Plasmablastic extramedullary plasmacytoma associated with Epstein-Barr virus arising in an immunocompetent patient with multiple myeloma.

We encountered a case of plasmablastic extramedullary plasmacytoma with multiple myeloma. Histological findings revealed that the extramedullary plasmacytoma of this patient was of the plasmablastic type, which was positive for λ-stain and EBV-encoded RNA. In contrast, bone marrow aspiration demonstrated a common-type multiple myeloma, which was positive for λ-stain and negative for EBV-encoded RNA. This was a rare case of plasmablastic extramedullary plasmacytoma associated with Epstein-Barr virus arising in an immunocompetent patient with multiple myeloma.

Timing of the restenosis following nitinol stenting in the superficial femoral artery and the factors associated with early and late restenoses.

OBJECTIVES: We sought to investigate the timing of restenosis and the restenosis factors following nitinol stenting in the superficial femoral artery (SFA). BACKGROUND: Restenosis following nitinol stenting in the SFA remains unsolved. METHODS: We analyzed 742 limbs in consecutive 585 patients who underwent successful endovascular therapy for de novo SFA lesions. Patency was assessed by duplex ultrasonography. Primary patency was defined as treated vessels without restenosis and secondary patency was defined as target vessels reopened by repeat revascularization. Receiver-operating characteristic (ROC) analysis was performed to delineate the timing of restenosis. Patients were subsequently classified into three groups: no restenosis, early restenosis, and late restenosis. Cox proportional hazard regression analyses were performed to explore the determinants of restenosis in each restenosis group. RESULTS: Primary and secondary patency was 67 and 86% at 6 years, respectively. ROC curves indicated the 369th day was the best cutoff point distinguishing the early (144 limbs) and the late (42 limbs) restenoses. Sustained patency was observed in 556 limbs. After multivariate analysis, cilostazol (P = 0.0007) was negatively associated; female gender (P = 0.0071), diabetes mellitus (P = 0.0428), critical limb ischemia (P = 0.0435), and stent fracture (P = 0.0004) were positively associated with the early restenosis. Trans Atlantic Inter-Society Consensus II C/D was positively associated with both the early (P = 0.0017) and the late (P = 0.0359) restenoses. CONCLUSIONS: Restenosis predominantly occurred within a year following nitinol stenting in the SFA, and the factors associated with the early restenosis were different from those with the late restenosis.

Angioscopic assessment of arterial repair following biodegradable polymer-coated biolimus A9-eluting stent implantation. - Comparison with durable polymer-coated sirolimus-eluting stent-.

BACKGROUND: Second-generation drug-eluting stents (DES) are expected to show better arterial repair than older DES. We angioscopically compared the biodegradable polymer-coated biolimus A9-eluting stent (BES) and durable polymer-coated sirolimus-eluting stent (SES) to explore differences in arterial repair. METHODS AND RESULTS: Angioscopy was performed 9 ± 1 months after 15 BES and 16 SES were implanted initially in the native coronary artery. Heterogeneity of neointimal coverage (NIC) as well as the dominant NIC grade was examined. NIC was defined as: grade 0 = fully visible struts; grade 1 = struts bulging into the lumen, but covered; grade 2 = embedded, but translucent struts; grade 3 = invisible struts. Heterogeneity was judged when the NIC grade varied ≥ 1. In-stent late loss (0.06 ± 0.23 vs. 0.07 ± 0.18 mm, P = 0.80), and dominant NIC grade (1.5 ± 0.8 vs. 1.3 ± 0.7, P = 0.45) were similar for BES and SES. Within the stents, NIC was more heterogeneous in SES than in BES (P = 0.035). 80% of BES showed homogeneous NIC, while 56% of SES had heterogeneous NIC. CONCLUSIONS: BES showed limited late loss similar to that for SES. Nonetheless, the NIC with BES was more homogeneous than that with SES. Biodegradable polymer-coated BES may have an advantage in homogeneous NIC.

