Novel combination therapy of pedal arch angioplasty and dual distal bypass as an alternative treatment option for vasculitis in patients with chronic limb-threatening ischemia.

A 68-year-old man with chronic limb-threatening ischemia caused by atypical vasculitis was successfully treated by the combination of pedal arch angioplasty and dual distal bypass. Angioplasty alone failed; therefore, we performed pedal arch angioplasty followed by distal bypass revascularized to the newly created dorsalis pedis artery and posterior tibial artery anastomosis sites. Restenosis occurred twice, and both cases were successfully treated by immediate angioplasty. Both branches of the graft remained patent for >2.5 years, and the wound healed completely. This unique combination of techniques can provide favorable results for selected patients with chronic limb-threatening ischemia.

Effect of Target Lesion Revascularization on Restenosis Lesions of the Superficial Femoral Artery without Recurred Symptoms after Endovascular Therapy.

AIM: This study aims to elucidate the effects of early application of target lesion revascularization (TLR) to restenosis lesions of the superficial femoral artery (SFA) without recurrence of symptoms. Despite recent improvements in endovascular therapy (EVT) for the SFA, restenosis remains to be a problem. However, restenosis is not always associated with the recurrence of limb symptoms. Although early application of TLR is not generally approved for restenosis lesions of the SFA without recurred symptoms, it is expected to contribute to long-term patency and other favorable outcomes. Nonetheless, its effectiveness remains to be determined. METHODS: We retrospectively analyzed 616 patients who developed restenosis after undergoing femoro-popliteal EVT for claudication (Rutherford category 1 to 3) due to de novo femoro-popliteal lesions between January 2010 and December 2016 at 11 centers in Japan. Recurred symptoms were defined as symptoms of the same or higher Rutherford categories than those immediately before the initial EVT. RESULTS: Of the patients, 291 (47 %) lacked recurred symptoms; 69 (24 %) underwent TLR for restenosis. After propensity matching, the risk of occlusion was determined to be not significantly different between the TLR and observation groups; the 3-year occlusion-free rate was 68 % and 62 %, respectively (P=0.84). The risk of recurring symptoms, critical limb ischemia, and all-cause death was also found to be comparable between groups. The incidence of target vessel revascularization was significantly higher in the TLR than in the observation group (1.55 [95 % confidence interval: 1.25-1.93] vs. 0.59 [0.41-0.85] per 3 person-years). CONCLUSIONS: In patients with SFA restenosis without recurred symptoms, early application of TLR showed no advantages.

Feasibility and Safety of the Direct Occluded Vessel Puncture Technique as a New Access Site for Complex Peripheral Artery Occlusive Disease.

AIM: This study aims to describe the feasibility and safety of direct occluded vessel puncture as a new access site for complex peripheral artery occlusive disease. METHODS: Eleven consecutive patients with symptomatic peripheral artery disease underwent endovascular therapy using the direct occluded vessel puncture technique. The occluded vessel was punctured using a dedicated 20 G needle and the Hi-Torque Command 18 ST guidewire under duplex echo or fluoroscopic guidance, and a 6 Fr sheath was then inserted. Hemostasis was achieved with the Exoseal® Vascular Closure Device. RESULTS: Direct occluded vessel puncture was achieved in 10 of 11 cases (90.9%), and procedural success was achieved in all cases. There were no in-hospital deaths or any complications, including bleeding, pseudoaneurysms, thrombosis, or surgical conversion. CONCLUSION: The direct occluded vessel puncture technique using a 20 G needle and the Hi-Torque Command 18 ST is feasible and safe. This technique may also be used as an alternative option when there are no appropriate approach sites.

Vascular response to paclitaxel-eluting nitinol self-expanding stent in superficial femoral artery lesions: post-implantation angioscopic findings from the SHIMEJI trial (Suppression of vascular wall Healing after IMplantation of drug Eluting peripheral stent in Japanese patients with the Infra inguinal lesion: serial angioscopic observation).

