Obesity May Not Be a Risk of Non-Target Lesion Revascularization in the Elderly Patients.

Obesity is assumed to be one of the robust risk factors for coronary artery disease. However, the effects of obesity on the progression of atherosclerosis in patients in different age groups after percutaneous coronary intervention (PCI) remain unclear. This study aimed to examine the effect of obesity on prognosis in different age groups.Consecutive patients who underwent urgent or elective PCI were surveyed for this study and were then divided into the elderly group and middle-aged group with a cut-off age of 70 years. All patients underwent coronary angiography or coronary computed tomography angiography 1 year after PCI to examine the progression of atherosclerosis. The primary endpoint was revascularization for a new lesion within 2 years after PCI. In addition, the main effects and correlations between obesity and age were examined. Multivariate logistic regression analysis was conducted to identify independent predictors of non-target lesion revascularization (non-TLR).Of the 711 patients who met the criteria and were available for follow-up analysis, the incidence of non-TLR within 2 years was 97/711 (13.6%). The higher incidence of non-TLR in patients with obesity was observed only in the middle-aged group. Furthermore, in the multivariate analysis, obesity was independently associated with non-TLR only in the middle-aged group.The findings of the present study would enable us to construct the hypothesis that obesity in elderly patients may not be an independent predictor of the incidence of non-TLR, indicating that the management to prevent non-TLR may vary depending on the age of the patient.

Impact of lesion morphology on angiographic and clinical outcomes in patients with chronic total occlusion after recanalization with drug-eluting stents: a multislice computed tomography study.

OBJECTIVES: The aim of this study was to investigate the multislice computed tomography (MSCT) parameters associated with adverse outcomes after chronic total occlusion percutaneous coronary intervention (CTO-PCI) with drug-eluting stents. METHODS: A total of 285 patients who underwent MSCT before CTO-PCI were analyzed. Lesion morphology was assessed with MSCT. Angiographic restenosis, reocclusion, and MACE (a composite of cardiac death, myocardial infarction, stent thrombosis, and target lesion revascularization) were analyzed. RESULTS: MACE was observed in 36 patients (13.6%). Occlusion length was greater (39.5 ± 19.9 mm vs. 22.3 ± 13.7 mm, p < 0.01), minimal vessel area smaller (11.2 ± 5.7 mm(2) vs. 14.5 ± 5.6 mm(2), p < 0.01), and severe calcification more common (36% vs. 12 %, p < 0.01) in the MACE group compared to the non-MACE group. We defined occluded length >25.4 mm, minimal vessel area <11.9 mm(2), which were identified by receiver operating characteristic analysis, and severe calcification as CT-derived risk factors. Angiographic restenosis (60% vs. 12% vs. 7%, p < 0.01), reocclusion (29% vs. 2% vs. 2%, p < 0.01), and MACE (43% vs. 6% vs. 3%, p < 0.01) were more common in patients with 2 or more risk factors than in those with 1 or 0. CONCLUSIONS: MSCT characteristics associated with adverse outcomes after CTO-PCI were occlusion length, minimal vessel area, and severe calcification. KEY POINTS: • Percutaneous coronary intervention of chronic total occlusion remains a challenge. • The parameters related to adverse outcomes after CTO-PCI have not been clarified. • MSCT can provide useful information associated with adverse outcomes after CTO-PCI.

Impact of sirolimus-eluting stent fractures without early cardiac events on long-term clinical outcomes: a multislice computed tomography study.