Retrospective multicentre analysis of S.M.A.R.T. vs. Luminexx nitinol stent implantation for superficial femoral artery lesions (REAL SL) Registry. 5 years' experience.

BACKGROUND: The nitinol stent has proven superior primary patency than balloon angioplasty in superficial femoral artery (SFA) lesions, but a systematic comparison of the patency of 2 different nitinol stents (S.M.A.R.T. and Luminexx) in patients with SFA lesions has not been done. METHODS AND RESULTS: A multicenter, prospective database that included 511 consecutive patients who had undergone endovascular therapy with nitinol stenting for 638 limbs (S.M.A.R.T.: n=503; Luminexx: n=135) was retrospectively analyzed. Patency was assessed by duplex ultrasound. Outcomes were compared between the groups by the Kaplan-Meier and log-rank methods. To minimize the differences between each group, propensity-matched analysis was also performed. Stent fracture occurred in 11% (57/503) of the S.M.A.R.T. and 23% (31/135) of the Luminexx stents (P=0.0005). Despite a higher prevalence of chronic total occlusion (55% vs. 40%, P=0.002) and longer lesions (154±93mm vs. 135±71mm, P=0.03) in the S.M.A.R.T. group, there was no significant difference in patency for up to 5 years (P=0.50). When 119 lesions per group were assessed after propensity-matched analysis, the 5-year patency rate was 74% for the S.M.A.R.T. and 65% for the Luninexx stent (P=0.10). CONCLUSIONS: Despite a different stent fracture rate, there was no significant difference in terms of patency between the S.M.A.R.T. and Luninexx stents for up to 5 years.

Objective interpretation of dobutamine stress echocardiography by diastolic dyssynchrony imaging: a practical approach.

BACKGROUND: Postsystolic shortening is a sensitive maker of myocardial ischemia. The aim of this study was to investigate whether diastolic dyssynchrony imaging is useful for the objective interpretation of dobutamine stress echocardiography. METHODS: Postsystolic shortening was detected by using tissue Doppler imaging displacement timing analysis: the delays of the displacement peaks from end-systole were displayed from green to red, depending on the preset time window on diastolic dyssynchrony imaging. Dobutamine stress echocardiography was performed in 59 patients with suspected coronary artery disease who presented with normal left ventricular wall motion at rest (age range, 44-83 years; 20 women). The optimal time windows for diastolic dyssynchrony imaging at rest and at peak dobutamine were determined by receiver operating characteristic analysis by measuring the delays of the displacement peaks in the left ventricular myocardial segments. Diastolic dyssynchrony imaging was performed using time windows of 100 msec at rest and 80 msec at peak dobutamine. The diagnostic power of diastolic dyssynchrony imaging was assessed with quantitative coronary angiography as the gold standard (>50% diameter stenosis) both at rest and at peak dobutamine. RESULTS: Coronary artery disease was present in 37 patients (63%). Diastolic dyssynchrony imaging at peak dobutamine predicted the presence of coronary artery disease with sensitivity of 89%, specificity of 77%, predictive accuracy of 85%, positive predictive value of 79%, and negative predictive value of 81%. Diastolic dyssynchrony imaging at rest yielded sensitivity of 62%, specificity of 73%, predictive accuracy of 66%, positive predictive value of 79%, and negative predictive value of 53%. Importantly, diastolic dyssynchrony imaging demonstrated excellent intraindividual (97%) and interindividual (90%) agreement. CONCLUSION: Diastolic dyssynchrony imaging is useful in the objective interpretation of dobutamine stress echocardiography.

Importance of the angiosome concept for endovascular therapy in patients with critical limb ischemia.