The aim of this study was to elucidate the vascular responses to paclitaxel-eluting stent (Zilver PTX stent) in superficial femoral artery lesion at different elapsed times using angioscopy. Patients who received Zilver PTX stent implantation from five centers were enrolled. We performed angioscopic examinations at 2, 6, and 12 months after implantation and evaluated neointimal coverage (NIC) grade, intra-stent thrombus (IS-Th) grade, and presence of yellow plaque. NIC grade 0 was defined as stent struts exposed; grade 1, struts transparently visible although covered; grade 2, struts embedded in the neointima, but translucent; and grade 3, struts fully embedded and invisible. IS-Th was graded as follows: grade 0 (none), 1 (focal), and 2 (diffusely spread). Angioscopic follow-up evaluation was performed at 2 months (25 patients, 42 lesions), 6 months (18 patients, 23 stents), and 12 months (14 patients, 24 stents) after stent implantation. Dominant NIC grade significantly increased over time; however, 16.3% of the cases had NIC grade 1 or 2 at 12 months. IS-Th grade decreased; however IS-Th and yellow plaque were persistently observed in 62.5% and 83.3% cases, respectively, at 12 months. An ongoing healing response was observed at 12 months after implantation; however, thrombogenic findings were noted. Prolonged dual antiplatelet therapy could potentially enhance the clinical utility of Zilver PTX.

Efficacy of CilostAzol for Below-the-Knee Artery Disease after Balloon AnGioplasty in PatiEnts with Severe Limb Ischemia (CABBAGE Trial).

BACKGROUND: Optimal medical therapy after endovascular therapy in patients with critical limb ischemia (CLI) remains unclear. Therefore, we investigated whether cilostazol reduce restenosis after balloon angioplasty for infrapopliteal lesions in CLI patients. METHODS: This study was performed as a multicenter, prospective, randomized, open-label, blinded-end point study with independent angiographic core laboratory adjudication. Sixty patients were eligible and 53 patients were enrolled and allocated. The primary end point was 3-month angiographic restenosis. The main secondary end points included major adverse limb event (MALE defined as requirement of any reintervention or major amputation), perioperative complications, major amputation, all-cause death, and hemorrhagic events. RESULTS: A total of 53 patients were randomized and all received their allocated intervention. Two patients in the cilostazol plus aspirin group and 1 in the aspirin group did not undergo any angioplasty for infrapopliteal stenotic lesions, and therefore were excluded from analysis. Finally, 38 vessels in 25 patients in the cilostazol plus aspirin group and as many cases in the aspirin group were included in the analysis. There were no significant differences in baseline characteristics between the 2 groups. The 3-month restenosis rate was 82% in the cilostazol + aspirin group and 81% in the aspirin group, with no significant difference (P = 0.91). The MALE rate was 11% in the cilostazol plus aspirin group and 8% in the aspirin group (P = 0.73). In addition, no significant difference was observed in any secondary points. CONCLUSIONS: Cilostazol did not reduce 3-month angiographic restenosis after balloon angioplasty for below-the-knee lesion in CLI patients.

The distribution of calcified nodule and plaque rupture in patients with peripheral artery disease: an intravascular ultrasound analysis.

In addition to plaque rupture (PR), calcified nodule (CN) may also have the potential to develop into arterial thrombus in the peripheral arteries. This study evaluated the distribution of plaque ruptures and calcified nodules in the peripheral arteries and their impact on the outcome of endovascular therapy (EVT). Consecutive 159 patients who underwent EVT with intravascular ultrasound guidance were enrolled. The position of CNs and PRs were assigned to any of common iliac artery, external iliac artery, common femoral artery, and superficial femoral artery. Forty-six (29%) patients had calcified nodule and twenty-eight (18%) patients had plaque rupture somewhere in the lower limb arteries. Although calcified nodules were evenly distributed throughout the length of the arteries plaque ruptures were predominantly located in the proximal segment of the iliofemoral arteries. Stent expansion ratio was significantly smaller in the target arteries with calcified nodules than in those with plaque rupture. Multivariate logistic regression analysis identified hemodialysis as an independent clinical predictor of calcified nodule (odds ratio 8.15, 95% confidence interval 1.73-38.3; P = 0.008). CN definitely affects incomplete stent deployment in the peripheral artery contributing to adverse events, on the other hand, PR has more acceptable outcomes after stent implantation. In the clinical setting, it is important that we realize the features of peripheral artery disease and its patient characteristics which having CNs and PRs to make a strategy for revascularization.

