The relative effects of abciximab and tirofiban on platelet inhibition and C-reactive protein during coronary intervention.

BACKGROUND: We sought to compare the efficacy of tirofiban and abciximab on platelet inhibition as well as their effects of platelet inhibition on C-reactive protein levels during percutaneous coronary intervention (PCI). METHODS: Using a randomized, double-blind study design, 95 consecutively eligible patients were randomized to receive either tirofiban or abciximab before undergoing native coronary artery revascularization with a stent. Clinical endpoints were death, nonfatal MI, target vessel revascularization (TVR) with coronary artery bypass grafting or PCI within 30 days of the study procedure. The medications were compared for differences in platelet aggregation as measured by a rapid function platelet assay, as well as measurements of the inflammatory marker C-reactive protein (CRP) at frequent intervals following drug administration during PCI. RESULTS: A total of 95 patients were randomized to abciximab (n = 44) or tirofiban (n= 51). There was no significant difference in platelet aggregation documented throughout the procedure (10-, 20-, 30-, 45-minute time points). In diabetic patients abciximab had significantly lower platelet inhibition as compared to tirofiban at 10 minutes (84.17 +/- 8.28% vs. 90.40 +/- 5.79%; p = 0.0097). Using a Spearman correlation coefficient model, hs-CRP demonstrated an inverse relationship with platelet inhibition over time (-0.7307, p = 0.0002) in patients treated with abciximab. CONCLUSION: There is no major difference in platelet inhibition between tirofiban and abciximab during PCI. In this study, tirofiban showed a greater inhibition in diabetic subsets at the first time point within PCI. Platelet inhibition may be inversely related to the levels of CRP during PCI.

Intravascular ultrasound assessment of the incidence and predictors of edge dissections after drug-eluting stent implantation.

OBJECTIVES: We used intravascular ultrasound (IVUS) to assess incidence, predictors, morphology, and angiographic findings of edge dissections after drug-eluting stent (DES) implantation. BACKGROUND: DES implantation strategies differ compared with bare-metal stenting; coronary dissections after DES implantation have not been well studied. METHODS: We studied 887 patients with 1,045 non-in-stent restenosis lesions in 977 native arteries undergoing DES implantation with IVUS imaging. RESULTS: Eighty-two dissections were detected; 51.2% (42 of 82) involved the proximal and 48.8% (40 of 82) the distal stent edge. Residual plaque area (8.0 +/- 4.3 mm(2) vs. 5.2 +/- 3.0 mm(2), p < 0.0001); plaque burden (52.2 +/- 11.7% vs. 36.2 +/- 15.3%, p < 0.0001); plaque eccentricity (8.4 +/- 5.5 vs. 4.0 +/- 3.4, p < 0.0001); and stent edge symmetry (1.2 +/- 0.1 vs. 1.1 +/- 0.1, p = 0.02) were larger; plaque burden > or =50% was more frequent (62.0% vs. 17.2%, p < 0.0001); calcium deposits (52.1% vs. 35.2%, p = 0.03) more common; and lumen-to-stent-edge-area ratio (0.9 +/- 0.2 vs. 1.0 +/- 0.2, p < 0.0001) was smaller in the edge dissection group compared with the nondissection group. Intramural hematomas occurred in 34.1% (28 of 82) of dissections. When compared with nonhematoma dissections, residual plaque and media area (6.4 +/- 2.5 mm(2) vs. 8.9 +/- 4.6 mm(2), p = 0.04) was smaller, and stent edges less asymmetric (1.1 +/- 0.1 vs. 1.2 +/- 0.1, p = 0.009) in the dissection with hematoma group. Independent predictors of any stent edge dissection were residual plaque eccentricity (odds ratio [OR]: 1.4, p = 0.02), lumen-to-stent-edge-area ratio (OR: 0.0, p = 0.007), and stent edge symmetry (OR: 1.2, p = 0.02 for each 0.01 increase). CONCLUSIONS: IVUS identified edge dissections after 9.2% of DES implantations. Residual plaque eccentricity, lumen-to-stent-edge-area ratio, and stent edge symmetry predicted coronary stent edge dissections. Dissections in less diseased reference segments more often evolved into an intramural hematoma.

