously demonstrated.

AIMS

To assess very long-term performance and outcomes of the EES in a real-world population.

METHODS

This single-center registry prospectively enrolled 6893 patients (mean age, 66 ± 9.7 years; 81.4% men) undergoing elective coronary intervention with the EES over a decade. Clinical follow-up (FU) was performed at 1 year and then yearly thereafter.

RESULTS

Multiple risk factors were present in 34%. Stable angina was the main stenting indication (78.1%), followed by unstable angina (5.3%) and positive stress test (16.6%) for 1-vessel (44%) or 2/3-vessel disease (56%). Multiple stents (stent/patient ratio: 2.1 ± 0.8) in >1 vessel were implanted in 36.9% (mean stent length, 43 ± 31.3 mm). At 1 year, 80% of patients were on dual-antiplatelet therapy, while only 3% were on therapy at 2 years. A low 1-year major adverse cardiac event (MACE) rate of 5.0% was observed; stent thrombosis (ST) occurred in 19 patients (0.3%), with a prevalence of early (n = 9) over late (n = 4) and very late events (n = 6; 0.08%). Clinically driven target- lesion revascularization/target-vessel revascularization (TLR/TVR) occurred in 3.3% at 1-year follow-up. Long-term FU (3 years) completed in 6210 patients (90.0%) showed a MACE rate of 5.9%, while very long-term FU (>5 years and up to 10 years), available in 3550 out of 4635 exposed patients (76.6%), showed a MACE rate of 8.6%. Independent MACE predictors were stented segment length (odds ratio [OR], 2.1; 95% confidence interval [CI] 1.57-2.82), small vessel stenting (OR, 1.34; 95% CI, 1.08-1.68), and multivessel disease (2-vessel disease: OR, 1.59; 95% CI, 1.21-2.08; 3-vessel disease: OR, 2.26; 95% CI, 1.72-2.97).

CONCLUSIONS

This large, prospective registry confirms the very long-term safety and efficacy of the EES in unselected real-world and complex coronary lesions.

Treatment of Drug-Eluting Stent In-Stent Restenosis With Drug-Eluting Balloons: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the efficacy of drug-coated balloon (DEB) for the treatment of drug-eluting stent (DES) in-stent restenosis (ISR).

METHODS

A comprehensive literature search was performed. The primary outcome was the composite of death, myocardial infarction (MI), and target-lesion revascularization (TLR) at longest available follow-up (range, 12-36 months). Outcomes for DEB vs balloon angioplasty (BA) and DEB vs DES were analyzed separately using a random-effect Mantel-Haenszel model, as per an a priori protocol.

RESULTS

The study cohort comprised 1526 patients (746 DEB, 537 DES, 243 BA). DEB was associated with lower composite outcome compared with BA alone (19% vs 47%; risk ratio [RR], 0.31; 95% confidence interval [CI], 0.11-0.84; P=.02), driven primarily by lower TLR (17% vs 34%; RR, 0.66; 95% CI, 0.46-0.95; P=.03), with no difference in death or MI. There was no difference in the composite outcome between DEB and DES (20% vs 17%; RR, 1.2; 95% CI, 0.82-1.74; P=.35); DEB was associated with higher TLR (17.4% vs 11.3%; RR, 1.48; 95% CI, 1.08-2.03; P=.01), but lower all-cause mortality (2.2% vs 5.7%; RR, 0.43; 95% CI, 0.22-0.82; P=.01), with no difference in MI or stent thrombosis.

CONCLUSIONS

DEB was associated with a lower TLR rate than BA alone, but associated with a higher TLR rate than implantation of another DES. However, additional DES use was associated with an increase in mortality, a finding that requires further investigation.

Diagnostic accuracy of coronary CT angiography performed in 100 consecutive patients with coronary stents using a whole-organ high-definition CT scanner

AIMS

To evaluate image quality, interpretability, diagnostic accuracy and radiation exposure of coronary CT angiography (CCTA) performed with a new scanner equipped with 0.23-mm spatial resolution, new generation iterative reconstruction, 0.28-second gantry rotation time and intra-cycle motion-correction algorithm in consecutive patients with coronary stents, including those with high heart rate (HR) and atrial fibrillation (AF).

MATERIALS AND METHODS

We enrolled 100 consecutive patients (85 males, mean age 65 ± 10 years) with previous coronary stent implantation scheduled for clinically indicated non-emergent invasive coronary angiography (ICA). Image quality, coronary interpretability and diagnostic accuracy vs. ICA were evaluated and the effective dose (ED) was recorded.

