Intraplaque wiring enables drug-coated balloons to be utilized for percutaneous recanalization of chronically occluded coronary arteries.

OBJECTIVES: This study aimed to determine whether drug-coated balloon (DCB) angioplasty following intraplaque wiring and the use of modified balloons is safe and effective in the percutaneous treatment of coronary chronic total occlusions (CTOs). BACKGROUND: DCB is an alternative therapeutic option without the limitations of permanent vascular implants. However, its efficacy in CTOs has yet to be confirmed. The combination of modified balloons and DCB can be effectively applied when the intraplaque passage of the guidewire is achieved in CTOs. METHODS: Data from 124 consecutive CTO lesions (105 patients) treated at our hospital between February 2016 and December 2020 were screened for inclusion and retrospectively analyzed. Among the 118 lesions successfully recanalized, intraplaque wiring was achieved in 108, and 85 were treated by the DCB-only approach following cutting/scoring balloon dilatation. RESULTS: Follow-up data were available for 82 lesions (71 patients). The median occlusion length was 18.5 mm, and the J-CTO score was 1.7 ± 0.9. No in-hospital major adverse cardiac events occurred, including abrupt vessel closure. During the median 29-month follow-up period, target lesion revascularization was performed for 10 lesions. Follow-up coronary angiography (8.7 ± 3.9 months after the index procedure) was performed for 64 lesions, demonstrating late lumen loss of -0.15 mm (interquartile range -0.4 to 0.23 mm), binary restenosis (diameter stenosis ≥50%) in 12 lesions (18.8%), and late lumen enlargement in 37 (57.8%). CONCLUSION: The DCB-only approach following the use of modified balloons is a promising strategy for coronary CTOs when intraplaque wiring is achieved.

Laser vaporization of atherothrombotic burden before drug-coated balloon application in ST-segment elevation myocardial infarction: Two-year outcomes of the laser-DCB trial.

OBJECTIVES: This study aimed to examine whether the combination of excimer laser coronary atherectomy (ELCA) and drug-coated balloon (DCB) angioplasty can provide feasible clinical outcome in patients with ST-segment elevation myocardial infarction (STEMI) with 8-month and 2-year scheduled follow-up angiography. BACKGROUND: Intracoronary thrombus elevates the risk of interventional treatment in patients with STEMI and hampers drug absorption into the vasculature released from DCB. METHODS: Sixty-two patients with STEMI within 24 h after the onset of symptoms were enrolled in this prospective, single-center, single-arm study. RESULTS: The laser catheter was successfully crossed distal to the culprit lesion in all cases. No ELCA-related adverse events occurred. Bail-out stenting was required in two patients (3.2%) after adjunctive ballooning; thus, the remaining 60 patients were completed with DCB angioplasty without stenting. Scheduled angiography at 8 months and 2 years was completed in 100% and 85.2%, respectively, and minimal lumen diameters were 3.4 ± 0.5, 3.4 ± 0.6, and 3.4 ± 0.5 mm after the procedure, at 8 months and at 2 years, respectively. Binary restenosis was observed in five patients (8.1%) in whom target lesion revascularization was performed. The duration of dual antiplatelet therapy was 2.3 ± 2.2 months, and neither abrupt vessel closure, reinfarction, cardiac death nor major bleeding was observed. CONCLUSION: A combination of DCB angioplasty with ELCA is a feasible therapeutic option for STEMI.

Laser Vaporization of Intracoronary Thrombus and Identifying Plaque Morphology in ST-Segment Elevation Myocardial Infarction as Assessed by Optical Coherence Tomography.