A volumetric intravascular ultrasound comparison of early drug-eluting stent thrombosis versus restenosis.

OBJECTIVES: We compared intravascular ultrasound findings of drug-eluting stent (DES)-treated lesions that developed thrombosis versus in-stent restenosis (ISR). BACKGROUND: Stent underexpansion is a predictor of both DES thrombosis and ISR. However, all underexpanded DES may not be equal. METHODS: Intravascular ultrasound findings from 20 definite DES thrombosis patients (representing all definite thromboses from 1,407 consecutive DES patients undergoing intravascular ultrasound imaging) were compared with 50 risk-factor-balanced ISR patients with no evidence of stent thrombosis and 50 risk-factor-balanced "no-event" patients with neither thrombosis nor ISR. RESULTS: Minimum stent area (3.9 +/- 1.0 mm(2) vs. 5.0 +/- 1.7 mm(2), p = 0.008), mean stent area (5.3 +/- 1.0 mm(2) vs. 7.2 +/- 2.0 mm(2), p = 0.001), and both focal (55.4 +/- 13.2% vs. 74.9 +/- 19.9%, p < 0.001) and diffuse stent expansion (77.4 +/- 19.3% vs. 109.5 +/- 23.1%, p < 0.001) were significantly smaller in the stent thrombosis group versus ISR and in both groups versus the "no-event" group. Minimum stent area <4.0 mm(2) (65% vs. 32%, p = 0.01) or <5.0 mm(2) (85% vs. 52%, p = 0.01) was more common in the stent thrombosis versus the ISR group and in both groups vs. "no-event" patients; and the relative length of the stent area <5 mm(2) was greatest in the stent thrombosis group (36.6 +/- 37.7%), intermediate in the ISR group (22.8 +/- 35.6%), and least in the "no-event" group (10.9 +/- 26.4%), p = 0.04. In the stent thrombosis group, the minimum stent area site occurred in the proximal stent segment in 50% versus 24% in the ISR group (p = 0.03). There were no differences in edge dissection, stent fracture, or stent-vessel-wall malapposition among the groups. CONCLUSIONS: The DES-treated lesions that develop thrombosis or restenosis are often underexpanded, but underexpansion associated with thrombosis is more severe, diffuse, and proximal in location.

Comparison of angiographic and intravascular ultrasonic detection of myocardial bridging of the left anterior descending coronary artery.

The purpose of this study was to determine the incidence, location, and clinical features of myocardial bridging (MB) detected by intravascular ultrasound (IVUS) and to compare IVUS-detectable versus angiographically detectable MBs. IVUS images were analyzed in 331 consecutive patients with de novo coronary lesions located in the left anterior descending coronary artery (LAD). MB was defined as a segment of coronary artery having systolic compression and echocardiographically lucent muscle surrounding the artery (IVUS) or systolic milking (angiography). Although angiography detected MB in only 3% of patients (11 of 331), 75 MB segments (23%, 75 of 331, p <0.001) were identified by IVUS. Maximum plaque burden within the MB segment measured only 25 +/- 7%, and abnormal intimal thickness (defined as >or=0.5 mm) was not observed within the bridged segment of any patient with MB, although the study population had advanced atherosclerosis. Vessel and lumen areas in the MB segment were significantly smaller than those in adjacent proximal and even distal reference segments. Angiographically detectable MB was significantly longer, located more proximally in the LAD, and had more severe systolic compression by IVUS. Angiographically silent MB more often occurred in the presence of an adjacent proximal stenosis and lower left ventricular ejection fraction. In conclusion, IVUS may provide useful anatomic information for the accurate diagnosis of MBs that are largely angiographically silent. IVUS-detectable MBs were observed in approximately 1/4 of patients undergoing LAD imaging at our center.

Clinical outcomes after heterogeneous overlap stenting with drug-eluting stents and bare-metal stents for de novo coronary artery narrowings.