OBJECTIVE: We investigated the role of the angiosome concept in endovascular therapy (EVT) for limb salvage. BACKGROUND: The angiosome concept is clinically useful in bypass surgery for critical limbs ischemia (CLI). However, comparison with direct and indirect flow to the site of ulceration based on angiosome concept regarding freedom from amputation has not been systematically studied for the patient with CLI undergoing EVT. METHODS: We analyzed 203 limbs in 177 consecutive patients (male = 127, age = 70 +/- 11 years) with ischemic ulceration that was Rutherford 5 or 6 (5 in 145 limbs and 6 in 58 limbs; pretreatment ankle-brachial index = 0.74 +/- 0.27), who underwent EVT alone without bypass surgery. We classified these patients into direct and indirect groups depending on whether feeding artery flow to the site of ulceration was successfully acquired or not acquired based on the angiosome concept. Freedom from amputation was compared between the direct and the indirect groups by Kaplan-Meier analysis. RESULTS: The overall limb salvage rate was 82% (167/203). Skin perfusion pressure was significantly higher in the direct group (67 +/- 25 mm Hg) than in the indirect group (41 +/- 20 mm Hg, P = 0.002). The limb salvage rate was also significantly (P = 0.03) higher in the direct group (86%) than in the indirect group (69%) for up to 4 years after the procedure. The number of vessels with run-off flow did not influence the limb salvage rate in either the direct group (P = 0.84) or the indirect group (P = 0.90). CONCLUSION: Acquiring direct flow based on the angiosome concept is important for limb salvage by EVT in patients with CLI.

Optimal stent-sizing with intravascular ultrasound contributes to complete neointimal coverage after sirolimus-eluting stent implantation assessed by angioscopy.

OBJECTIVES: The aim of this study was to explore the determinants of neointimal coverage after sirolimus-eluting stent (SES). BACKGROUND: Although SES has significantly reduced in-stent restenosis by inhibiting neointimal hyperplasia, insufficient neointimal coverage after stenting might result in adverse outcomes. METHODS: We evaluated 28 SES lesions with both angioscopy and intravascular ultrasound (IVUS). Quantitative assessments of the lesions and stent expansion were performed by IVUS at the time of stent implantation, and degree of neointimal coverage was judged by angioscopy at follow-up (11 +/- 6 months) whether the stent struts were embedded by the neointima ("complete/incomplete" neointimal coverage). RESULTS: "Complete" coverage was identified in 10 (36%), and "incomplete" coverage was identified in 18 (64%). Time from the stenting to angioscopy as well as the lesion and procedural characteristics were similar between the complete and incomplete coverage groups. The IVUS parameters were also similar, except for the final minimum stent cross-sectional area (CSA) (7.0 +/- 1.8 mm(2) in complete vs. 5.3 +/- 1.9 mm(2) in incomplete, p = 0.02) and lumen CSA at the distal reference site (6.1 +/- 1.4 mm(2) in complete vs. 4.9 +/- 1.2 mm(2) in incomplete, p = 0.02). The ratio of the stent area to the vessel area was significantly larger in the complete coverage than in the incomplete coverage group (0.52 +/- 0.11 vs. 0.39 +/- 0.09, p = 0.002). CONCLUSIONS: Adequate stent sizing relative to the vessel size might contribute to the angioscopically complete neointimal coverage after SES implantation.

Long-term results of endovascular therapy with nitinol stent implantation for TASC II A/B femoro-popliteal artery lesions: 4 years' experience.

BACKGROUND: Although in clinical practice endovascular therapy (EVT) with a nitinol stent for femoro-popliteal artery (FPA) lesions has been widely applied for TASC II A/B lesions, primary patency beyond 2 years remains unknown, as do the factors associated with restenosis. METHODS AND RESULTS: A prospectively maintained database that included 189 limbs treated with nitinol stents for de novo TASC II A/B FPA lesions was retrospectively analyzed. The outcomes were overall primary and secondary patency during the follow-up period and predictors associated with restenosis. Primary patency overall with nitinol stents was 84%, 82%, 80%, 80% and secondary patency was 96%, 93%, 90%, 90% at 12, 24, 36, 48 months, respectively. Primary patency was not statistically different between the 2 types of nitinol stents (Luminexx vs S.M.A.R.T. Control. stent, P=0.37) during follow-up period. From the multivariate analysis, administration of cilostazol was the strongest independent factor associated with restenosis (P=0.0012). CONCLUSIONS: Nitinol stent implantation for TASC II A/B FPA lesions is suitable and durable in sustaining freedom from restenosis through 4 years of follow-up.