OBJECTIVES: We evaluated the thrombus-vaporizing effect of excimer laser coronary angioplasty (ELCA) in patients with ST-segment elevation myocardial infarction (STEMI) by optical coherence tomography (OCT). BACKGROUND: Larger intracoronary thrombus elevates the risk of interventional treatment and mortality in patients with STEMI. METHODS: A total of 92 patients with STEMI who presented within 24 hours from the onset and underwent ELCA following manual aspiration thrombectomy (MT) were analyzed. RESULTS: The mean baseline thrombolysis in myocardial infarction flow grade was 0.4 ± 0.6, which subsequently improved to 2.3 ± 0.7 after MT (p < 0.0001) and 2.7 ± 0.5 after ELCA (p=0.0001). The median residual thrombus volume after MT was 65.7 mm3, which significantly reduced to 47.5 mm3 after ELCA (p < 0.0001). Plaque rupture was identified by OCT in only 22 cases (23.9%) after MT, but was distinguishable in 36 additional cases after ELCA (total: 58 cases; 63.0%). Ruptured lesions contained a higher proportion of red thrombus than nonruptured lesions (75.9% vs. 43.3%, p=0.001). Significantly larger thrombus burden after MT (69.6 mm3 vs. 56.3 mm3, p < 0.05) and greater thrombus reduction by ELCA (21.2 mm3 vs. 11.8 mm3, p < 0.01) were observed in ruptured lesions than nonruptured lesions. CONCLUSIONS: ELCA effectively vaporized intracoronary thrombus in patients with STEMI even after MT. Lesions with plaque rupture contained larger thrombus burden that was frequently characterized by red thrombus and more effectively reduced by ELCA.

Efficacy of Cutting Balloon Angioplasty for Chronic Total Occlusion of Femoropopliteal Arteries.

BACKGROUND: Chronic total occlusion (CTO) of femoropopliteal artery (FP) continues to be a lesion subset where maintaining long-term patency after endovascular treatment is challenging. We evaluated the efficacy of cutting balloon angioplasty (CBA) for de novo FP-CTOs in patients with symptomatic lower limb ischemia. METHODS: Seventy-three limbs of 67 symptomatic patients with de novo FP-CTOs successfully recanalized using CBA alone were enrolled in this study. Primary patency was defined as the absence of recurrent symptoms and no deterioration of the ankle-brachial index (ABI) >0.10 from the immediate postinterventional value. RESULTS: The mean age was 73.5 ± 7.3 years, and 59.7% of patients had diabetes mellitus. Most lesions were classified as Trans-Atlantic Inter-Society Consensus II type C (n = 18; 24.7%) or type D (n = 44; 60.3%), with mean lesion and occluded lengths of 24.8 ± 11.4 and 17.8 ± 11.2 cm, respectively. No procedure-related adverse events occurred, except one distal embolization. The ABI significantly increased after intervention from 0.52 ± 0.12 to 0.80 ± 0.15 (P < 0.0001), with marked improvement in clinical symptoms (Rutherford stage: 2.7 ± 1.0 to 1.1 ± 1.2, P < 0.0001). The mean follow-up period was 31.2 ± 18.0 months, and the primary patency rates at 12 and 24 months were 75.3% and 60.6%, respectively. The independent predictive factors of failed patency were baseline hemoglobin A1c (P = 0.031, hazard radio [HR] 1.51 per 1%), occluded length ≥15 cm (P = 0.036, HR 2.90), and severe dissection (P = 0.033, HR 2.85). Vessel calcification and diameter did not affect primary patency. CONCLUSIONS: CBA is a feasible option for endovascular treatment of FP-CTOs. Diabetic status, occlusion length, and severe dissection after CBA are independent negative predictors of long-term patency.

Feasibility and safety of a virtual 3-Fr sheathless-guiding system for percutaneous coronary intervention.

OBJECTIVES: To evaluate the feasibility and safety of a virtual 3-Fr system [5-Fr sheathless-guiding catheter (GC)] for percutaneous coronary intervention (PCI). BACKGROUND: The use of miniaturized devices for PCI is gaining popularity because of increased patient comfort and decreased risk of access site complications. METHODS: From July 2010 to December 2012, consecutive patients who underwent elective PCI (planned or ad hoc PCI) at our hospital were enrolled. PCI using the virtual 3-Fr system was attempted as our initial strategy, unless a 6-Fr or larger GC was considered to be suitable [lesions with heavy calcification, large (>2 mm) side branches, or chronic total occlusion]. RESULTS: Five hundred sixty-six patients underwent elective PCI during the study period, and 132 patients who met the criteria underwent PCI using the virtual 3-Fr system. Procedures using the virtual 3-Fr system were successful in 126 patients (95%); 111 (84%) were performed using the transradial approach, 110 (83%) were ad hoc procedures, and 45 (31%) were complex coronary lesions (type B2 or C). Six patients required conversion to a conventional 5- or 6-Fr sheath and catheter system. No intraoperative complications occurred, and radial artery patency was achieved in all patients who underwent transradial procedures. CONCLUSIONS: PCI using the virtual 3-Fr system is a feasible and viable alternative to conventional procedures that use a sheath and GC in appropriately selected patients. This small-caliber system may minimize endovascular trauma, particularly during transradial coronary procedures.