When it is difficult to deliver multiple drug-eluting stents (DES) or when size constraints limit DES implantation, bare-metal stents (BMS) may be implanted contiguous to DES. However, the clinical outcomes after overlapping DES and BMS implantation are not known. From September 2004 to June 2006, 4,872 consecutive patients who underwent percutaneous coronary intervention consented to be enrolled in a prospective registry. Of these patients, 44 (0.9%) with de novo lesions were treated with DES and BMS overlap stenting. All patients were followed to 12 months for the assessment of clinical outcomes. The average implanted stent diameter was 2.68 +/- 0.30 mm for DES and 2.35 +/- 0.38 mm for BMS. Overlapping BMS were implanted distal to DES in all but 1 case. One patient (2.3%) experienced acute stent thrombosis and died 2 days after the procedure. No other patient died or had a myocardial infarction during 12 months. The target vessel revascularization rate at 12 months, however, was 31.8%, mainly driven by diffuse in-stent restenosis in the BMS segments. In conclusion, the incidence of DES and BMS overlap stenting is rare in daily practice, but this procedure is associated with a high rate of target vessel revascularization.

Assessing intermediate left main coronary lesions using intravascular ultrasound.

BACKGROUND: Angiographic assessment of a left main coronary artery stenosis (LMCS) is often difficult and unreliable. We aimed to evaluate the severity of ambiguous LMCSs by intravascular ultrasound (IVUS) and to clarify how frequently significant stenosis occurs in the "real world". METHODS: We retrospectively found 115 consecutive patients in our clinical IVUS database with a de novo, angiographically ambiguous, intermediate LMCS who underwent IVUS evaluation. Quantitative coronary angiography (QCA) and IVUS analyses were performed. We define a significant LMCS as a diameter stenosis >50% by QCA and a minimal lumen area <6.0 mm2 by IVUS. RESULTS: Ostial, mid, and distal LMCSs were seen in 44 (38.3%), 6 (5.2%), and 65 (56.5%) lesions. Overall, IVUS minimal lumen area and plaque burden measured 6.8 +/- 2.6 mm2 and 63% +/- 14%. A significant LMCS was seen in 51 (44.3%) lesions by IVUS but in only 15 (13.0%) lesions by QCA. In particular, only 36.4% of ostial lesions had a significant IVUS stenosis, and minimal lumen diameter by QCA was less well correlated with IVUS in ostial lesions than in other lesion locations. CONCLUSIONS: This real-world IVUS analysis showed that less than half of intermediate LMCSs had significant stenoses by IVUS assessment, especially for lesions located at the left main ostium. Such patients deserve IVUS assessment or physiologic assessment before blindly proceeding to revascularization.

Nonrandomized comparison of coronary stenting under intravascular ultrasound guidance of direct stenting without predilation versus conventional predilation with a semi-compliant balloon versus predilation with a new scoring balloon.

This study was conducted to determine the influence of lesion preparation using the AngioSculpt balloon on final stent expansion. Stent expansion remains an important predictor of restenosis and subacute thrombosis, even in the drug-eluting stent (DES) era. In these patients, the role of different predilation strategies has yet to be established. Two hundred ninety-nine consecutive de novo lesions treated with 1 >2.5-mm DES (Cypher or Taxus) under intravascular ultrasound guidance without postdilation, using 3 implantation strategies, were studied: (1) direct stenting without predilation (n = 145), (2) predilation with a conventional semi-compliant balloon (n = 117), and (3) predilation with the AngioSculpt balloon (n = 37). Stent expansion was defined as the ratio of intravascular ultrasound-measured minimum stent diameter and minimum stent area to the manufacturer's predicted stent diameter and area. These ratios were larger after AngioSculpt predilation, and a greater percentage of stents had final minimum stent areas >5.0 mm(2) (another commonly accepted criterion of adequate DES expansion). Lesion morphology, stent and lesion length, and reference vessel size did not affect DES expansion. In conclusion, in this observational, nonrandomized study, pretreatment with the AngioSculpt balloon enhanced stent expansion and minimized the difference between predicted and achieved stent dimensions.