Comparison of the OUTBACK® Elite Reentry Catheter and the Bi-directional Approach after Failed Antegrade Approach for Femoro-popliteal Occlusive Disease.

AIM: A successful antegrade wire crossing for femoro-popliteal chronic total occlusion (FP-CTO) is still a technical challenge. We attempted to demonstrate the safety and feasibility of the OUTBACK® Elite reentry catheter and the bi-directional approach for failed FP-CTO cases with the antegrade approach. METHODS: Endovascular therapy for FP-CTO was performed in 219 lesions from May 2013 to December 2016 at Morinomiya Hospital. We retrospectively analyzed the data of 43 consecutive lesions which underwent endovascular therapy using the bi-directional approach with distal access and the mono-directional approach with the OUTBACK® Elite reentry catheter for FP-CTO lesions. The antegrade success using a combination of traditional and Intravascular Ultrasound (IVUS) -guided techniques was achieved in 170 lesions out of a total of 219 lesions. From May 2013 to June 2016 (phase 1), the bi-directional approach with distal access was applied to 22 lesions after failed antegrade approaches. From July 2016 to December 2016 (phase 2), the mono-directional approach with the OUTBACK® Elite reentry catheter was applied to 21 lesions. RESULTS: Clinical and lesion characteristics in phase 1 were not significantly different from those in phase 2. The overall initial technical success rate was 100% in both phases. The total wire number and amount of contrast media were significantly less, and the total procedure time and the total fluoroscopic time were significantly shorter in phase 2 than in phase 1 (p＜0.01). CONCLUSIONS: Endovascular therapy for FP-CTO using the OUTBACK® Elite reentry catheter is feasible and safe after a failed antegrade approach.

Histopathological validation of optical frequency domain imaging to quantify various types of coronary calcifications.

AIMS: This study evaluated whether optical frequency domain imaging (OFDI) could identify various coronary calcifications and accurately measure calcification thickness in comparison with histopathology. METHODS AND RESULTS: A total of 902 pathological cross-sections from 44 coronary artery specimens of human cadavers were examined to compare OFDI and histological images. Histological coronary calcification was classified into four different types: (i) superficial dense calcified plates, (ii) deep intimal calcification, (iii) scattered microcalcification, and (iv) calcified nodule. The thickness of calcification was measured when both the leading and trailing edges of calcification were visible on OFDI. Of the 902 histological cross-sections, 158 (18%) had calcification: 105 (66%) were classified as superficial dense calcified plates, 20 (13%) as deep intimal calcifications, 30 (19%) as scattered microcalcifications, and 3 (2%) as calcified nodules. Superficial dense calcified plates appeared as well-delineated heterogeneous signal-poor regions with sharp borders on OFDI. Deep intimal calcifications could not be identified on OFDI. Scattered microcalcification appeared as homogeneous low intensity areas with indiscriminant borders. Calcified nodule, a high-backscattering protruding mass with an irregular surface, also appeared as a low intensity area with a diffuse border. The ROC analysis identified calcium thicknesses <893 µm as cut points for the prediction of measurable calcification (72% sensitivity and 91% specificity, area under the curve = 0.893, P < 0.001). CONCLUSION: Our study demonstrated the potential capability of OFDI to characterize various types of coronary calcifications, which may contribute to the understanding of the pathogenesis of coronary atherosclerosis.

Ex vivo assessment of neointimal characteristics after drug-eluting stent implantation: Optical coherence tomography and histopathology validation study.