RESULTS

Mean HR during the scan was 67 ± 13 bpm. Twenty-six patients had >65 bpm HR during scanning and 13 patients had AF. Overall, image quality was high (Likert = 3.2 ± 0.9). Stent interpretability was 95.8% (184/192 stents). Among 192 stented segments, CCTA correctly identified 22 out of 24 with >50% in-stent restenosis (ISR) (sensitivity 92%). In a stent-based analysis, specificity, positive and negative predictive values and diagnostic accuracy for ISR detection were 91%, 99%, 60% and 91%, respectively. In a patient-based analysis, CCTA diagnostic accuracy was 85%. Overall, mean ED of CCTA was 2.4 ± 1.2 mSv.

CONCLUSIONS

A whole-organ CT scanner was able to evaluate coronary stents with good diagnostic performance and low radiation exposure, also in presence of unfavorable HR and heart rhythm.

TRANSLATIONAL ASPECT

The present study is the first to evaluate the CCTA capability of detecting in-stent restenosis in consecutive patients, including those with high HR and AF, using a recent scanner generation that combines improved spatial and temporal resolution with wide coverage. Using the whole-organ high-definition CT scanner we obtained high quality images of coronary stents with good interpretability and diagnostic accuracy combined with low radiation exposure, even in patients with unfavorable HR or heart rhythm for CCTA evaluation.

An Impressive Case of "Honeycomb" In-Stent Restenosis

Our image shows an impressive "honeycomb" pattern of neoatherosclerosis in the context of very late in-stent restenosis. In this case, OCT excluded the most common mechanisms of late in-stent restenosis, underlying the complexity of this unpredictable disease.

Management of a Balloon Shaft Fracture During Subintimal Retrograde Chronic Total Occlusion Percutaneous Coronary Intervention Due to In-stent Restenosis

Balloon shaft fracture can be challenging to treat in the setting of retrograde CTO-PCI with guidewire externalization; withdrawal of the guide catheter may allow successful removal of the balloon shaft fragment.

Percutaneous coronary intervention of lesions with in-stent restenosis: A report from the ADAPT-DES study

BACKGROUND

There is a paucity of data from large contemporary cohorts of patients with in-stent restenosis (ISR) treated with drug-eluting stents (DESs), and no studies have examined the impact of high platelet reactivity (HPR) on the occurrence of ischemic events after ISR percutaneous coronary intervention (PCI) with DESs. We sought to report outcomes after PCI of ISR lesions and its association with HPR.

METHODS

Patients in the prospective, multicenter ADAPT-DES study were stratified according to whether they had ISR versus non-ISR PCI. Two-year outcomes were compared between the groups using Cox proportional hazards models. HPR was defined as on-clopidogrel P2Y12 platelet reaction units >208 as measured by the VerifyNow assay; target vessel failure (TVF) was defined as the composite of all-cause death, myocardial infarction, or ischemia-driven target vessel revascularization.

RESULTS

Among the 8,582 patients included in the ADAPT-DES study, 840 (9.8%) patients underwent successful ISR PCI. ISR PCI was independently associated with a higher 2-year risk of TVF (adjusted hazard ratio [HR] 1.95; 95% CI 1.68-2.27; P<.001) and stent thrombosis (adjusted HR 1.95; 95% CI 1.08-3.51; P=.027) but not bleeding (adjusted HR 0.94; 95% CI 0.73-1.21; P=.64). There was no statistical interaction between HPR and ISR versus non-ISR PCI in regard to TVF (adjusted P_interaction=.81).

CONCLUSIONS

ISR PCI is associated with a considerably higher risk of 2-year adverse ischemic events, with HPR conferring similar risk in ISR and non-ISR PCI. More effective therapeutic strategies for managing ISR lesions are necessary.

Lower Repeat Revascularization Rates Among Patients With Prior Coronary Artery Bypass Graft Surgery are Due to Lack of Adequate Target Vessels

BACKGROUND

Studies comparing percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery in patients with multivessel coronary artery disease (CAD) have shown lower repeat revascularization rates in patients who undergo CABG. The reason remains unclear.

METHODS

We identified patients with multivessel CAD who received CABG or PCI enrolled in the Duke Databank for Cardiovascular Disease (2003 to 2012). We compared the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) between the two groups. Clinically performed follow-up angiograms for CABG patients were reviewed to determine adequacy of intervenable targets.