Volumetric intravascular ultrasound assessment of neointimal hyperplasia and nonuniform stent strut distribution in sirolimus-eluting stent restenosis.

The neointimal hyperplasia (IH) distribution pattern of in-stent restenotic lesions after sirolimus-eluting stent (SES) implantation has not been well described. We identified 48 in-stent restenotic lesions (41 patients) after SES implantation and performed volumetric intravascular ultrasound analyses. Lumen area, stent area, and IH area at the minimal lumen area site were 2.7 +/- 1.0, 5.4 +/- 1.9, and 2.7 +/- 1.4 mm(2), respectively. IH area at the minimal lumen site was larger in the group with a stent area > or =5.0 mm(2) than the group with a stent area <5.0 mm(2) (3.7 +/- 1.3 vs 1.9 +/- 0.8 mm(2), p <0.001). There were fewer visualized stent struts in lesions with a minimum stent area > or =5.0 mm(2) at the minimum lumen site compared with those with a stent area <5.0 mm(2) (0.69 +/- 0.25 vs 0.83 +/- 0.16, p = 0.04). When we compared lesions in patients with diabetes mellitus with patients without diabetes, minimum lumen areas, percent IH at minimal lumen area, percent IH, and neointima-free stent length were identical. In conclusion, (1) lesions without SES underexpansion at the minimum lumen site had more IH and greater nonuniform stent strut distribution compared with restenotic SESs that were underexpanded, and (2) the IH response did not appear to be more aggressive in patients with diabetes mellitus than in those without diabetes mellitus.

Outcome after acute incomplete sirolimus-eluting stent apposition as assessed by serial intravascular ultrasound.

We investigated the fate of postprocedural incomplete stent apposition (ISA) after sirolimus-eluting stent (SES) implantation by evaluating long-term intravascular ultrasound findings in 168 consecutive patients (182 de novo lesions). Postprocedural ISA was defined as > or = 1 stent strut that was clearly separated from the vessel wall with evidence of blood speckle behind the strut without overlapping a side branch. After SES implantation, there were 61 ISA sites in 46 stents in 31 patients (23 at the proximal edge, 7 at the distal edge, and 31 within the stent body). There were no clinical, procedural, or intravascular ultrasound measurement differences between patients and lesions with versus without ISA. At follow-up, 15 acute ISA sites (25%) in 11 patients completely resolved and 40 sites (75%) in 20 patients persisted, although 32 of 46 persisting ISA sites (70%) decreased. There was a greater decrease in effective lumen area and a greater increase in peristent plaque area in the complete-resolution group than in the persistent-ISA group. No lesion developed stent thrombosis or in-stent restenosis (angiographic diameter stenosis > 50%). Six acute ISA sites were also associated with new, late acquired ISA, only 1 of which resulted in aneurysm formation. Although most ISAs after SES implantation do not resolve completely, the incidence of restenosis or thrombosis is not affected.

Intravascular ultrasonic differences between aorto-ostial and shaft narrowing in saphenous veins used as aortocoronary bypass grafts.

Previous studies have reported differences in interventional complication rates that depend on saphenous vein graft (SVG) lesion location. However, little is known about morphologic differences between lesions in different SVG locations. We evaluated preintervention intravascular ultrasound (IVUS) images of 75 de novo SVG lesions (aorto-ostial, n = 15; shaft, n = 60) in 63 patients. IVUS data were measured at the minimal lumen area and at 2 proximal and 2 distal references. Positive remodeling was defined as a lesion site SVG area that was larger than the average of the 2 distal references. Shaft lesions more often contained soft plaque (60.0% vs 26.7%, p = 0.02). Minimal lumen areas were identical (4.5 +/- 2.9 vs 4.3 +/- 1.5 mm2, p = 0.3); however, plaque burden at the minimal lumen area was greater in shaft locations (79.3 +/- 9.4% vs 72.1 +/- 9.2%, p = 0.01). The frequency of positive remodeling in shaft versus aorto-ostial lesions was 70.2% versus 26.7% (p = 0.002). SVG shaft lesions have more soft plaque and larger plaque burdens and undergo positive remodeling more frequently than SVG aorto-ostial lesions. These IVUS differences may account for some of the location-specific differences in interventional complications.

