To Whom Thrombus Aspiration May Concern?

BACKGROUND: Thrombus aspiration for ST-segment elevation myocardial infarction (STEMI) may improve myocardial perfusion. However, these favourable results called into a question by data indicating not only a lack of efficacy but a risk of potentially deleterious complications. AIM: To assess the effect of thrombus aspiration during the primary percutaneous coronary intervention (PPCI) on procedural angiographic results, stent characteristics, and major adverse cardiac and cerebrovascular events (MACCE). METHODS: All consecutive STEMI patients candidate for PPCI and admitted to Critical Care Department, Cairo University hospitals, managed either by thrombectomy before primary PCI (if thrombus score ≥ 3) or conventional PPCI, Six hundred seven subjects were enrolled in the study divided into Group with thrombectomy before PPCI (107 subjects, 18%), and group with Conventional PCI (500 subjects, 82%). ST-segment resolution, peak CK-MB, TIMI score, thrombus score, and MBG were assessed; stent number, diameter, length and stented segment were reported and follow up MACCE was reported (in hospital and 1-year post-intervention). RESULTS: Mean values for peak CKMB were less in thrombectomy group (228 ± 174 I/U vs 269 ± 186 I/U, p = 0.04), ST segment resolution ≥ 70% occurred in {63 subjects (58.9%) vs 233 (46.6%), p = 0.001} in thrombectomy vs conventional group respectively. TIMI score pre procedure was zero in (102 subjects (95%) vs 402 (80.4%), p = 0.001), while TIMI III post procedure was reported in (100 subjects (93.4%) vs 437 (87%), p = 0.06), MBG mean values were (2.4 ± 0.6 vs 2.0 ± 1, p = 0.001), thrombus score was higher in thrombectomy group (4.6 ± 0.4 vs 0.8 ± 1.7, p = 0.001) in thrombectomy vs conventional group respectively. Direct stenting was { 34 patients (31%) vs 102 patients (20%), p = 0.05}, mean stent diameter (2.7 ± 1.3 mm vs 3.5 ± 1.3 mm, p = 0.3), mean stent length was (19.9 mm ± 10 versus 22.7 mm ± 8 in p 0.01). mean stent number was (1.0 ± 0.5 vs 1.2 ± 0.6, p = 0.001), mean stented segment was (22.5 ± 13.5 vs 28.5 ± 15.2 mm, p = 0.001) in thrombectomy vs conventional group respectively. MACCE in hospital were reported in {9 subjects (8.4%) vs 70 (14%), p = 0.07)}. Follow up MACCE after 1 year reported in {6 subjects (5.6 %) vs 80 (16 %), p 0.= 4} in thrombectomy vs conventional group respectively. CONCLUSION: Thrombus aspiration before primary PCI (in a selected group with thrombus score ≥ 3) improves myocardial perfusion, suggested by better ST-segment resolution, TIMI flow, less peak CKMB and MBG, associated with a higher rate of direct stenting, shorter stent length, stented segments and less number of stents. Although thrombus aspiration was done in more risky patients (higher thrombus score) MACCE (in hospital and 1 year follow up) showed no statistical difference.

Coronary Atherosclerotic Plaque Vulnerability Rather than Stenosis Predisposes to Non-ST Elevation Acute Coronary Syndromes.

