Comparison of the efficacy of excimer laser coronary angioplasty for ST-segment elevation myocardial infarction with onset-to-balloon time.

Excimer laser coronary angioplasty (ELCA) vaporizes plaques and thrombi, provides better microcirculation, and reduces peripheral embolism when treating acute coronary syndrome. Studies on the efficacy of ELCA for long onset-to-balloon time ST-segment elevation myocardial infarction (STEMI) are limited. Thus, we aimed to examine the efficacy of ELCA for STEMI using the onset-to-balloon time (OBT). A total of 319 patients with STEMI who underwent percutaneous coronary intervention from 2009 to 2012 and from 2015 to 2019 were enrolled. Patients who underwent PCI in 2009-2012 were considered the conventional group, and those treated with ELCA in 2015-2019 were considered the ELCA group. Patients were stratified by OBT. The endpoints were the final thrombolysis in myocardial infarction (TIMI) grade, myocardial blush grade (MBG), and slow-flow or no-reflow phenomenon during the procedure. The ELCA group had 167 patients, and the conventional group had 123. There was no significant difference in achieving final TIMI 3 between the groups. The acquisition rate of final MBG 3 was significantly higher in the ELCA than in the conventional group (79.6% vs. 65.9%; P = 0.01). There was a significant difference between the groups with OBT 12-72 h (82.1% vs. 56.0%; P = 0.031). The slow- or no-reflow incidence during the procedure was significantly lower in the ELCA than in the conventional group with OBT 12-72 h (17.8% vs. 52.2%; P = 0.019). ELCA improves the MBG and reduces intraoperative slow- or no-reflow phenomenon in patients with STEMI, 12-72 h after onset. ELCA will be useful in preventing peripheral embolism in patients with long onset-to-balloon time STEMI.

Benefits of excimer laser coronary angioplasty over thrombus aspiration therapy for patients with acute coronary syndrome and thrombolysis in myocardial infarction flow grade 0.

In primary percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS), the presence of a thrombus or unstable plaque can cause microvascular obstructions, which may increase infarct size and reduce survival. Excimer laser coronary angioplasty (ELCA) is a unique revascularization technique that can vaporize plaques and thrombi. However, to date, only few reports indicate the efficacy of ELCA for ACS. We retrospectively analyzed 113 consecutive ACS patients who underwent PCI with either ELCA or manual thrombus aspiration therapy (TA) before balloon angioplasty or stenting and who had a Thrombolysis in Myocardial Infarction flow (TIMI) grade 0 on the first contrast injection within 24 h of onset at our hospital from March 2011 to March 2020. Patients were divided into two groups by the procedure used: ELCA (N = 48) and TA (N = 50). Door-to-reperfusion time was significantly shorter in the ELCA group than TA group (89.2 ± 6.7 vs. 137.9 ± 12.3 min, respectively; P < 0.01). There was also a significant difference in peak creatine kinase-myocardial band between the ELCA and TA groups (242 ± 25 vs. 384 ± 63 IU/L, respectively; P = 0.04). Although there was no difference in myocardial blush grade (MBG) before treatment, the MBG after treatment was higher in the ELCA group (P < 0.01). In-hospital major adverse cardiac events (MACE) were also significantly fewer in the ELCA group than in the TA group (8% vs. 20%, P = 0.045). ELCA for TIMI grade 0 ACS may shorten reperfusion time, improve the MBG score, and reduce MACE when compared to TA.

Impact of small diameter and low level of emission laser coronary atherectomy in patients with acute myocardial infarction.

Excimer laser coronary atherectomy (ELCA) is an effective treatment to remove intracoronary thrombi. In the present study, we compared in-hospital mortality in patients with acute myocardial infarction (AMI) who underwent conventional treatment and conventional treatment plus ELCA. Among 656 patients who were admitted to our hospital through the Tokyo CCU Network, 104 patients with AMI who were treated by percutaneous coronary intervention between January 2013 and December 2016 met inclusions criteria and underwent conventional treatment with ELCA (ELCA group) and 89 underwent conventional treatment alone (conventional group). We retrospectively evaluated in-hospital mortality within 30 days and used propensity score (PS) matching to reduce assignment bias and multivariate analysis to detect the predictors of in-hospital mortality. In-hospital mortality rate was significantly lower in the ELCA group before and after PS matching (2.9% vs. 13.5%, p = 0.006 before PS matching, and 2.8% vs. 14.1%, p = 0.016 after PS matching). After PS matching, ß-blocker or statins use, incidence of shock, Killip classification, and door-to-balloon time were not significantly different. A multivariate logistic regression analysis identified ELCA, dyslipidemia, shock, and left ventricular ejection fraction as independent predictors of in-hospital mortality (odds ratio (OR), 0.147, 95% confidence interval [CI], 0.022-0.959, p = 0.045; OR, 0.077, 95% CI, 0.007-0.805, p = 0.032; OR, 6.494, 95% CI, 1.228-34.34, p = 0.028; OR, 0.890, 95% CI, 0.828-0.957, p = 0.002, respectively). Our data indicate that ELCA with the small diameter and low level emission may reduce the in-hospital mortality compared to conventional methods in patients with AMI in drug-eluting stent era.