BACKGROUND: Optical coherence tomography (OCT) is one of the tools trying to distinguish neoatherosclerosis from other neointimal tissue but its role has to be still validated. This study evaluated the diagnostic accuracy of OCT for characterization of lipid-atherosclerotic neointima following drug-eluting stent (DES) implantation. METHODS: Twelve stented coronary arteries from the 7 autopsy hearts were imaged by OCT. These OCT images were compared with histology. By OCT, the morphological appearances of neointima were classified into three patterns: homogeneous pattern, heterogeneous pattern with visible strut, or heterogeneous pattern with invisible strut. RESULTS: Of 21 histological cross-sections, 6 were categorized as homogeneous patterns (29%), 11 as heterogeneous patterns with visible stent strut (52%), and 4 as heterogeneous patterns with invisible stent strut (19%). All homogeneous patterns were composed of smooth muscle cells with collagen fibers. The heterogeneous patterns with visible stent strut included proteoglycan-rich myxomatous matrix and calcium deposition. On the other hand, the heterogeneous patterns with invisible stent strut comprised atheromatous tissue, including a large amount of foam cell accumulation (25%) or large fibroatheroma/necrotic core (75%) inside the stent struts within neointima. The optical attenuation coefficient was highest in the heterogeneous pattern with invisible stent strut due to scattering of light by atheromatous tissue. CONCLUSION: The heterogeneous patterns with invisible stent strut on OCT imaging identify the presence of lipid-atherosclerotic tissue within neointima after DES. This may suggest the potential capability of OCT based on visualization of stent struts for discriminating atheromatous formation within neointima from other neointimal tissue.

Ex vivo comparison of angioscopy and histopathology for the evaluation of coronary plaque characteristics.

The yellow plaque has been considered to be a vulnerable and high risk for acute coronary syndrome events but not fully evaluated. The aim of this study was to evaluate the relationship between angioscopic color grade and histological features in coronary autopsy specimens. We longitudinally sectioned 110 coronary arteries from 40 autopsy hearts with non-cardiovascular death. Harvested arteries were imaged with intravascular ultrasound to identify the focal plaque (plaque burden >50 %). An angioscopic examination of each focal plaque evaluated its color intensity as follows: 0 (white), 1 (light yellow), 2 (yellow), or 3 (dark yellow). The corresponding histological assessment was classified according to a modified version of the American Heart Association classification of atherosclerosis. Two hundred six plaques were matched to the histological analysis. Of these, 82 (40 %) were categorized as yellow (≥grade 1). Although, yellow plaque often includes thin-cap fibroatheroma (TCFA), the sensitivity, specificity, positive predictive value, negative predictive value, and overall diagnostic accuracy for histological TCFA were 83, 91, 22, 99 and 91 %, respectively. The false-positive coronary angioscopic diagnoses for TCFA that contributed to the low positive predictive value consisted of the following plaques: thick FA (>65 µm), accumulations of large quantities of foam cells on the luminal surface, or dense calcified plates at the surface of the intima. Vulnerable coronary plaques were detected with high sensitivity and low positive predictive value from their yellow color on angioscopy. Not only fibroatheroma but also various types of plaques and their components, such as immature lipidic components and superficial calcium plates, appeared yellow on coronary angioscopy.

Morphological, Functional, and Biological Vascular Healing Response 6 Months After Drug-Eluting Stent Implantation: A Randomized Comparison of Three Drug-Eluting Stents.

OBJECTIVES: This study evaluated coronary endothelial function after the implantation of sirolimus-eluting stents (SESs), everolimus-eluting stents (EESs), and zotarolimus-eluting stents (ZES) by a different methodology, and also analyzed whether optical coherence tomography (OCT) findings represent endothelial healing after stenting. BACKGROUND: It is unclear whether OCT assessment of stent strut coverage represents endothelial healing after drug-eluting stent implantation. METHODS: Thirty patients with a left anterior descending artery lesion were randomized 1:1:1 to receive an SES, EES, or ZES. The vascular response was evaluated 6 months after stenting by three methods: the functional response by acetylcholine infusion, the morphological response by OCT, and the biological response by measuring vascular endothelial growth factor (VEGF) levels. RESULTS: The proportion of uncovered struts by OCT at 6 months was significantly higher in both SES and EES than in ZES. However, the vasomotor response was impaired and the VEGF level of the coronary sinus was significantly lower in SES than in EES and ZES. There were no relationships between the OCT findings and vasomotor response to acetylcholine and VEGF levels in all cohorts. CONCLUSIONS: The vascular response at 6 months was more preserved in ZES and EES than in SES. Our results suggest that the morphological assessment with OCT may not always be used as a surrogate for functional and biological healing response after stenting. © 2015 Wiley Periodicals, Inc.