RESULTS

A total of 1555 patients were included: 861 underwent PCI and 694 underwent CABG. Patients with index PCI were more often female, African-American, presented with ST-elevation myocardial infarction (MI), and had previous MI; they were less often diabetic and had less heart failure or proximal left anterior descending disease. The adjusted hazard ratio of MACCE for CABG vs PCI was 0.68 (95% confidence interval, 0.58-0.80; P<.001). The adjusted odds ratio for repeat revascularization for CABG vs PCI was 0.45 (95% confidence interval, 0.28-0.72; P<.001). Fifty-seven patients with index CABG were found to have ≥1 occluded graft on subsequent angiography without repeat revascularization; 48 patients (6.9%) had inadequate targets for intervention.

CONCLUSION

Among patients with multivessel CAD, repeat revascularization rates are lower among CABG patients compared with PCI patients. However, a high proportion of CABG patients with occluded grafts on repeat angiography lack targets for repeat revascularization. This may partially explain the disparity in repeat revascularization rates and suggests that future comparison studies should additionally assess angiographic outcomes.

One-Year Clinical Outcomes of the Hybrid CTO Revascularization Strategy After Hospital Discharge: A Subanalysis of the Multicenter RECHARGE Registry

OBJECTIVES

Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) has historically been associated with higher event rates during follow-up. The hybrid algorithm and contemporary wiring and dissection re-entry (DR) techniques can potentially improve long-term outcomes after CTO-PCI. This study assessed the long-term clinical outcomes of the hybrid CTO practice, when applied by operators with varying experience levels.

METHODS

We examined the 1-year clinical events after hospital discharge of the RECHARGE population, according to technical outcome and final technique. The primary endpoint was major adverse cardiac event (MACE) rate. Centers that provided ≥90% complete 12-month follow-up were included.

RESULTS

Follow-up data of 1067 out of 1165 patients (92%) were provided by 13 centers. Mean follow-up duration was 362.8 ± 0.9 days. One-year MACE-free survival rate was 91.3% (974/1067). MACE included death (1.9%; n = 20), myocardial infarction (1.4%; n = 15), target-vessel failure (5.9%; n = 63), and target-vessel revascularization (TVR) (5.5%; n = 59). Non-TVR was performed in 6.7% (n = 71). MACE was significantly in favor of successful CTO-PCI (8.0% vs 13%; P=.04), even after adjusting for baseline differences (adjusted hazard ratio, 0.59; 95% confidence interval, 0.36-0.98; P=.04). Other events, including individual MACE components, were comparable with respect to technical outcome and final technique (DR vs non-DR techniques).

CONCLUSIONS

The use of the hybrid algorithm with contemporary techniques by moderate to highly experienced operators for CTO-PCI is safe and associated with a low 1-year event rate. Successful procedures are associated with a better MACE rate. DR techniques can be used as first-line strategies alongside intimal wiring techniques without compromising clinical outcomes.

Excimer Laser With and Without Contrast for the Management of Under-Expanded Stents

Under-expanded and under-deployed stents carry a high risk of restenosis and thrombosis, with inherent serious clinical complications. The management of under-expanded stents is a difficult clinical entity.

METHOD

A retrospective analysis of prospectively collected data on all under-expanded, under-deployed stents that were managed by excimer laser, with and without contrast, performed at the Freeman Hospital, a large tertiary cardiac center, in the northeast of England.

RESULTS

Between November 2014 and September 2016, a total of 19 cases were treated with excimer laser with or without contrast, with the initial approach done without contrast. All cases were successful with a stepwise energy-level approach. There were no clinical, procedural, or in-hospital complications, with full expansion of the stents after laser application.

CONCLUSION

The use of excimer laser with or without contrast offers a safe and effective method for managing under-expanded and under-deployed stents and potentially avoiding long-term complications of under-expansion.

Embolization of a Large Intracoronary Thrombus During ST-Segment Elevation Myocardial Infarction

Aspiration thrombectomy was performed to retrieve intact thrombus in a 69-year-old woman. Bradycardia and hypotension rapidly resolved. Balloon angioplasty was performed at the site of proximal RCA in-stent restenosis with improved angiographic appearance and TIMI 3 flow in the major branches.

Coronary CT Angiography for In-Stent Restenosis: Diagnosis and Therapeutic Planning

A 64-year-old man presented with previous non-ST elevation myocardial infarction and cardiogenic shock. Due to hemodynamic instability, percutaneous coronary intervention (PCI) was performed with implantation of two everolimus-eluting stents by V-stenting technique to LM-LAD and LM-LCX. After 9 months without symptoms, he developed progressive angina. Non-selective LM coronary angiography was performed due to stents protrusion in the aortic root. A 128-slice dual-source coronary CT angiography showed severe LM-LAD stent underexpansion with critical in-stent restenosis at the proximal third. Two days later, selective angiography and optical coherence tomography depicted stent underexpansion and confirmed the in-stent restenosis. This case is illustrative of the potential role of the complementary use of invasive and non-invasive imaging techniques. The coronary CT angiography was very useful to identify the severity and mechanism of restenosis, and thus guiding the PCI procedure in a case of especially difficult catheterization.