Influence of stent fracture on the long-term patency in the femoro-popliteal artery: experience of 4 years.

OBJECTIVES: We investigated the time course of stent patency in the femoro-popliteal artery for as long as 4 years. BACKGROUND: Stent fracture has been related to poor 2-year patency in the femoro-popliteal artery. METHODS: We studied 239 consecutive patients who underwent provisional de novo stenting with nitinol stents for 333 limbs (Luminexx stent [C. R. Bard, Inc., Murray Hill, New Jersey] in 91 limbs; Smart stent [Cordis Corp., Miami Lakes, Florida] in 242 limbs) from April 2004 to December 2007. Stent fracture was determined by X-ray with multiple projections. Patency was assessed by duplex ultrasonography as peak systolic velocity ratio <2.4 or by angiography (% diameter stenosis <50%). Primary patency in those with and without stent fracture at follow-up was assessed along with factors influencing stent fracture. RESULTS: Primary patency was 81%, 74%, 68%, and 65% at 1, 2, 3, and 4 years, respectively. Stent fracture occurred in 14% (78 of 544) per stent and 17% (55 of 333) per limbs. Stent fracture was significantly associated with multiple stent deployments (with fracture = 2.3 +/- 0.9 stents vs. without fracture = 1.5 +/- 0.7 stents, p < 0.001) and long lesions (with fracture = 208 +/- 84 mm vs. without fracture = 121 +/- 79 mm, p < 0.001). Primary patency was 68% with fracture versus 83% without fracture at 1 year, p = 0.03; 65% versus 75% at 2 years, p = 0.05; 61% versus 69% at 3 years, p = 0.06; and 61% versus 65% at 4 years, p = 0.07. Neither type 1 nor type 3 fracture affected patency, although type 2 showed the worst patency. CONCLUSIONS: Stent fracture worsened the patency during the first 2 years, but it did not apparently affect patency beyond 2 years. In particular, complete stent separation did not affect patency.

Heterogeneous arterial healing in patients following paclitaxel-eluting stent implantation: comparison with sirolimus-eluting stents.

OBJECTIVES: We angioscopically compared paclitaxel-eluting stents (PES) and sirolimus-eluting stents (SES) to explore differences in arterial healing. BACKGROUND: Drug-eluting stents may demonstrate different arterial healing processes. METHODS: Angioscopy was performed 9 +/- 2 months after 30 PES and 36 SES were implanted initially in the native coronary artery. Heterogeneity of the neointimal coverage (NIC) as well as the dominant grade was examined. Neointimal coverage was defined as follows: grade 0 = fully visible struts; grade 1 = struts bulged into the lumen, but covered; grade 2 = embedded, but translucent struts; grade 3 = invisible struts. Heterogeneity was judged when the NIC grade variation >or=1. Thrombi and yellow plaques (YP) were also explored. RESULTS: In-stent late loss (0.44 +/- 0.44 mm vs. 0.13 +/- 0.33 mm; p < 0.0001) and dominant NIC grade (1.8 +/- 1.1 vs. 1.3 +/- 0.7; p = 0.02) were greater in PES than in SES. Of PES, 48% showed the heterogeneity of 1 grade; 26% showed that of 2 grades. Of SES, 53% showed homogeneous coverage; the remaining SES showed the heterogeneity of 1 grade; and 72% showed dominant grade 1. Thrombi were more common in PES than in SES (43% vs. 19%; p = 0.04). Both stents commonly revealed YP (83% vs. 78%; p = 0.76). CONCLUSIONS: NIC was more heterogeneous in PES, associated with a higher incidence of thrombi. Homogeneous NIC may be an important factor for competent arterial healing.

Detection of diastolic abnormality by dyssynchrony imaging: correlation with coronary artery disease in patients presenting with visibly normal wall motion.