Excimer laser coronary atherectomy prior to paclitaxel-coated balloon angioplasty for de novo coronary artery lesions.

This study aimed to evaluate the efficacy and safety of excimer laser coronary atherectomy (ELCA) prior to paclitaxel-coated balloon angioplasty for de novo coronary artery lesions. This retrospective observational study analyzed 118 eligible patients with de novo coronary artery disease whose only percutaneous coronary intervention was a drug-coated balloon angioplasty (i.e., no subsequent stent placement). Data related to our primary outcomes of interest-incidence of major adverse cardiovascular and cerebral events (MACCE), and incidence of procedural complications (bailout stenting and minor complications)-were collected and retrospectively analyzed. ELCA was used significantly more often in the cases of main branch and ostial lesions (i.e., of the circumflex, right coronary, or left anterior descending arteries, or high lateral branch), normally associated with poor treatment outcomes (55.6% vs. 14.3%, p < 0.0005). However, the two groups were not different in terms of cumulative incidence as estimated by the Kaplan-Meier method (log-rank test, p = 0.603) and a causal relationship between ELCA and MACCE was not identified (OR, 2.223; 95% CI, 0.614-8.047; p = 0.223). This study confirms the safety of ELCA prior to paclitaxel DCB angioplasty to treat de novo coronary artery lesions. While difficult-to-treat lesions were significantly more prevalent in the group treated by ELCA, the study revealed similar efficiency as conventional pre-dilation methods. Our findings provide grounds for a prospective randomized trial with consistent lesion and procedural characteristics to evaluate the potential benefits of combining paclitaxel DCB angioplasty following ELCA for de novo coronary artery lesions.

Comparison of 0.9-mm and 1.4-mm catheters in excimer laser coronary angioplasty for acute myocardial infarction.

Excimer laser coronary angioplasty (ELCA) is a unique revascularization modality that can vaporize plaque and thrombus. Compared to thrombus aspiration therapy, ELCA is reported to provide better microcirculation and reduced peripheral embolism in treatment for acute coronary syndrome. Excimer laser catheters come in various sizes, and we sought to compare the 0.9- and 1.4-mm-diameter catheters. We retrospectively enrolled 90 acute myocardial infarction (AMI) patients who underwent primary percutaneous coronary intervention with excimer laser from August 2013 to March 2017 in our hospital. Patients were grouped by diameter of catheter that had been used, the 0.9 mm group (n = 51) and 1.4 mm group (n = 39). We evaluated myocardial perfusion, procedural success rate, short-term outcome, lesion crossability, and complications between the two groups. The percentage of patients whose final thrombolysis in myocardial infarction (TIMI) grade was 3 (0.9 mm 86.3% vs 1.4 mm 89.7% p = 0.75) and final myocardial blush grade (MBG) was 3 (0.9 mm 72.5% vs 1.4 mm 69.2% p = 0.82) was similarly high for both groups. Procedural success rate, in-hospital major adverse cardiac events (MACE), lesion crossability, and complications were also similar. This study showed that efficacy of 0.9 and 1.4 mm excimer laser catheter was equivalent in ELCA for AMI patients. If one takes into account lesion crossability, debulking effects, and the stunned platelets phenomenon, the 0.9 mm excimer laser catheter is sufficient for ELCA in AMI patients.

Sodium Bicarbonate-Ascorbic Acid Combination for Prevention of Contrast-Induced Nephropathy in Chronic Kidney Disease Patients Undergoing Catheterization.

BACKGROUND: Sodium bicarbonate and ascorbic acid have been proposed to prevent contrast-induced nephropathy (CIN). The present study evaluated the effect of their combined use on CIN incidence.Methods and Results:We prospectively enrolled 429 patients with chronic kidney disease (CKD: baseline estimated glomerular filtration rate <60 mL/min/1.73 m2) prior to elective coronary catheterization. CIN was defined as absolute (≥0.5 mg/dL) or relative (≥25%) increase in serum creatinine within 72 h. In the saline hydration (n=218) and combined sodium bicarbonate+ascorbic acid (n=211) groups, a total of 1,500-2,500 mL 0.9% saline was given before and after the procedure. In addition, the combination group received 20 mEq sodium bicarbonate and 3 g ascorbic acid i.v. before the procedure, followed by 2 g ascorbic acid after the procedure and a further 2 g after 12 h. There were no significant differences between the basic characteristics and contrast volume in the 2 groups. CIN occurred in 19 patients (8.7%) in the saline group, and in 6 patients (2.8%) in the combined treatment group (P=0.008). CONCLUSIONS: Combined sodium bicarbonate and ascorbic acid could prevent CIN following catheterization in CKD patients.

A case report of Bow Hunter's syndrome with intravascular ultrasound showing changing significant severe stenosis of the left vertebral artery associated with turning left.