A risk scoring system to predict coronary stent thrombosis

OBJECTIVE

Stent thrombosis (ST) is a potentially life-threatening complication of percutaneous coronary intervention (PCI). We aimed to develop a scoring system to predict the risk of ST following PCI.

RESEARCH DESIGN AND METHODS

Odds ratios (ORs) for risk factors associated with ST were identified from a meta-analysis based on a systematic literature review, and through consensus expert opinion (Delphi-RAND method). The combined ORs were used to calculate risk scores for acute (within 24 hours), early (within 30 days) and late (31 days to 1 year) ST. Risk scores were validated against patient-level data from the TRITON-TIMI 38 study. Twenty risk factors were identified.

RESULTS

The most highly predictive factor for early and late ST was "incomplete duration of dual antiplatelet therapy". Derived total risk scores ranged from 0 to 22 for acute and early ST, and from 0 to 20 for late ST. Increasing scores were associated with an increasing risk of ST when applied to trial data. Model discrimination was 0.60 (p = .0028), 0.67 (p < .0001) and 0.66 (p < .0001) for acute, early and late ST respectively, indicating good discriminatory power for predicting ST. Key limitations included a lack of published data on acute ST, resulting in a risk score for this time point being based predominantly on expert opinion, and that it was not possible to map all risk factors to variables collected in the TRITON-TIMI 38 study.

CONCLUSION

Our weighted scoring system may help to stratify ST risk and individualize antiplatelet therapy in patients undergoing PCI.

Randomized Angiographic and Intravascular Ultrasound Comparison of Dual-Antiplatelet Therapy vs Triple-Antiplatelet Therapy to Reduce Neointimal Tissue Proliferation in Diabetic Patients

BACKGROUND

Previous studies have suggested a benefit of cilostazol in addition to standard dual-antiplatelet therapy (DAPT), reducing in-stent late luminal loss and restenosis after percutaneous coronary intervention (PCI) with bare-metal and drug-eluting stent (DES) implantation. However, there is a paucity of intravascular ultrasound (IVUS) assessment of neointimal tissue hyperplasia (NIH) after triple-antiplatelet therapy (TAPT), especially in diabetic patients treated with DES.

METHODS

This prospective, placebo-controlled trial was conducted in diabetic patients randomized (1:1) to receive either standard DAPT (aspirin and clopidogrel) vs TAPT with cilostazol for a minimum of 12 months after PCI with Endeavor zotarolimus-eluting stent (E-ZES). The primary endpoint was the 9-month comparison of percentage of NIH in both groups. Additionally, we compared in-stent late lumen loss, binary restenosis, major adverse cardiac event (MACE; cardiac death, non-fatal myocardial infarction, and restenosis) rates, and the incidence of vascular/bleeding complications.

RESULTS

In total, 133 diabetic patients were enrolled (cilostazol cohort = 65 patients) with 56.4% male and mean age of 60.8 years. Overall, the two cohorts were comparable in terms of baseline clinical and angiographic characteristics, except for the reference vessel diameter, which was smaller among patients randomized to cilostazol (2.48 ± 0.46 mm vs 2.69 ± 0.48 mm; P=.01). At 9 months, there was a non-significant trend toward less percentage of NIH obstruction in the TAPT cohort (33.2 ± 8.29% vs 35.1 ± 8.45%; P=.07). However, this finding did not impact angiographic late-lumen loss (0.60 ± 0.46 mm cilostazol group vs 0.64 ± 0.48 mm control group; P=.30) and binary restenosis (9.8% vs 6.8%; P=.99). MACE rate also did not significantly differ between the cohorts (13.8% cilostazol group vs 8.8% control group; P=.81). Of note, the addition of a third antiplatelet agent did not increase vascular and bleeding complications.

CONCLUSION

In diabetic patients treated with E-ZES, TAPT with cilostazol did not add any significant benefit in terms of NIH suppression or MACE reduction.