BACKGROUND: Post-systolic shortening (PSS) is a sensitive indicator of myocardial ischemia. METHODS AND RESULTS: We have developed a tissue Doppler imaging technique that portrays PSS, and whether PSS correlates with coronary artery disease (CAD) was investigated in 186 patients presenting with chest pain and normal echocardiograms. Delays of the displacement peaks from end-systole were calculated in the apical views and displayed from green (0 ms) to red (>or=100 ms): detection of diastolic abnormality by dyssynchrony imaging (DADI). CAD was judged positive by DADI when the left ventricular segments were color-coded red. Patients subsequently underwent thallium-201 myocardial perfusion single-photon emission computed tomography (n=150), coronary angiography (CAG, n=74), or both (n=37). CAD(-) was defined as negative scintigraphy test and/or no significant coronary artery stenosis by CAG. In 43 patients (23%), CAD(+) was confirmed by CAG as >75% diameter stenosis. DADI predicted CAD with sensitivity of 60%, specificity of 75%, predictive accuracy of 72%, positive predictive value of 42%, and negative predictive value of 86%. Among 74 patients who underwent CAG, sensitivity was best for the left anterior descending artery. CONCLUSIONS: DADI detected the regional diastolic abnormality, which correlated with the presence of CAD in patients presenting with visibly normal wall motion.

Cilostazol reduces restenosis after endovascular therapy in patients with femoropopliteal lesions.

BACKGROUND: Despite the recent development of endovascular therapy (EVT), a high incidence of restenosis remains as an unsolved issue in patients presenting with femoropopliteal lesions. We investigated whether cilostazol reduces restenosis after successful EVT for de novo femoropopliteal lesions. METHODS: This study was designed as a prospective, randomized, open-label, blinded end point study in a single institution. Between March 2004 and June 2005, we randomized 127 patients who were successfully treated with EVT for de novo femoropopliteal lesions to receive cilostazol (200 mg/d, n = 63) or ticlopidine (200 mg/d, n = 64) in addition to aspirin (100 mg/d). Antiplatelet medications were started at least 1 week before EVT and were continued until the end of follow-up. Patency was defined by duplex ultrasound imaging with peak systolic velocity ratio >2.4. RESULTS: There were no significant differences in the patients and lesion characteristics. Sixteen patients dropped out of the study protocol, six of whom were withdrawn due to adverse drug effects (cilostazol, n = 5; ticlopidine, n = 1; P = .09). Ten patients died (cilostazol, n = 4; ticlopidine, n = 6; P = .53) during the follow-up period. Patency rates at 12, 24, and 36 months were 87%, 82%, and 73% in the cilostazol group and 65%, 60%, and 51% in ticlopidine group by intention-to-treat analysis (P = .013) and were 87%, 82%, and 73% in the cilostazol group and 64%, 57%, and 48% in the ticlopidine group (P = .0088) by as-treated analysis. Freedom from target lesion revascularization and all adverse events (restenosis, amputation, and death) was significantly higher in cilostazol group than in ticlopidine group (P = .036, P = .031). No acute, subacute, or chronic thrombotic occlusion was encountered, and bleeding complication rates were similar between the two groups. CONCLUSIONS: Cilostazol significantly reduces restenosis after EVT in femoropopliteal lesions.

Endovascular therapy for limb salvage in a case of critical lower limb ischemia resulting from fibromuscular dysplasia.

Fibromuscular dysplasia (FMD) is a nonatherosclerotic, noninflammatory vascular disease that mostly affects the renal and internal carotid arteries, rarely complicating lower limbs. We report a case of FMD complicating critical limb ischemia due to the obstruction of below the knee arteries, diagnosed and treated with the support of skin perfusion pressure (SPP) measurement. Initial angiogram revealed the anterior tibial artery (ATA) was subtotally occluded showing a "strings of beads" pattern, which is typical of the arteries affected by FMD. SPP guided endovascular therapy was successful for ATA lesions. Intractable rest pain subsequently disappeared and the ulcer was completely healed without amputation.

Serial angioscopic evidence of incomplete neointimal coverage after sirolimus-eluting stent implantation: comparison with bare-metal stents.