Impact of spotty calcification on long-term prediction of future revascularization: a prospective three-vessel intravascular ultrasound study.

To date, there are no prospective studies on the relationship between plaque characteristics identified by 40 MHz IVUS and future adverse events. This prospective study evaluated the relationship between plaque morphology in nonculprit nonsignificant lesions, determined by 40 MHz IVUS, and long-term clinical outcomes. Consecutively, 45 patients who underwent 3-vessel intravascular ultrasound (IVUS) examinations were prospectively enrolled. Qualitative and quantitative IVUS analyses including scoring of echogenicity for assessment of plaque characterization were performed for each nonsignificant nonculprit lesion. The number, the length, the location (superficial or deep), and maximum arc were measured for each calcium deposit within plaques. Spotty calcification was defined as calcium deposits <90° and <6 mm in length. Primary end point was defined as nonsignificant nonculprit lesion-related revascularization (NNLR) during 6 years of follow-up. A total of 163 nonsignificant nonculprit lesions with mild to moderate stenosis were identified on baseline 3-vessel IVUS. Of those 163 lesions, six lesions required NNLR during the follow-up period. There were no differences in quantitative IVUS parameters including remodeling index, plaque burden, and echogenicity between lesions requiring and not requiring NNLR. However, deep spotty calcification was more frequently identified in lesions requiring NNLR than in those not requiring NNLR (33 vs. 8 %, P = 0.02). Spotty calcium deposits identified by 40 MHz IVUS predicted the need for NNLR during a 6-year follow-up period. This finding suggests that deep spotty calcium may be a surrogate marker for plaque progression and the subsequent need for revascularization in the future.

Tissue Characterization of In-Stent Neointima Using Optical Coherence Tomography in the Late Phase After Bare-Metal Stent Implantation--An Ex Vivo Validation Study.

BACKGROUND: We performed an ex vivo study to investigate optical coherence tomography (OCT) imaging for differentiating several types of neointimal tissue during the later phases after bare-metal stent (BMS) implantation as compared with histologic results. METHODS AND RESULTS: OCT imaging was performed in 6 autopsy hearts for 10 BMS with implant duration >4 years. OCT qualitative neointimal tissue characterization was based on tissue structure and classified as homogeneous pattern, heterogeneous pattern with visible struts, or heterogeneous pattern with invisible struts. Corresponding histological analyses of each 2-mm cross-section of the entire BMS were performed. Of 81 cross-sections, histological analysis revealed that the homogeneous pattern of neointima on OCT (n=39) contained smooth muscle cells with collagen, indicating high neointimal maturity. The heterogeneous patterns with visible struts (n=35) contained different tissues, including a proteoglycan-rich myxomatous matrix or dense calcified plate deposition. The heterogeneous patterns with invisible struts (n=7) included neointimal lipid/necrotic core formation, accumulation of foam cells, or microcalcification scattering. Of the 66 cross-sections containing large microvessels within the neointima on histology, only 6 (9%) were visualized by OCT. CONCLUSIONS: The present study confirmed the potential use of OCT in differentiating several types of neointima after BMS implantation. The image interpretation of OCT, based on visualization of stent struts, enables identification of several types of neointimal tissues, including in-stent fibroatheroma formation, more accurately.

Wire Passages of 0.035-inch Looped Wire Technique for Femoropopliteal Long Total Occlusions.

AIM: Although it is understood that a looped wire technique using a 0.035-inch wire for femoropopliteal (FP) long chronic total occlusions (CTOs) goes to the subintima, there has been no systematic assessment of wire passages. The purpose of this study is to examine these passages by intravascular ultrasound (IVUS) after looped wire technique for FP long CTOs. METHODS: Between March 2012 and October 2014, 57 consecutive FP long CTO lesions (mean lesion length, 246 ± 42 mm), involving the superficial femoral artery ostium and treated with IVUS-guided endovascular therapy, were enrolled. After IVUS confirmed that the initial wire passage was intraplaque, the looped wire technique was routinely conducted through the CTO body. Based on IVUS findings, the wire passage was classified into 3 types: intraplaque, subintimal, and intramedia. RESULTS: At the FP lesion in the proximal, middle, and distal segments, the wire proceeded intraplaque in 98%, 25%, and 20% cases; subintimal in 2%, 61%, and 52%; and intramedia in 0%, 14%, and 28%, respectively. The success rate of antegrade wiring was 74%, with the remaining 26% cases requiring an additional retrograde approach. CONCLUSIONS: The looped wire technique variably proceeds to intraplaque, subintimal, or intramedia, even starting from intraplaque in FP long CTOs.