OBJECTIVES: This study sought to evaluate the impact of sirolimus-eluting stent (SES) fractures on long-term clinical outcomes using multislice computed tomography (MSCT). METHODS: In this study, 528 patients undergoing 6- to 18-month follow-up 64-slice MSCT after SES implantation without early clinical events were followed clinically (the median follow-up interval was 4.6 years). A CT-detected stent fracture was defined as a complete gap with Hounsfield units (HU) <300 at the site of separation. The major adverse cardiac events (MACEs), including cardiac death, stent thrombosis, and target lesion revascularisation, were compared according to the presence of stent fracture. RESULTS: Stent fractures were observed in 39 patients (7.4 %). MACEs were more common in patients with CT-detected stent fractures than in those without (46 % vs. 7 %, p < 0.01). Univariate Cox regression analysis indicated a significant relationship between MACE and stent fracture [hazard ratio (HR) 7.65; p < 0.01], age (HR 1.03; p = 0.04), stent length (HR 1.03; p < 0.01), diabetes mellitus (HR 1.77; p = 0.04), and chronic total occlusion (HR 2.54; p = 0.01). In the multivariate model, stent fracture (HR 5.36; p < 0.01) and age (HR 1.03; p = 0.04) remained significant predictors of MACE. CONCLUSIONS: An SES fracture detected by MSCT without early clinical events was associated with long-term clinical adverse events. KEY POINTS: • Long-term outcomes of sirolimus-eluting stent fracture have not been fully clarified. • MSCT could detect stent fracture with high accuracy. • Sirolimus-eluting stent fracture detected by MSCT was associated with long-term adverse events.

Impact of epicardial fat volume on coronary artery disease in symptomatic patients with a zero calcium score.

BACKGROUND: This study sought to evaluate the prevalence of coronary artery disease (CAD) and the impact of epicardial fat volume (EFV) on CAD in symptomatic patients with a zero calcium score (CS) using multislice computed tomography (MSCT). METHODS: In this study, 1308 consecutive symptomatic patients who underwent 64-slice MSCT with a zero CS were evaluated. EFV was quantified with CS data sets. Presence of an obstructive plaque (diameter stenosis >50%) and a CT-derived vulnerable plaque, which was defined as a plaque with remodeling index >1.10 and mean CT density value <3 0HU, was assessed with a CT coronary angiography. RESULTS: Obstructive plaques were detected in 86 patients (7%) and CT-derived vulnerable plaques in 63 (5%). EFV was larger in patients with obstructive plaques than no plaque (124.3 ± 43.2 cm(3) vs. 95.1 ± 40.3 cm(3); p<0.01). Patients with CT-derived vulnerable plaques had a greater amount of EFV than no plaque (133.0 ± 40.2 cm(3) vs. 95.1 ± 40.3 cm(3); p<0.01). Multivariate analysis revealed EFV as a predictor of the presence of an obstructive and a CT-derived vulnerable plaque (per 10 cm(3); Odds ratio (OR) 1.10; 95% confidence interval (CI), 1.04-1.16; p<0.01 and OR 1.19; 95% CI, 1.12-1.27; p<0.01). The combination of EFV and Framingham risk score (FRS) resulted in an area under the receiver-operating characteristic curve for prediction of obstructive and CT-derived vulnerable plaque of 0.75 and 0.75, which was significantly higher than 0.68 and 0.64 for FRS alone (p=0.02 and p<0.01). CONCLUSIONS: A zero CS doesn't exclude CAD and EFV can be a useful marker of CAD in symptomatic zero CS patients.

The impact of epicardial fat volume on coronary plaque vulnerability: insight from optical coherence tomography analysis.

AIMS: Epicardial fat volume (EFV) has been implicated in coronary artery disease. Relationship between EFV and coronary plaque vulnerability has not been elucidated. The aim of this study was to investigate the association of EFV with coronary plaque vulnerability by using optical coherence tomography (OCT). METHODS AND RESULTS: We enrolled 117 patients who underwent multislice computed tomography (MSCT) and OCT. EFV was quantified on MSCT. Patients were categorized according to tertiles of EFV: low tertile, EFV < 104.1 cm(3); mid-tertile, 104.1 cm(3)≤ EFV ≤ 130.7 cm(3); high tertile, EFV > 130.7 cm(3). A total of 180 vessels and 221 plaques were assessed with OCT to detect a thin-capped fibroatheroma (TCFA). TCFA was defined as a plaque with necrotic lipid pools ≥ 2 quadrants and minimum fibrous cap thickness measuring <65 µm. Patients with low computed tomographic attenuation and positive remodelling were frequently observed and patients with OCT-derived TCFA were more common in the high tertile EFV. EFV was associated with a maximal lipid arc (103.4 ± 28.2 cm(3) in 0 quadrant, 120.2 ± 35.2 cm(3) in 1-2 quadrants, and 131.5 ± 41.1 cm(3) in >2 quadrants; P= 0.01) and inversely correlated with a minimum fibrous cap thickness of the patients (r = -0.400, P<0.01). In multivariate analysis, the high tertile of EFV remained an independent predictor for patients with OCT-derived TCFA [odds ratio (OR) 2.92; 95% confidence interval (CI) 1.13-7.55; P= 0.027] and acute coronary syndrome (ACS) patients (OR 2.89; 95% CI 1.14-7.29; P= 0.025). CONCLUSION: EFV was associated with coronary plaque vulnerability and high EFV was an independent predictor of ACS in patients with coronary artery disease.