Background: Bow Hunter's syndrome is vertebral basilar artery insufficiency caused by mechanical occlusion of the vertebral artery during head rotation. This is often due to the formation of osteophytes, herniated discs, cervical spondylosis, or tumours. However, whether the contralateral vessel is organically stenotic is not well known. Case summary: A 79-year-old man was referred to our department for a close examination of syncope because the transient loss of consciousness occurring when he was made to turn his head to the left was reproducibly induced and recovered when his face was returned to the normal position. The carotid massage did not induce significant bradycardia or hypotension bilaterally, and Holter electrocardiography, echocardiography, head-up tilt test, coronary angiography, and an acetylcholine stress test showed no obvious abnormalities. A 3D CT angiography was performed to investigate the possibility of vertebrobasilar artery insufficiency, as C3/4 cervical spondylosis, and the left vertebral artery was compressed by the C4 superior process osteophyte, indicating hypoplasia of the contralateral vertebral artery. Vertebral artery angiography and intravascular ultrasound (IVUS) showed moderate stenosis of the left vertebral artery, and IVUS showed a half-circumferential calcified lesion. Compared to the midline position, the stenosis worsened at the site of compression and drainage when the patient turned left downward, and a diagnosis of Bow Hunter's syndrome was made. Discussion: Bow Hunter's syndrome is characterized by vertebrobasilar insufficiency. Intravascular ultrasound clearly showed that the lesion was not only stenotic due to compression but also had plaque growth due to continuous mechanical stimulation.

Delayed bleeding complication due to internal mammary artery injury after ultrasound-guided percutaneous catheter drainage for liver cyst infection.

BACKGROUND: Ultrasound-guided percutaneous catheter drainage (PCD) is widely accepted as a primary treatment for pyogenic liver abscess. Severe PCD-related complications have been reported; however, delayed bleeding complications due to internal mammary artery injury are unknown. CASE PRESENTATION: An 84-year-old man undergoing hemodialysis owing to chronic kidney disease due to focal segmental glomerulosclerosis was admitted to our hospital for liver cyst infection. Ultrasound-guided PCD was carried out through the normal liver at the upper abdominal midline at the level of the sixth intercostal space. Two days later, an abdominal hematoma occurred at the puncture site. Contrast-enhanced computed tomography revealed extravasation of the distal right internal mammary artery, which was successfully treated with percutaneous coil embolization. CONCLUSION: Internal mammary artery injury should be considered as a differential diagnosis when a progressing hematoma develops after PCD.

Rotational Atherectomy for Ablation of Multiple Channel Structure Observed by Optical Frequency Domain Imaging.

BACKGROUND Previous case reports have shown that regardless of the etiology, multiple channel structures can be treated successfully by routine percutaneous coronary intervention. However, there are no general recommendations for intervention because multiple channel structures are complex and rarely diagnosed. CASE REPORT A 71-year-old male was admitted to our hospital due to bronchial pneumonia. After admission, the patient experienced acute decompensated heart failure. Coronary angiogram revealed 3 diseased vessels with heavy calcification. Although the patient's syntax score was high, we performed percutaneous coronary intervention (PCI) on each vessel based on his request and in consideration of his dementia. After PCI for the left circumflex and descending arteries, we performed PCI for the right coronary artery (RCA) using optical frequency domain imaging (OFDI). A multiple channel structure and calcified nodule were observed by OFDI. We performed rotational atherectomy (RA) on the RCA, and the 2 structures were ablated. After RA, we dilated the lesions with a scoring balloon and deployed a drug-eluting stent. CONCLUSIONS RA was effective in ablating partition walls of the multiple channel structure observed using OFDI.

[Two distinct types of neuropathy associated with Sjögren's syndrome developed in one patient. The importance of the selection of an appropriate therapeutic regimen].

A 62-year-old woman was admitted to our hospital because of muscle weakness and sensory disturbance in extremities. She showed weakness, muscle atrophy and sensory abnormality in four limbs with patchy distribution, suggesting involvement of multiple peripheral nerve trunks. Serum titers of anti-SS-A, SS-B, and antinuclear antibody were elevated. Sural nerve biopsy showed recanalization and lymphocytic infiltration in the epineural small vessels, suggesting the presence of vasculitis. She was diagnosed as having vasculitic neuropathy complicated with Sjögren's syndrome. Methylprednisolone pulse therapy followed by oral prednisolone was started and these symptoms gradually improved in one month. At age 63, she felt dysesthesia in the right lower limb and this sensory abnormality spreaded to upper limbs. Two years later, she was admitted again due to clumsiness of hands and gait disturbance. Neurological examination showed decreased vibration and position sense of lower limbs and limb ataxia in addition to dysesthesia. Electrophysiological studies demonstrated significant decrease in amplitude of sensory nerve action potentials and delayed somatosensory evoked potentials after N13, indicating impairment of dorsal root ganglions. She was treated with intravenous immunoglobulin (400 mg/kg, total 15 g/day) for 5 days. One week later, sensory ataxia was improved. It has been known that Sjögren's syndrome is often complicate with various types of neuropathies including vasculitic neuropathy and sensory neuropathy. Our patient developed these two different types of neuropathies which were dramatically improved after two different therapeutic regimens; indicating the importance to select a suitable treatment regimen in accordance with the mechanism of neuropathy associated with Sjögren's syndrome.