Aspiration thrombectomy in a patient with suprarenal inferior vena cava thrombosis.

DVT has rarely been observed in the inferior vena cava (IVC). Pulmonary embolism (PE), which can be life-threatening, often occurred in patients with IVC thrombosis. Therefore, an IVC filter is frequently used in those patients for the prevention of PE. A case of successful endovascular treatment of an IVC thrombus in a patient with relative contraindications to implantation of an IVC filter is presented. This case report shows that aspiration of thrombi caught in the removable IVC filter may be an alternative to surgery in high-risk patients with catheter-related suprarenal inferior vena cava thrombosis.

Endovascular therapy by CO2 angiography to prevent contrast-induced nephropathy in patients with chronic kidney disease: a prospective multicenter trial of CO2 angiography registry.

OBJECTIVES: To assess the safety and efficacy of carbon dioxide (CO2) angiography-guided endovascular therapy (EVT) for renal, iliofemoral artery disease. BACKGROUND: Patients with peripheral vascular disease (PVD) often have chronic kidney disease (CKD) and the use of iodinated contrast media may enhance the risk of contrast-induced nephropathy (CIN). Contrast volume reduction is an effective CIN preventive strategy. METHODS: A prospective multicenter registry was developed and six clinical centers participated in the study. Patients with an estimated glomerular filtration rate (eGFR) of <60 ml/min/1.73 m2 and stage-3 CKD were recruited between February 2012 and March 2013. CO2 angiography-guided EVT was performed; incomplete CO2 angiograms were supplemented by intravascular ultrasound, pressure wire, and/or minimal iodinated contrast media. The primary endpoint was a composite of freedom from renal events and freedom from major CO2 angiography related complications. RESULTS: This study included 98 patients with 109 lesions. The mean eGFR baseline was 35.2±12.7 ml min(-1). CO2 angiography-guided angioplasty were performed in 16 renal arteries, 31 aortoiliac arteries, and 62 superficial femoral arteries. The technical success rate was 97.9%. Average CO2 consumption was 281.4±155.8 ml, average dose of iodinated contrast media was 15.0±18.1 ml. Primary endpoint was 92.8% (91/98). Incidence of CIN was 5.1% (5/98) and CO2 angiography-related complications occurred in 17.3% (17/98). Two cases (2%) developed severe, fatal, nonocclusive mesenteric ischemia (NOMI). CONCLUSIONS: This trial showed that CO2 angiography-guided angioplasty was effective for preventing CIN, however, CO2 angiography related complication was somewhat high.

Effect of bare-metal nitinol stent implantation and paclitaxel-eluting nitinol stent implantation on vascular response in the superficial femoral artery lesion assessed on intravascular ultrasound.

BACKGROUND: Although previous intravascular ultrasound (IVUS) studies reported that the drug-eluting stent (DES) has successfully decreased in-stent restenosis (ISR) by inhibiting neointimal hyperplasia (NIH) in the coronary artery lesion, no IVUS data for vascular response after DES implantation in the superficial femoral artery (SFA) have been published. METHODS AND RESULTS: We retrospectively analyzed 38 de novo SFA lesions from 32 patients who underwent endovascular therapy (EVT) with self-expanding bare-metal nitinol stent (25 lesions; BMS group) or self-expanding paclitaxel-eluting nitinol stents (13 lesions; PES group). At 6 months after EVT, follow-up IVUS was done to evaluate NIH. Serial IVUS volumetric analysis was done after stent deployment and at follow-up. Mean stent, lumen and neointimal areas were calculated as the volume divided by the stent length. The primary endpoint of this study was mean late lumen loss at 6-month follow-up. The mean follow-up period was 189±39 days. Mean neointimal area was smaller in the PES group compared to the BMS group (3.3±1.0mm(2) vs. 10.2±4.1mm(2), P<0.001). Mean late lumen loss was significantly lower in the PES group compared to the BMS group (-2.3±3.7mm(2) vs. 2.1±4.7mm(2), P<0.05). CONCLUSIONS: EVT with DES in SFA lesions might decrease NIH associated with ISR in short-term follow-up.