Protective effect of telmisartan against endothelial dysfunction after coronary drug-eluting stent implantation in hypertensive patients.

OBJECTIVES: The aim of this prospective, randomized study was to evaluate the effects of telmisartan, compared with the calcium-channel blocker amlodipine, on endothelial function after coronary drug-eluting stent (DES) implantation in hypertensive patients. BACKGROUND: DES implantation impairs local endothelial function, which may be associated with future cardiovascular events. Telmisartan, which has unique peroxisome proliferator-activated-receptor-gamma-mediated effects in addition to its renin-angiotensin system-inhibition effects, has favorable effects on endothelial function. METHODS: Fifty-one hypertensive patients with coronary artery stenosis but without coronary artery spasm, treated with a sirolimus-eluting stent, were randomly assigned to either the telmisartan (25 cases) or amlodipine (26 cases) treatment groups. At baseline and at 3 months after DES implantation, endothelium-dependent and -independent vasomotion were evaluated by quantitative coronary angiography under the condition of medication withdrawal. The mean luminal diameter of a 20-mm coronary segment, beginning 5 mm distal to the stent, was measured before and after infusion of intracoronary acetylcholine (10(-7), 10(-6) mol/l) and then again after infusion of nitroglycerin. RESULTS: Blood pressure was comparable between groups at baseline and after 3 months. Vasoconstriction after acetylcholine infusion at 3 months (impaired endothelial function) was less pronounced in the telmisartan group than in the amlodipine group (p<0.0001), although there was no significant difference between the 2 groups before DES implantation. The response to nitroglycerin did not differ between groups before or at 3 months after DES implantation. CONCLUSIONS: Telmisartan, compared with amlodipine, significantly ameliorated endothelial dysfunction after DES implantation in terms of vasoconstriction induced by acetylcholine.

In vivo assessment of ergonovine-induced coronary artery spasm by 64-slice multislice computed tomography.

BACKGROUND: The potential of multislice CT (MSCT) to predict coronary spasm has not been elucidated. The aim of this study was to investigate whether the morphological features observed on MSCT at the site of ergonovine-induced epicardial spasm could be used as diagnostic criteria for coronary spasm. METHODS AND RESULTS: A total of 296 plaques in 199 patients with clinically suspected coronary spastic angina without coronary stenosis (<75%) who underwent invasive angiography with intravenous ergonovine provocative testing were analyzed by MSCT. Calcification, CT attenuation, and patterns of vascular remodeling were evaluated in each plaque by MSCT. Plaques were divided into spasm group or nonspasm group based on the results of the ergonovine provocative test. On a per-plaque basis, noncalcified plaques were more frequently observed in the spasm group (96% versus 20%, P<0.01). Intermediate attenuation plaques (CT density ≥53.8 Hounsfield units identified by receiver operating characteristic analysis) were more common in the spasm group (93% versus 28%, P<0.01), as was negative remodeling (67% versus 11%, P<0.01). Multivariable analysis revealed noncalcified (odds ratio [OR], 48.7; 95% CI, 8.81-269; P<0.01), intermediate attenuation (OR, 19.3; 95% CI, 4.96-75.4; P<0.01); negative remodeling (OR, 8.83; 95% CI, 2.87-27.2; P<0.01); and male sex (OR, 4.55; 95% CI, 1.24-16.6; P=0.02) as predictors of the plaque associated with coronary spasm. CONCLUSIONS: MSCT can detect differences in individual plaque composition and morphology among atherosclerotic plaques without significant luminal narrowing in areas of inducible vasospasm compared to areas without vasospasm.

Association of coronary plaque composition and arterial remodelling: a optical coherence tomography study.