[Risk factors for progression of atherosclerosis of the shunted coronary artery in the remote postoperative period]

The study was aimed at revealing risk factors for progression of atherosclerosis in the shunted coronary artery in the remote period following coronary artery bypass grafting. Our prospective study included a total of 292 patients having endured coronary artery bypass grafting. All patients were divided in two groups depending on the type of the bypass grafts used: either autoarterial shunts (Group 1) or autovenous grafts (Group 2). We thus assessed a total of 516 autoarterial grafts and 257 autovenous grafts, as well as the coronary arteries shunted thereby. The long-term results were evaluated by means of coronaroshuntography performed not earlier than 12 months after surgery. The average duration of follow up amounted to 53.4±26.5 months. Analysing the cumulative risk for progression of atherosclerosis in the arteries shunted demonstrated that for autoarterial grafts the rate of the development of proximal stenosis of the coronary artery (CA) shunted was lower compared with autovenous grafts (p≤0.001). The Cox regression model showed that an autovein used as a graft increased the risk for the development of occlusion of the shunted CA by 43% from the baseline each postoperative month. The presence of proximal stenosis of the shunted coronary artery amounting to or exceeding 90% increases the risk of occlusion by 68% per month. Also, for the patients with the SYNTAX scoring ≥ 32 points the risk of coronary artery occlusion increases 2.2-fold each month after the operation. Such factors as the patient's gender, the diameter of the shunted artery, diabetes mellitus, tobacco smoking, multifocal atherosclerosis by the findings of the study exerted no influence on the progression of proximal stenosis of the shunted coronary artery.

Recurrent in-stent restenosis, certainty of its origin, uncertainty about treatment

Treatment of recurrent in-stent restenosis is a real brainteaser for the interventional cardiologist who cannot resort to the guidelines to have indications about the type of treatment to be preferred. The use of intracoronary imaging may provide insights into the underlying mechanisms of this complication and use of drug-coated balloons may be a valid alternative and especially a thoughtful treatment when the repeated and perseverant use of drug-eluting stents clearly fails. In this setting, we present a review of the literature about this interesting topic, going deep into the heart of the problem, its origin and possible treatment options.

Rationale and design of the East-West late lumen loss study: Comparison of late lumen loss between Eastern and Western drug-eluting stent study cohorts

BACKGROUND

The contemporary evaluation of novel drug-eluting stents (DES) includes mechanistic observations that characterize postdeployment stent behavior. Quantification of late lumen loss due to neointimal hyperplasia 8-13 months after stent implantation, via quantitative coronary angiography (QCA), constitutes such an observation and is required by most regulatory authorities. Late lumen loss, as determined by QCA, has been validated as a surrogate for clinical endpoints such as target vessel revascularization. The mechanistic response to DES has not been directly compared across predominantly Asian or Western populations, whereas understanding their comparability across geographic populations could enhance global DES evaluation.

OBJECTIVE

The East-West late lumen loss study is designed to demonstrate whether the residual differences in late lumen loss, as assessed by QCA, is different between Eastern and Western DES recipients from studies with protocol angiography at 8-13 months of follow-up.

METHODS

Data from independent core laboratories that have characterized angiographic late lumen loss in DES clinical trials with protocol follow-up angiography will be compiled and dichotomized into Eastern and Western populations. A prospectively developed propensity score model incorporating clinical and anatomic variables affecting late lumen loss will be used to adjust comparisons of QCA measurements.

CONCLUSION

Documentation of whether there are clinically meaningful differences in mechanistic response to DES implantation across genetically unique geographies could facilitate both the quality and efficiency of global device evaluation requiring invasive follow-up for novel stent designs.

The Difference Between Success and Failure: Subintimal Stenting Around an Occluded Stent for Treatment of a Chronic Total Occlusion Due to In-Stent Restenosis

We present a case where conventional wire and equipment passage through the proximal cap of a chronic total occlusion due to in-stent restenosis was not possible. The lesion was then safely and successfully treated by deliberate passage into the subintimal space outside the previous stent with subsequent subintimal dissection and reentry into the true lumen beyond the occlusion. We then stented around the occluded stent, effectively crushing the previous stent in the true lumen and restoring flow by stenting open the new subintimal lumen. Follow-up angiography and optical coherence tomography at 6 months demonstrated good medium-term results.

The Absorb Limits

A patient presented with an inferior non-ST segment elevation myocardial infarction and a tight lesion on the distal right coronary artery. After stent implantation, a large scaffold malapposition was observed by optical coherence tomography. This case emphasizes the importance of not expanding a bioresorbable vascular scaffold more than 0.5 mm over its nominal size.

Radial Artery Embolism: A Rare Complication of Angioplasty

We present a 55-year-old man with multivessel coronary artery disease previously treated with stenting of the left main, left anterior descending, right coronary, circumflex, and first diagonal branch. He was diagnosed with in-stent restenosis of a diagonal branch, but treatment was complicated by radial artery coronary embolism, which is a rare complication of radial intervention.