A prospective registry to evaluate sirolimus-eluting stents implanted at coronary bifurcation lesions using the "crush technique".

The "crush technique" has been proposed as an alternative approach to treat bifurcation lesions because of its predictability and high procedural success rate. However, few data are available regarding its safety and long-term efficacy. We report the long-term clinical outcomes of patients with coronary bifurcation lesions treated with sirolimus-eluting stents using the crush technique. From April 2003 to May 2004, 120 patients with coronary bifurcation lesions were treated with sirolimus-eluting stents using the crush technique. Six months of clinical follow-up was completed in 95.8% of patients. Mean patient age was 64 years; 36% had diabetes mellitus, and the left anterior descending artery/diagonal was the most frequent bifurcation location (69%). Final kissing balloon inflation was performed in 87.5% of patients. Compared with the main vessel, side branch lesions were shorter, with a smaller reference diameter and final in-stent minimum lumen diameter. Procedural success was achieved in 97.5%. At 30 days of follow-up, 1 patient had died of noncardiac causes and 2 patients (1.7%) had subacute stent thrombosis. At 6 months of follow-up, target lesion revascularization was required in 13 patients (11.3%), all of whom had focal restenosis predominantly at the side branch ostium. In conclusion, the crush technique with final kissing balloon inflation can be safely used by experienced operators to treat highly complex bifurcation lesions with sirolimus-eluting stents. The safety profile of this technique is similar to that of other bifurcation stenting techniques reported thus far. Nonetheless, despite the excellent patency rates of the main vessel, the need for revascularization at the ostium of the side branch was not fully eliminated.

Intravascular ultrasound study of patterns of calcium in ruptured coronary plaques.

Coronary calcium is intimately associated with coronary atherosclerotic plaque development, although it is controversial as to whether coronary calcium is associated with plaque instability. We analyzed 101 IVUS-detected ruptured plaques and compared them with 101 computer-matched control plaques without evidence of plaque rupture. The arc of calcium was measured every 0.5 mm within 10-mm-long segments that spanned the minimum lumen cross-sectional area, and the number and length of calcium deposits were assessed. Ruptured plaques had a significantly larger number of individual calcium deposits than control plaques (3.5 +/- 1.7 vs 1.8 +/- 1.1, p <0.001). However, the arc of the largest calcium deposit was smaller and the length of the largest calcium deposit in each plaque was shorter in ruptured plaques compared with control plaques (67.3 degrees +/- 41.4 degrees vs 114.9 degrees +/- 77.4 degrees , p <0.001, and 1.6 +/- 1.3 vs 4.0 +/- 2.7 mm, p <0.001, respectively). There was no difference in the number of superficial calcium deposits between the 2 groups, although ruptured plaques had significantly smaller arcs of superficial calcium compared with control plaques (56.2 degrees +/- 35.5 degrees vs 95.8 degrees +/- 65.2 degrees , p <0.001). Conversely, the number of deep calcium deposits was significantly larger in ruptured plaques than in control plaques (1.8 +/- 1.4 vs 0.3 +/- 0.6, p <0.001), although the arc of deep calcium was similar in the 2 groups. Ruptured plaques had quantitatively less calcium, especially superficial calcium, but a larger number of small calcium deposits, especially deep calcium deposits. In conclusion, ruptured plaques are associated with a larger number of calcium deposits within an arc of <90 degrees , a larger number of deep calcium deposits, and a remodeling index.

Bifurcation coronary lesions treated with the "crush" technique: an intravascular ultrasound analysis.