BACKGROUND: Conflicting data have been reported about the association between plaque composition and remodelling index (RI). The aim of this study is to evaluate the relationship between plaque morphology obtained by optical coherence tomography (OCT) and arterial remodelling. METHODS AND RESULTS: OCT and intravascular ultrasound imaging pull back was performed at corresponding sites on 94 lesions in 47 patients. OCT plaque characteristics for lipid content, fibrous cap thickness, thin-cap fibroatheroma (TCFA), plaque rupture, thrombus, calcification and erosion were derived using validated criteria. Compared with intermediate/negative remodelling (RI<1.0), positive remodelling (RI>1.0) was associated with presence of higher lipid pool (2.86 ± 0.42 vs. 2.20 ± 0.78; p<0.001), thin fibrous cap (47.86 ± 25.43 µm vs. 74.41 ± 32.41 µm; p<0.001), TCFA>3mm (82.1% vs. 22.7%; p<0.0001), plaque rupture and thrombus (42.8% vs. 19.7%; p = 0.024), and higher plaque burden (73.70 vs. 70.70; p = 0.048). No difference was observed in the presence of calcification and plaque erosions. CONCLUSIONS: Coronary lesions with positive remodelling show higher incidences of vulnerable plaque and plaque rupture across the lesion length. This potentially explains the correlation between unstable coronary syndromes and positive remodelling.

Phenylsulfanylation of 3',4'-unsaturated adenosine employing thiophenol-N-iodosuccinimide leads to 4'-phenylsulfanylcordycepin: synthesis of 4'-substituted cordycepins on the basis of substitution of the phenylsulfanyl leaving group.

Upon reaction of the 3',4'-unsaturated adenosine derivative 2 with N-iodosuccinimide (NIS) and thiophenol, an unexpected electrophilic hydrophenylsulfanylation proceeded to provide 4'-phenylsulfanylcordycepin 7 in 79% yield with the ratio 7a/7b = 6.6/1. A study of the reaction mechanism revealed that hydrogen iodide (HI) generated from NIS and PhSH acted as an active species. On the basis of a deuterium experiment using PhSD, initial protonation occurred at the ß face of the double bond to furnish the ß-π complex III, which underwent anti addition of PhSH as a major pathway. Nucleophilic substitution of N(6)-pivaloylated 9 with various alcohols in the presence of N-bromosuccinimide (NBS) gave the respective 4'-α-alkoxycordycepins 15a-21a as the major stereoisomers. Use of DAST in place of an alcohol gave the 4'-α-fluoro analogue 23a stereoselectively. Radical-mediated carbon-carbon bond construction was also applicable to 7, giving 4'-α-allylcordycepin (24a) and 4'-α-cyanoethylcordycepin (25) derivatives.

Comparison of in vivo assessment of vulnerable plaque by 64-slice multislice computed tomography versus optical coherence tomography.

The aim of this study was to investigate the possibility of 64-slice multislice computed tomography (MSCT) to detect vulnerable plaque derived by optical coherence tomography. From September 2007 through December 2009, 122 lesions in 81 patients were evaluated by 64-slice MSCT and optical coherence tomography. Based on optical coherence tomographic findings, lesions were classified as thin-capped fibroatheroma (TCFA; n=37) and non-TCFA (n=85). Mean computed tomographic density value of the lesion was lower and remodeling index was larger in the TCFA group (44.9 ± 19.2 vs 78.7 ± 25.0 HU, p <0.0001; 1.14 ± 0.20 vs 0.95 ± 0.16, p<0.0001, respectively). Mean computed tomographic density value was correlated and remodeling index was inversely correlated with fibrous cap thickness (r=0.605, p<0.0001; r=-0.591, p<0.0001, respectively). Optimal threshold of mean computed tomographic value and remodeling index identified by receiver operating characteristic curve were 62.4 HU and 1.08 (area under the curve 0.859 and 0.781). Signet ringlike appearance was observed more frequently in the TCFA group (65% vs 16%, p<0.0001). In multivariate analysis, independent predictors of TCFA were mean computed tomographic density value ≤62.4 HU (odds ratio 8.20, 95% confidential interval 2.49 to 27.0, p=0.0005), remodeling index ≥1.08 (odds ratio 6.10, 95% confidential interval 2.04 to 18.2, p=0.0012), and signet ringlike appearance (odds ratio 6.33, 95% confidential interval 2.03 to 19.7, p=0.0014). In conclusion, based on comparisons with optical coherence tomographic findings, 64-slice MSCT may have the potential to detect vulnerable plaque.