BACKGROUND: The time course of neointimal formation after stent implantation has not been studied extensively by angioscopy in the drug-eluting stent era. METHODS AND RESULTS: Serial angioscopic findings at first follow-up (3.6+/-1.1 months), second follow-up (10.5+/-1.6 months), and third follow-up (21.2+/-2.2 months) after stent implantation were compared between sirolimus-eluting stents (SES, n=17) and bare-metal stents (BMS, n=11). Neointimal coverage, thrombus, and presence of yellow plaques underneath the stents were assessed. Neointimal coverage was graded as follows: grade 0, stent struts were fully visible; grade 1, struts bulged into the lumen, although they were covered; grade 2, struts were embedded by the neointima but were seen translucently; or grade 3, struts were fully embedded and invisible. Neointimal coverage was remarkably different between SES and BMS at each follow-up point. Neointimal coverage grade was 1.1+/-0.5 in SES versus 2.9+/-0.3 in BMS at the first follow-up (P<0.0001), 1.1+/-0.5 in SES versus 3.0+/-0.0 in BMS (P<0.0001) at the second follow-up, and 1.3+/-0.5 in SES versus 3.0+/-0.0 in BMS at the third follow-up (P=0.0009). No significant serial changes in coverage grade were noted in the BMS group, whereas coverage grade slightly but significantly increased at the third follow-up in the SES group (P<0.05). Thrombi were detected in 4 SES: a red thrombus was seen from the first to the third follow-up in 2; another was detected only at the third follow-up; and the fourth was seen at the first follow-up but disappeared at the second follow-up, associated with a new white thrombus despite dual antiplatelet therapy. Yellow plaques had disappeared by the time of the second follow-up in BMS. In contrast, yellow plaques were exposed in 71% of SES at the first follow-up and remained exposed until the third follow-up. Neointimal coverage grades correlated with thrombi (P=0.002) and with yellow plaques (P<0.0001). CONCLUSIONS: Serial angioscopic findings up to 2 years after SES implantation were markedly different from those after BMS. Neointimal coverage was completed by 3 to 6 months in BMS. In contrast, SES demonstrated the presence of thrombi and yellow plaques even as much as 2 years after implantation.

[Shoshin beriberi complicating severe pulmonary hypertension: a case report].

A 44-year-old male was admitted to our hospital for dyspnea, associated with severe pulmonary hypertension. The patient fell into a shock state on the next day. Hemodynamic measurements revealed high output heart failure with low peripheral vascular resistance. We suspected shoshin beriberi, a fulminant form of cardiac beriberi, by ruling out other common causes of pulmonary hypertension. The rapid recovery after intravenous thiamine administration and the patient's history of improper diet strongly supported the diagnosis. The present case of shoshin beriberi complicating severe pulmonary hypertension shows that history taking is important in elucidating the etiology and selecting the correct treatment.

Positive isovolumic relaxation velocity detected by a spectral tissue Doppler mapping technique as an indicator of coronary artery disease: a prospective study.

BACKGROUND: A positive myocardial velocity during isovolumic relaxation phase (V(IR)) detected by spectral tissue Doppler imaging has been shown to indicate ischemic myocardium. We sought to examine the diagnostic value of positive V(IR) for detecting coronary artery disease (CAD) in patients with chest pain and apparently normal left ventricular contraction. METHODS: A total of 138 patients (74 men, age 69 +/- 8 years) underwent spectral Doppler tissue imaging measurements at the annular and mid left ventricular levels in the apical 4- and 2-chamber views (8 points/patient) at rest in addition to standard echocardiography. Subsequently, patients underwent thallium-201 myocardial perfusion single photon emission computed tomography (n = 98) and/or coronary angiography (n = 60). The duration of positive V(IR) was also assessed. CAD was diagnosed by having more than 75% diameter stenosis in coronary angiography. RESULTS: CAD was present in 41 patients (30%). The duration of positive V(IR) was distributed from 0 to 280 milliseconds with the median value of 100 milliseconds. Presence of positive V(IR) predicted CAD with sensitivity of 80% and specificity of 61%. CONCLUSIONS: Positive V(IR) detected by spectral tissue Doppler imaging is a useful indicator of CAD in patients with apparently normal left ventricular contraction and chest pain.