BACKGROUND: Non-ST elevation acute coronary syndromes (NSTE-ACS) may arise from moderately stenosed atherosclerotic lesions that suddenly undergo transformation to vulnerable plaques complicated by rupture and thrombosis. OBJECTIVE: Assessment and tissue characterization of the coronary atherosclerotic lesions among NSTE-ACS patients compared to those with stable angina. METHODOLOGY: Evaluation of IVUS studies of 312 coronary lesions was done by 2 different experienced IVUS readers, 216 lesions in 66 patients with NSTE-ACS (group I) versus 96 lesions in 50 patients with stable angina (group II). Characterization of coronary plaques structure was done using colored-coded iMap technique. RESULTS: The Syntax score was significantly higher in group I compared to group II (18.7 ± 7.8 vs. 8.07 ± 2.5, p=0.001). Body mass index (BMI) was significantly higher in group II while triglycerides levels were higher in group I (P=0.01 & P=0.04, respectively). History of previous MI and PCI was significantly higher in group I (P=0.016 & P=0.001, respectively). The coronary lesions of NSTE-ACS patients had less vessel area (9.86 ± 3.8 vs 11.36 ± 2.9, p=0.001), stenosis percentage (54.7 ± 14.9% vs 68.6 ± 8.7%, p=0.001), and plaque burden (54.4 ± 14.7 vs 67.8 ± 9.8, p=0.001) with negative remodeling index (0.95 ± 20 vs 1.02 ± 0.14, p=0.008) compared to the stable angina group. On the other hand, they had more lipid content (21.8 ± 7.03% vs 7.26 ± 3.47%, p=0.001), necrotic core (18.08 ± 10.19% vs 15.83 ± 4.9%, p=0.02), and calcifications (10.4 ± 5.2% vs 4.19 ± 3.29%, p=0.001) while less fibrosis (51.67 ± 7.07% vs 70.37 ± 11.7%, p=0.001) compared to the stable angina patients. Syntax score and core composition especially calcification and lipid content were significant predictors to NSTE-ACS. CONCLUSIONS: The vulnerability rather than the stenotic severity is the most important factor that predisposes to non-ST segment elevation acute coronary syndromes. The vulnerability is related to the lesion characteristics especially lipidic core and calcification while lesion fibrosis favours lesion stability.

Intravascular evaluation of coronary atherosclerotic lesions among Egyptian diabetic patients with acute coronary syndromes.

BACKGROUND: Coronary artery disease is one of the main causes of death in diabetes mellitus (DM). Egypt was listed among the world top 10 countries regarding the number of diabetic patients by the International Diabetes Federation (IDF). AIM OF WORK: Assessment of the extent of coronary atherosclerotic disease and lesion tissue characterization among diabetic compared to non-diabetic Egyptian patients. METHODOLOGY: IVUS studies of 272 coronary lesions in 116 patients presented with unstable angina were examined. The patients were divided into two groups: diabetic group (50 patients with 117 lesions) and non-diabetic group (66 patients with 155 lesions). RESULTS: As compared to the non-diabetic group, the diabetic patients were more dyslipidemic (84% vs 39.4%, p = 0.001) with higher total cholesterol level (194.6 ±â€¯35.3 vs 174.4 ±â€¯28.5 mg/dl, p = 0.001) and higher LDL-C (145.3 ±â€¯27.1 vs 123.2 ±â€¯31.4, p = 0.001). Regarding lesions characteristics, the diabetic group had longer lesions (19.4 ±â€¯7.4 vs 16.3 ±â€¯7.9 mm, p = 0.002) with higher plaque burden (60.8 ±â€¯15.3 vs 54.8 ±â€¯14.0, p 0.002) and more area stenosis percentage (60.8 ±â€¯15.6 vs 55.6 ±â€¯14.1, p = 0.008). Structurally, the diabetic group lesions had more lipid content (19.8 ±â€¯8.8 vs 16.8 ±â€¯8.7, p = 0.008) and more necrotic core (17.6 ±â€¯7.4 vs 14.7 ±â€¯4.8, p = 0.008) but less calcification (6.9 ±â€¯3.6 vs 11.8 ±â€¯6.3, p = 0.001). The RI was negative in both groups, 0.95 ±â€¯0.13 in the diabetic group vs 0.98 ±â€¯0.19 in non-diabetic group (p = 0.5). Within the diabetic group lesions, the dyslipidaemic subgroup had more lipid content (23. ±â€¯5.2 vs 14.6 ±â€¯8.6, p = 0.01) but less fibrotic component (48.6 ±â€¯4.7 vs 59.1 ±â€¯13.6%, p = 0.01) and less calcification (10.9 ±â€¯6.8% vs 14.07 ±â€¯3.8%, p = 0.02) as compared to the nondyslipidaemic subgroup. CONCLUSIONS: Diabetic patients with coronary atherosclerosis in Egypt have longer lesions with higher plaque burden and more percent area stenosis with negative remodeling index. The diabetic lesions had more lipid content and more necrotic core but less calcification.