Sirolimus eluting stent restenosis: impact of angiographic patterns and the treatment factors on angiographic outcomes in contemporary practice.

OBJECTIVE: This study compared the impact of pattern of sirolimus eluting stent restenosis (SES ISR) on the angiographic outcomes following conventional modalities of treatment. METHODS: A total of 344 consecutive patients who underwent treatment for SES ISR were included in the study. Lesions were divided into focal< 10 mm, 156 (45.3%)); and non focal> 10 mm, 188 (54.7%). The endpoints analysed were angiographic restenosis and target lesion revascularisation. A total of 31%, 41%, and 23% patients were treated with cutting balloon angioplasty, balloon angioplasty, and repeat stenting. RESULTS: Baseline characteristics were similar for two patterns, except for young age, more AMI and severe angina, more CTO lesions, long lesions, and more use of repeat stenting in non focal ISR group. Follow up angiography shows binary restenosis was significantly lower in the focal group (32.4% vs. 49.2; p = 0.012) and target lesion revascularisation were also lower with focal pattern ISR (30.6 vs. 42.9; p = 0.06). Restenosis rates are similar between balloon angioplasty and repeat stenting (28 vs. 23%) in focal ISR group, and repeat stenting showed better outcomes in the non focal group (60% vs. 36%). CONCLUSION: The recurrent ISR remains high with available treatments and the pattern of SES ISR predicted the outcomes, with lower restenosis rates with focal pattern of ISR.

In-vivo detection of the frequency and distribution of thin-cap fibroatheroma and ruptured plaques in patients with coronary artery disease: an optical coherence tomographic study.

OBJECTIVES: The purpose of this study was to assess the prevalence and to quantify the thin-cap fibroatheroma (TCFA) and ruptured plaques in patients with coronary artery disease using optical coherence tomography (OCT). BACKGROUND: TCFA lesions are the most prevalent precursors of plaque rupture, and are responsible for acute coronary syndromes (ACS). There are limited data regarding the frequency and distribution of TCFA in diseased coronary arteries. METHODS: Coronary artery OCT was performed in 78 vessels in 47 patients, with stable angina (SA) or ACS. OCT plaque characteristics were derived using criteria that had been validated earlier. TCFA was defined as rich in lipid (two or more quadrants) with thin fibrous cap (<65 µm). Comparison was made between SA and unstable angina, and culprit and nonculprit vessels. RESULTS: There was a higher incidence of TCFA and plaque rupture (65 vs. 24%, P=0.003, and 40 vs. 15%, P=0.04) in ACS patients. This was reflected in a higher lipid pool (2.66 vs. 2.26 quadrants, P=0.04) and minimum fibrous cap thickness (52 vs. 74 µm, P=0.001) in ACS patients. The mean numbers of TCFA (2.5) were similar in patients with SA and ACS. However, the maximal length of TCFA (2.63 vs. 5.54 mm, P=0.026) and plaque rupture sites (P=0.046) were higher in ACS vessels. No relationship was found between baseline characteristics and TCFA incidence and plaque rupture. We identified ACS (P=0.002), higher mean lipid pool (P=0.002), longer TCFA length (P=0.007) and higher number of TCFA (P=0.02) as predictors of plaque rupture sites. CONCLUSION: In this in-vivo study, we identified a higher incidence of longer TCFAs and plaque rupture sites associated with ACS.

Different patterns of vascular response between patients with or without diabetes mellitus after drug-eluting stent implantation: optical coherence tomographic analysis.