A case of acute thrombotic occlusion of the popliteal artery occurring immediately after the total knee arthroplasty recanalized by ballooning alone.

Arterial complications associated with total knee arthroplasty are rare but occasionally life-threatening. Although popliteal artery injuries have been repaired by bypass surgery historically, there are potentially multiple useful methods for the restoration. In this report, we describe a case of acute thrombotic occlusion of the popliteal artery occurring immediately after total knee arthroplasty, and successfully repaired by endovascular therapy with endoluminal balloon inflation. .

The impact of plaque characterization assessed by intravascular ultrasound on myocardial perfusion after primary angioplasty in patients With ST-segment elevation myocardial infarction.

BACKGROUND: Previous studies described that inadequate tissue perfusion after primary angioplasty in ST-elevation myocardial infarction (STEMI) patients is associated with adverse cardiac events. This study evaluated whether plaque morphological intravascular ultrasound (IVUS) characteristics affects tissue perfusion after stent implantation in STEMI patients. METHODS AND RESULTS: A total of consecutive 306 STEMI patients who underwent primary angioplasty with IVUS were analyzed. Maximum ST-segment elevation before angioplasty was compared with ST-segment levels 60min after angioplasty. Percent ST-segment resolution (STR) was calculated and categorized as complete (>70%), partial (30-70%), and absent (<30%). Qualitative and quantitative IVUS analyses were performed using standard methods. Plaque with ultrasound attenuation was defined as IVUS finding with backward signal attenuation behind plaque >180° without dense calcium. One-hundred-fifty patients had complete, 101 had partial, and 55 had absent STR. The incidence of in-hospital death tended to be higher in absent STR than in partial and complete STR groups. Multivariate analysis indicated that remodeling index (P=0.004), the presence of ultrasound attenuation (P=0.02), percentage stent expansion (P=0.03), and the presence of deep calcium (P=0.049) were the independent predictors related to the occurrence of absent STR after angioplasty. CONCLUSIONS: Positive vessel remodeling, plaque with ultrasound attenuation >180°, deep calcium, and stent overexpansion as assessed by IVUS are associated with the absence of STR after primary angioplasty in patients with STEMI.

Preprocedural evaluation and endovascular treatment of iliofemoral artery disease without contrast media for patients with pre-existing renal insufficiency.

BACKGROUND: Generally, both the preprocedural evaluation and endovascular therapy (EVT) for lower limb arteries require contrast media that is harmful for patients with chronic renal insufficiency. In the present study these procedures were performed without using nephrotoxic contrast media in patients with preexisting renal insufficiency and iliofemoral artery disease. METHODS AND RESULTS: The 36 consecutive patients with chronic renal insufficiency underwent preprocedural evaluation with duplex examination, magnetic resonance angiography (MRA) without contrast media, and plain computed tomography (CT). A total of 51 lesions were treated using intravascular ultrasound (IVUS) without contrast media. The overall technical success was 100% without any complications. Pre- and postprocedural ankle-brachial indices changed from 0.59 ± 0.23 to 0.92 ± 0.14. The mean serum creatinine concentration before and after treatment, and 3 months after treatment did not change (2.1 ± 1.4, 2.0 ± 1.4, and 2.1 ± 1.6 mg/dl, respectively). The overall 3-month survival rate and limb salvage rate was 100%. CONCLUSIONS: EVT comprising duplex, MRA, and CT for preprocedural evaluation and IVUS-guided procedure is feasible and may avoid intra-arterial contrast injection in selected patients deemed at high risk for renal failure from nephrotoxic contrast material.