Tissue characterization of non-culprit intermediate coronary lesions in non ST elevation acute coronary syndromes.

BACKGROUND: Disruption of vulnerable plaques is the most common cause of acute coronary syndromes. Intravascular ultrasound facilitates cross-sectional imaging of coronary arteries. We aimed at using IVUS to investigate the morphology and tissue characteristics of atherosclerotic plaques of non-culprit intermediate coronary lesions in non-ST elevation ACS setting. METHODS: IVUS assessment of sixty-one intermediate coronary lesions in twenty-eight patients with the diagnosis of Non ST elevation acute coronary syndromes. Ultrasound signals were obtained by an IVUS system using a 40-MHz catheter. RESULTS: Mean age was 53.2 ± 9.1 years. Males = 20 (71.4%). Smoking in 17 (60.7%), hypertension in 16 (57.1%), Dyslipidemia in 12 (42.9%) and DM in 8 (28.6%). Culprit vessels represent 42% of affected vessels. Sixty-one intermediate lesions were detected. Twenty-nine lesions in culprit vessels and thirty-two lesions in non-culprit vessels with higher lipidic content in lesions of culprit vessels (P < 0.001) while a higher calcific content in lesions of non-culprit vessels (P < 0.001). Higher calcific content of proximal more than distal lesions (P = 0.048). Negative remodeling in 55.7% of lesions. CONCLUSIONS: A higher lipidic content in lesions of culprit vessels, while the lesions of non-culprit vessels were more calcific. Higher calcific content of proximal more than distal lesions was defined as well.

Stent boost enhancement compared to intravascular ultrasound in the evaluation of stent expansion in elective percutaneous coronary interventions.

BACKGROUND: Stent underexpansion is a major risk factor for in-stent restenosis and acute in-stent thrombosis1Intravascular ultrasound (IVUS) is one of the standards for detection of stent underexpansion (de Feyter et al. 1999; Mintz et al., 2001). StentBoost (SB) enhancement allows an improved angiographic visualization of the stent (Koolen et al., 2005). AIM OF WORK: Comparison of stent expansion by IVUS and SB enhancement and detection of value of SB to guide dilatation post stent deployment. METHODOLOGY: IVUS, SB enhancement and QCA were done in 30 patients admitted for elective stenting procedures .We compared measurements of mean ±standard deviations of (Max SD, Min SD, Mean SD, stent symmetry index) using IVUS, SB and QCA after stent deployment and after postdilatation whenever necessary to optimize stent deployment. The Stent symmetry index was calculated [(maximum stent diameter minus minimum stent diameter) divided by maximum stent diameter]. RESULTS: The Max SD was (3.45 ± 0.62 vs 3.55 ± 0.56 vs 2.97 ± 0.59) by IVUS vs SB vs QCA respectively. Max SD was significantly higher by IVUS vs QCA (p .009) and between SB vs QCA (p .001) while there was nonsignificant difference between IVUS vs SB (p .53). The Min SD was (2.77 ± 0.53 vs 2.58 ± 0.56 vs 1.88 ± 0.60) by IVUS vs SB vs QCA respectively. Min SD was significantly higher by IVUS vs QCA (p .001) and between SB vs QCA (p .001) while there was nonsignificant difference between IVUS vs SB (p .07). The stent symmetry index was (0.24 ±0.09 vs 0.34 ± 0.09 vs 0.14 ±0.27) by IVUS vs SB vs QCA respectively. It was significantly higher by IVUS vs QCA (p .001) and between SB vs QCA (p .001) while there was nonsignificant difference between IVUS vs SB (p .32). SB was positively correlated with IVUS measurements of Max SD (p < .0001 & r 0.74) and Min SD (p < .0001 & r 0.68). QCA was positively correlated with IVUS measurements of Max SD correlation (p < .0001 & r 0.69) and Min SD (p < .0001 & r 0.63). QCA was positively correlated with SB measurements of Max SD (p < .0001 & r 0.61) and Min SD (p .003 & r 0.49). CONCLUSIONS: StentBoost enhancement has superior correlations for stent expansion measured by IVUS when compared with QCA. SB enhancement improved stent visualization and identification of stent underexpansion to guide stent postdilatation.