OBJECTIVES: We performed this study to investigate with optical coherence tomography (OCT) the vascular response after sirolimus-eluting stent (SES) implantation between patients with and those without diabetes mellitus (DM). BACKGROUND: The difference in vascular response after SES implantation between patients with and those without DM has not been fully evaluated with OCT. METHODS: Optical coherence tomography was performed to examine 74 nonrestenotic SES implanted in 63 patients (32 with DM and 31 without DM) at 9 months after SES implantation. For struts showing neointimal coverage, the neointimal thickness on the luminal side of each strut section was measured, and neointimal characteristics were classified into high, low, and layered signal pattern. RESULTS: Baseline patient characteristics and lesion and procedural characteristics data were similar between the 2 groups. In total, 11,422 struts were analyzed. High signal neointima was observed in 90.2 ± 13.9%, low signal neointima in 7.3 ± 10.0%, and layered neointima in 2.7 ± 5.8%/stents. There was higher incidence of low signal neointima (10.5 ± 10.3% vs. 4.5 ± 5.6%, p = 0.003), neointimal thickness was larger (median: 106.8 µm, interquartile range: 79.3 to 130.4 µm vs. median: 83.5 µm, interquartile range: 62.3 to 89.3 µm; p < 0.0001), and neointimal coverage of stent struts was higher (92.1 ± 6.2% vs. 87.2 ± 11.9%; p = 0.03) in DM patients. CONCLUSIONS: High signal neointimal pattern was predominantly observed, and low or layered signal pattern was observed in some cases. In DM patients, low signal neointima was observed with high frequency. Neointimal coverage and neointimal thickness was also higher in DM patients as compared with non-DM patients.

Rotational atherectomy for fibro-calcific coronary artery disease in drug eluting stent era: procedural outcomes and angiographic follow-up results.

OBJECTIVES: The aim of this study was to examine the binary re-stenosis rates, procedural success, and in hospital outcomes following treatment of fibro-calcified coronary lesion with rotational atherectomy in drug eluting stent era. BACKGROUND: Binary restenosis rates have remained high with the use of bare metal stents following rotational atherectomy in calcified lesions. There is limited data available following rotational atherectomy in drug eluting stent era. METHODS: We evaluated the procedural and angiographic outcomes following a consecutive series of 516 procedures treated with rotational atherectomy followed by stenting. We compared the results between Rota + Drug eluting stent (DES) and Rota + bare metal stent (BMS) groups. RESULTS: Procedural success was achieved in 97.1% of the lesions with overall low in hospital adverse events (death in 1.1%, Q MI in 1.3%, Non Q MI in 5.3%, and urgent repeat PCI in 0.4%). There was significant reduction in the binary restenosis rates following Rota + DES use as compared to Rota + BMS use (11% vs. 28.1%, P < 0.001; OR = 3.17, 95% CI: 1.76-5.93) and similar reduction was seen in the target lesion revascularization (10.6% vs. 25%, P = 0.001; OR = 2.81, 95% CI: 1.53-5.14). We have identified ostial lesions, chronic total occlusion lesions, and use of bare metal stents as independent predictors of restenosis in this group of patients. CONCLUSIONS: Rotational atherectomy can be performed with high success rates and low complications, and rotational atherectomy followed by drug eluting stent implantation significantly reduces binary restenosis rates in fibrocalcific lesions as compared to rotational atherectomy and bare metal stents.

A comparison of clinical presentations, angiographic patterns and outcomes of in-stent restenosis between bare metal stents and drug eluting stents.

AIMS: This paper studies in-stent restenosis (ISR) after percutaneous coronary intervention (PCI) following bare-metal stent (BMS) and drug-eluting stent (DES) in all consecutive patients between 2004 and 2007 undergoing PCI for ISR lesions at our centre. METHODS AND RESULTS: We compared the clinical presentation, pattern and angiographic outcomes in 838 patients with BMS ISR (487) and SES ISR (351). About 18% of the patients presented with acute coronary syndrome with 2% presenting as ST elevation myocardial infarction, similar in both groups. Angiographic pattern was predominantly focal with SES ISR (47%SES ISR vs. 19% BMS ISR; p<0.001) and diffuse with BMS ISR (SES ISR 16% vs. BMS ISR 36%; p=0.003). In our series the use of balloon angioplasty was higher for the treatment of SES ISR patients as compared to BMS ISR (41.6% vs. 18.3%; p<0.001) and the usage of stent was higher in BMS ISR patients (38.6% vs. 23.4%; p<0.001). Angiographic recurrent restenosis with conventional treatment in a consecutive series of patients was 38.6% and target lesion revascularisation was seen in 33.6%. These outcomes were seen slightly higher in SES ISR group (41.1% vs. 36.9%, p=ns). We have identified unstable angina at presentation (OR 3.02; 95%CI: 1.58-5.77, p=0.001), focal pattern of ISR (OR 0.50; 95% CI: .25-.99, p=0.04), stent usage (OR .25; 95% CI .13-.47, p<0.001), and baseline% diameter stenosis (OR1.03; 95%CI: 1.03-1.06, p=0.01) as independent predictors of BMS ISR recurrent restenosis. Unstable angina, focal pattern of ISR, reference vessel diameter, and% diameter stenosis were shown to be independent predictors of SES ISR. CONCLUSIONS: ISR is not a benign condition, and one fifth of the patients presented with acute coronary syndrome. The pattern of restenosis is predominantly non-focal with BMS ISR and focal with SES ISR. Recurrent restenosis rates are high following conventional treatment and further optimal therapies mainly with SES ISR needs to defined.