Effect of exercise on frequency of stent fracture in the superficial femoral artery.

Stent fracture has emerged as a new problem in the percutaneous transluminal angioplasty of the superficial femoral artery (SFA). The aim of our study was to delineate the factors influencing nitinol stent fracture in the SFA. Forty consecutive patients with peripheral artery disease who underwent rescue stenting with a nitinol stent (Luminexx, Bard) in the SFA were enrolled between May 2004 and January 2005. Follow-up angiography was performed 13.6+/-1.0 months later to detect stent fracture. Stent fracture occurred in 11 patients (28%). Lesion length>100 mm, the number of stents used, the lesion involving the distal SFA, chronic total occlusion, and walking>5,000 steps per day were more frequently observed in those with stent fracture than in those without fracture. Of these variables, walking>5,000 steps per day was the strongest independent determinant associated with stent fracture by discriminant analysis (p=0.0027). Vigorous exercise adversely affects stent fracture in patients implanted with a nitinol stent in the SFA.

Sustained attenuation of neointimal coverage over the stent following brachytherapy for in-stent restenosis: angioscopic findings.

BACKGROUND: The nature of the vessel lumen following vascular brachytherapy (VBT) has not been extensively explored in the clinical setting. METHODS AND RESULTS: By using angioscopy, 33 stents treated with percutaneous balloon angioplasty with or without VBT for in-stent restenosis after 8.9 +/- 2.1 months of the treatment were followed (VBT =14 lesions; control =19 lesions). Neointimal coverage, stent attachment, and the presence of red or white thrombi were factors that were assessed. The majority of the stents (74%) were fully covered with non-transparent neointima in the control group. In contrast, stent struts were clearly seen in 57% lesions with VBT. The absence of neointima with glittering stent struts were only seen in 29% of lesions in VBT (p = 0.03). Incomplete stent attachment was not detected in the controls, whereas 14% were in VBT (p = 0.17). Red thrombi were observed in 14% with VBT and in 16% in controls, which showed that there was a similar incidence regardless of the treatment. Neither exposure of stent struts (p = 0.5) nor incomplete stent attachment (p = 1.0) was related to thrombi. CONCLUSIONS: The exposure of stent struts and incomplete stent attachment were occasionally observed by angioscopy even 9 months after VBT for the treatment of in-stent restenosis.

Incomplete neointimal coverage of sirolimus-eluting stents: angioscopic findings.

OBJECTIVES: The goal of this study was to use angioscopy to investigate the amount of neointimal coverage after sirolimus-eluting stent (SES) implantation. BACKGROUND: Sirolimus-eluting stents reduce intimal hyperplasia. METHODS: We used angioscopy to evaluate 37 consecutive stented coronary artery lesions (15 SES and 22 bare-metal stents [BMS]) in 25 patients (18 men, 7 women) at 3 to 6 months after stent implantation. Angioscopic evaluation focused on: 1) neointimal coverage of stent struts, and 2) the existence of thrombi. The degree of neointimal coverage was classified as grade 0 when there was no neointimal coverage (similar to immediately after the implantation); grade 1 when stent struts bulged into the lumen, but were covered and still translucently visible; grade 2 when stent struts were visible but not clearly seen (not translucent); and grade 3 when stent struts were not visible because they were embedded in the neointima. RESULTS: Thrombi were identified in eight stented segments, tended to be more common with SES (p = 0.14), but were not seen on angiography. Three of the 15 SES (20%) had grade 0 neointimal coverage, and only 2 SES (13.3%) had complete coverage (grades 2/3). In contrast, all 22 BMS showed complete intimal coverage (grades 2/3). Thrombi were more common in stents with incomplete neointimal coverage (p = 0.09). CONCLUSIONS: The SES had incomplete neointimal coverage three to six months after implantation, and this was associated with subclinical thrombus formation.