The effect of complex vascular anatomy on silent new ischemic cerebral lesions in carotid artery stenting procedures (from the COMPLEX-CAS Trial).

BACKGROUND: Carotid artery stenting is a minimally invasive, durable alternative treatment option, which is an alternative to the reference method, carotid endarterectomy, for patients with carotid artery stenosis; however, silent new ischemic cerebral lesions (SNICLs) after carotid artery stenting remain as a matter of concern. Hence, we aimed to assess the effect of complex vascular anatomy on silent new ischemic cerebral lesions in carotid artery stenting procedures. METHODS: We prospectively evaluated 122 patients (mean age: 69.5 ± 7.1 years, male:83) who underwent carotid artery stenting for carotid artery revascularization. The patients having symptomatic transient ischemic attack or stroke after carotid artery stenting were excluded. The presence of a new hyperintense lesions on diffusion-weighted imaging without any neurological findings was considered as the SNICL. Patients were classified into two groups as DWI-positive and DWI-negative patients. RESULTS: Among the study population, 32 patients (26.2%) had SNICLs. The DWI-positive group had a significantly higher common carotid artery (CCA)-internal carotid artery (ICA) angle, older age, more frequent history of stroke, a higher proportion of type III aortic arch, and longer fluoroscopy time than the DWI-negative group. High CCA-ICA angle was identified as one of the independent predictors of SNICL (OR (odds ratio) = 1.103 95%CI (confidence interval): (1.023-1.596); p = 0.034), and CCA-ICA angle higher than 34.5 degrees predicted SNICL with a sensitivity of 62.5% and a specificity of 62.2% (area under the curve: 0.680; 95% CI: 0.570 to 0.789; p = 0.003). CONCLUSIONS: The higher CCA-ICA angle may predict pre-procedure SNICL risk in carotid artery stenting and may have clinical value in the management of patients with carotid artery stenosis.

Coronary artery ectasia is associated with the c.894G>T (Glu298Asp) polymorphism of the endothelial nitric oxide synthase gene.

Coronary artery ectasia (CAE) is characterized by inappropriate dilation of the coronary vasculature. The underlying mechanisms of CAE formation are not yet entirely known. A polymorphism in the endothelial nitric oxide synthase (eNOS) gene, which reduces eNOS activity, might be a risk factor for coronary heart diseases. However, its role in CAE is unknown. One of the most studied eNOS gene polymorphisms is a c.894G>T polymorphism that results in the conversion of Glu (GAG) to Asp (GAT) at position 298. In this study, we investigated the potential association between the c.894G>T (Glu298Asp) polymorphism and CAE. The present study included 84 subjects from 2,980 consecutive patients in whom elective diagnostic coronary angiography was performed. Forty patients with isolated CAE and 44 subjects with normal coronary arteries were enrolled. The frequencies of the G allele were 78.4% in the control and 57.5% in CAE patients. The TT genotype was more frequent in patients with CAE than that in the controls (20% vs. 4.5%, p = 0.013). Furthermore, the risk of developing CAE in the presence of the homozygous TT genotype was significantly higher in the patients than that in the controls (OR = 7.7, 95% CI = 1.44-41.3). The presence of an 894T allele increased the risk of CAE 2.8-fold (95% CI = 1.15-6.73; p = 0.027). The frequencies of the T allele were 65% in CAE patients and 38.6% in the controls. In conclusion, the c.894G>T polymorphism in the eNOS gene may be a risk factor for CAE.

Can Syntax Score predict angiographically visible distal embolization during primary percutaneous coronary intervention?

BACKGROUND: Primary percutaneous coronary intervention (PPCI) is the most effective and validated treatment strategy of ST segment elevation myocardial infarction (STEMI). Nevertheless, normal myocardial perfusion cannot always be achieved at the end of the procedure in a significant number of patients with STEMI. The aim of this study was to investigate angiographic and procedural predictors of angiographically visible distal embolization (AVDE) during PPCI and the assessment of mid and long term mortality. METHODS: Four hundred and sixty five consecutive patients undergoing PPCI for acute STEMI and matching eligibility criteria of the study between January 2010 and December 2011 were enrolled in the study. Patients were divided into two groups; 61 (13.1%) with AVDE and 404 patients without AVDE based on angiograms performed during PPCI. RESULTS: Longer stent length, higher balloon diameter, low Syntax score (SxS), low LVEF, high neutrophil/lymphocyte ratio and chronic renal failure were seemed to be associated with AVDE in univariate analysis and these variables were entered into multivariate analysis. In multivariate analyzes, stent length, LVEF and low SxS were found to be associated with AVDE (OR: 1,11, 95 % CI: 1,06-1,16, p< 0,001; OR: 0,80, 95%CI: 0.80-0.91, p< 0,001; OR: 0,85, 95%CI: 0,79-0,91, P< 0,001, respectively). CONCLUSIONS: This study concluded that low SxS, longer stent length, low LVEF were predicting risk factors associated with the development of AVDE in patients undergoing PPCI. Low SxS associated with AVDE may be linked to the strong relation between AVDE and high thrombus burden and composition of atherosclerotic plaque rather than complex coronary lesions.