First clinical experience of "flower petal stenting": a novel technique for the treatment of coronary bifurcation lesions.

OBJECTIVES: We sought to report the results of both bench-testing and our first clinical experience with this novel technique. BACKGROUND: The optimal stenting technique for bifurcation lesions has yet to be defined. METHODS: This technique works by flaring the proximal side of the stent in side branch out like a flower petal. We tested it in vitro and the resultant stent structure and stent polymer damage was observed in both main branch and side branch with an optical microscopy, multislice computer tomography, intravascular ultrasound, endoscopy, and by electron microscopy. We also applied this technique in 33 patients and assessed patient outcomes up to 9 months prospectively. Drug-eluting stents were used for the bench tests and for all patients. RESULTS: Bench-testing showed complete coverage of the bifurcation with minimal stent-layer overlapping. There was little polymer damage by electron microscopy. Procedural success was achieved in all cases and restenosis occurred in 2 cases. In both restenosis cases, "petal" stenting technique was done reluctantly after another stent had already been deployed in the main branch before any stenting of the side branch. There were no incidences of restenosis when this technique was used electively. CONCLUSIONS: In terms of damage to the polymer and ostial strut coverage, this new "flower petal stenting" technique is effective for treatment of bifurcation lesion and it may well be superior to other available techniques.

Retrograde percutaneous recanalization of chronic total occlusion of the coronary arteries: procedural outcomes and predictors of success in contemporary practice.

BACKGROUND: Retrograde approach through collaterals has been introduced for percutaneous recanalization of chronic total occlusion (CTO) of the coronary arteries. We investigated the safety and efficacy of retrograde approaches used for percutaneous recanalization of CTO in a consecutive series of patients. METHODS AND RESULTS: We studied 157 consecutive patients who underwent retrograde CTO recanalization between 2003 and 2008 at a single center. A total of 118 (75.2%) of these patients have had previously failed antegrade attempts. Septal, epicardial, and saphenous vein graft collaterals were used in 67.5%, 24.8%, and 7.6% of cases, respectively. Collateral channel was crossed by guide wire successfully in 115 (73.2%) cases, and the procedure was successful by retrograde approach in 103 (65.6%) cases. Collateral channels (CCs) were graded as follows: CC0, no continuous connection; CC1, continuous thread-like connection; and CC2, continuous, small sidebranch-like connection. CC1, collateral tortuosity < 90 degrees , and angle with recipient vessel < 90 degrees (P<0.0001) were significant predictors of success. Epicardial channel use (P=0.01), CC0, corkscrew channel (P<0.0001), angle with recipient vessel > 90 degrees (P=0.0007), and nonvisibility of connection with recipient vessel were found to be significant predictors of procedural failure. The CC dissection was observed in 6 patients, with 1 needing coil embolization and others who were managed conservatively. The major adverse cardiac events were low, with 1 coronary artery bypass graft, 1 Q-wave myocardial infarction, 5 non-Q-wave myocardial infarctions, and no deaths in this group of patients. CONCLUSIONS: The retrograde approach in CTO percutaneous coronary intervention is effective in recanalizing CTO. The success rate by retrograde approach was 65.6%, and final success was 85% in this group with acceptable overall adverse events. We have identified predictors of failure related to collateral morphology.