OBJECTIVES: We report intravascular ultrasound (IVUS) findings after crush-stenting of bifurcation lesions. BACKGROUND: Preliminary results with the crush-stent technique are encouraging; however, isolated reports suggest that restenosis at the side branch (SB) ostium continues to be a problem. METHODS: Forty patients with bifurcation lesions underwent crush-stenting with the sirolimus-eluting stent. Postintervention IVUS was performed in both branches in 25 lesions and only the main vessel (MV) in 15 lesions; IVUS analysis included five distinct locations: MV proximal stent, crush area, distal stent, SB ostium, and SB distal stent. RESULTS: Overall, the MV minimum stent area was larger than the SB (6.7 +/- 1.7 mm2 vs. 4.4 +/- 1.4 mm2, p < 0.0001, respectively). When only the MV was considered, the minimum stent area was found in the crush area (rather than the proximal or MV distal stent) in 56%. When both the MV and the SB were considered, the minimum stent area was found at the SB ostium in 68%. The MV minimum stent area measured <4 mm2 in 8% of lesions and <5 mm2 in 20%. For the SB, a minimum stent area <4 mm2 was found in 44%, and a minimum stent area <5 mm2 in 76%, typically at the ostium. "Incomplete crushing"--incomplete apposition of SB or MV stent struts against the MV wall proximal to the carina--was seen in >60% of non-left main lesions. CONCLUSIONS: In the majority of bifurcation lesions treated with the crush technique, the smallest minimum stent area appeared at the SB ostium. This may contribute to a higher restenosis rate at this location.

Intravascular ultrasonic assessment of stent diameters derived from manufacturer's compliance charts.

We used intravascular ultrasound (IVUS) to assess the accuracy of manufacturers' stent balloon compliance charts. Many interventional cardiologists rely on manufacturers' compliance charts to select stent size and optimize stent diameters according to inflation pressures during percutaneous procedures. We randomly selected 212 patients who had de novo coronary lesions that had been treated with a single, bare metal, > or =3.0-mm stent (Bx velocity, NIR, TETRA/PENTA, S660/S670/S7) under IVUS guidance. Cases of stent overlap and postdilatation with another balloon were excluded. Predicted stent diameters were derived from each manufacturer's compliance charts, and stent size and final maximal deployment pressures were derived from each physician's report. IVUS-measured minimum stent diameters (range 1.4 to 4.0 mm, mean 2.79 +/- 0.48) were smaller than predicted diameters (range 3.1 to 4.57 mm, mean 3.79 +/- 0.44). The ratio of IVUS to predicted diameters ranged from 44% to 97% (mean 74 +/- 10%). This finding was common to all 3 stent sizes: 74 +/- 12% for 3.0 mm, 73 +/- 9% for 3.5 mm, and 74 +/- 9% for 4.0-mm stents (p = 0.9). This finding was also common to all 4 stent manufacturers, 72 +/- 8% for Boston Scientific, 76 +/- 11% for Guidant, 73 +/- 9% for Cordis, and 74 +/- 11% for Medtronic (p = 0.13), and to different stent lengths. Only 3.8% of the stents achieved 90% of the predicted minimum stent diameters, and only 24.6% achieved 80% of the predicted minimum stent diameters. In conclusion, in human coronary arteries, minimal stent diameter measured by IVUS is significantly smaller than that predicted by in vitro compliance charts. These differences are independent of stent manufacturer, length, diameter, and deployment pressure.

Stent underexpansion and residual reference segment stenosis are related to stent thrombosis after sirolimus-eluting stent implantation: an intravascular ultrasound study.

OBJECTIVES: We sought to determine the predictors of stent thrombosis after sirolimus-eluting stent (SES) implantation. BACKGROUND: A number of cases of stent thrombosis have been reported after commercial release of the SES in the "real world," such that the U.S. Food and Drug Administration issued a warning. METHODS: Fifteen patients who developed stent thrombosis after successful SES implantation were analyzed and compared with 45 matched control patients who had no evidence of stent thrombosis. RESULTS: Minimum stent cross-sectional area (MSA) (4.3 +/- 1.6 mm(2) vs. 6.2 +/- 1.9 mm(2), p < 0.001) and stent expansion (0.65 +/- 0.18 vs. 0.85 +/- 0.14, p < 0.001) were significantly smaller in the stent thrombosis group than in the matched control patients. There was no significant difference in the rate of SES malapposition between the groups. However, the presence of a significant residual reference segment stenosis was more common in the stent thrombosis group compared with the matched control group (67% vs. 9%, p < 0.001). Independent predictors of stent thrombosis were stent underexpansion (p = 0.03) and a significant residual reference segment stenosis (p = 0.02). CONCLUSIONS: Stent underexpansion and residual reference segment stenosis are associated with stent thrombosis after successful SES implantation.

Creatine kinase-MB enzyme elevation and long-term clinical events after successful coronary stenting in lesions with ruptured plaque.

Patients with acute coronary syndrome are at increased risk of acute and long-term events after stent implantation. We compared the impact of intravascular ultrasound detected plaque rupture on creatine kinase-MB (CK-MB) isoenzyme release and clinical outcomes by comparing 62 patients with ruptured plaques with 62 matched control patients who underwent stent implantation. Two thirds of the patients in each group presented with an acute coronary syndrome. There were no differences in procedural complications between groups, although patients with ruptured plaque had higher CK-MB elevation rates than those without ruptured plaque (1 to 3 times the upper limit of normal CK-MB, 35% vs 10%, p <0.001; >3 times the upper limit, 15% vs 2%, p = 0.02). Independent predictors of CK-MB elevation were presence of ruptured plaque (p = 0.03) and unstable angina (p = 0.04). Patients with ruptured plaque had higher composite rates of late events (target lesion revascularizations/myocardial infarctions/cardiac deaths) than controls (25% vs 9%, p = 0.03). These results were similar when only patients with acute coronary syndrome were studied. Plaque rupture morphology is associated with higher periprocedural CK-MB release and worse 1-year clinical outcome in patients treated with coronary stenting.

Luminal narrowing due to intramural hematoma shift from left anterior descending coronary artery to left circumflex artery.

This case report demonstrates subacute luminal narrowing 20 days after balloon angioplasty in the left anterior descending coronary artery due to an intramural hematoma. Stenting was performed and resulted in side-branch compromise caused by squeezing the hematoma from the left anterior descending coronary artery into the left circumflex artery. Another stent was deployed to treat the stenosis in the left circumflex artery.

Correlation of coronary arterial remodeling determined by intravascular ultrasound with angiographic diameter reduction of 20% to 60%.

Negative remodeling is commonly observed in stenotic coronary lesions. It is unknown whether negative remodeling is an early or late event. This study was designed to elucidate when negative remodeling occurs in the development of coronary stenosis. Remodeling was assessed by preintervention intravascular ultrasound in 104 native coronary lesions with intermediate stenosis (20% to 60% of diameter stenosis measured by quantitative coronary angiography). Positive remodeling was defined as lesion external elastic membrane (EEM) cross-sectional area (CSA) greater than the proximal reference, intermediate remodeling as lesion EEM CSA between those of the proximal and distal references, and negative remodeling as lesion EEM CSA less than the distal reference. Positive, intermediate, and negative remodeling were observed in 18%, 32%, and 50%, respectively, of lesions with intermediate stenosis. Lesions with negative and intermediate remodeling had more hard plaque compared with those with positive remodeling (79% vs 70% vs 42%, p = 0.02). Calcium was more frequent in lesions with negative and intermediate remodeling than in those with positive remodeling (52% vs 55% vs 16%, p = 0.01). Lesions with negative remodeling had smaller EEM CSA (11.5 +/- 5.2 vs. 13.7 +/- 3.4 vs 14.5 +/- 5.6 mm(2), p = 0.03) and less plaque (7.9 +/- 4.6 vs 10.8 +/- 3.4 vs 10.8 +/- 4.9 mm(2), p = 0.004) compared with positive and intermediate remodeling lesions, although lumen CSA (3.7 +/- 1.7 vs 2.8 +/- 0.8 vs 3.6 +/- 1.3 mm(2), p = 0.1) and area stenosis (57 +/- 15% vs 59 +/- 14% vs 56 +/- 10%, p = 0.7) were similar. Negative remodeling is frequently observed in lesions with intermediate stenosis. This suggests that negative remodeling occurs early in lesion formation.