Transcollateral retrograde approach with rendezvous technique for recanalization of chronically occluded tibial arteries.

PURPOSE: To describe a novel technique using an antegrade wire in a retrograde microcatheter advanced through a transcollateral vessel for recanalization of challenging infrapopliteal chronic total occlusions. TECHNIQUE: A 75-year-old diabetic man presented with critical limb ischemia manifested as nonhealing ulcers on the toes. Baseline angiography revealed a blunt, long, total occlusion of the anterior tibial artery. A retrograde microcatheter was advanced over a guidewire tracking the collateral channel from the planter artery. Antegrade and retrograde microcatheters were aligned inside the occluded lesion. An antegrade wire was then advanced further down through the retrograde microcatheter. Final angiography of the anterior tibial artery following balloon dilation demonstrated a satisfactory result, without evidence of significant residual stenoses or flow-limiting dissections. Complete wound healing was achieved at 3 weeks. CONCLUSION: This alternative wire method may be useful when traditional interventional approaches are unfeasible.

The significance of chymase in the progression of abdominal aortic aneurysms in dogs.

In this study, we investigated the effect of a specific chymase inhibitor, NK3201, in the progression of abdominal aortic aneurysm in a dog experimental model. Abdominal aortic aneurysms were induced in dogs by injecting elastase into the abdominal aorta. NK3201 (1 mg/kg per day, p.o.) or a placebo was started 3 days before elastase injection and continued for 8 weeks after the injection. On abdominal ultrasound, the aortic diameter was seen to gradually expand in the placebo-treated group, but not in the NK3201-treated group. Eight weeks after elastase injection, the ratio of the medial area to the total area in the placebo-treated group was significantly smaller than that in the normal group, but it was significantly larger than that in the NK3201-treated group. In addition to chymase activity, angiotensin II-forming and matrix metalloproteinase-9 activities were significantly higher in the placebo-treated group than in the normal group; in the NK3201-treated group, all of these activities were significantly decreased. On immunohistochemical analyses, there was a significantly greater number of chymase-positive cells in the placebo-treated group than in the normal group, but the number was significantly smaller in the NK3201-treated group than in the placebo-treated group. Thus, chymase inhibition may become a useful strategy for preventing abdominal aortic aneurysms.

Mechanism of atrial functional mitral regurgitation in patients with atrial fibrillation: A study using three-dimensional transesophageal echocardiography.

BACKGROUND: Functional mitral regurgitation (MR) can occur in patients with atrial fibrillation (AF) despite having preserved left ventricular (LV) systolic function. This MR is known as atrial functional MR. The aim of this study was to clarify the mechanism of atrial functional MR using real-time three-dimensional transesophageal echocardiography (3DTEE). METHODS: Sixty patients underwent transthoracic echocardiography and 3DTEE: 16 patients with AF and significant non-organic MR and preserved LV ejection fraction (>50%) constituted the AF-MR group, 20 patients with AF and no significant MR formed the AF-NSMR group, and 24 normal subjects comprised the control group. RESULTS: The left atrial volume index was significantly larger in the AF-MR group (95±41ml/m2) than in the AF-NSMR group (38±13ml/m2, p<0.05) or the control group (21±7ml/m2, p<0.05). The 3D annular circumference was significantly longer in the AF-MR group than in the AF-NSMR group. The annular-anterior leaflet coaptation angle was smaller in the AF-MR group than in the AF-NSMR group (11±6° vs. 18±9°, p<0.05). The annular-posterior leaflet coaptation angle was comparable between the two AF groups (26±12° vs. 28±10°), whereas the annular-posterior leaflet tip angle was larger in the AF-MR group than in the AF-NSMR group (59±13° vs. 44±11°, p<0.05). The posterior leaflet bending toward LV cavity was therefore significantly larger in the AF-MR group than in the AF-NSMR group (32±10° vs. 18±15°, p<0.05). CONCLUSIONS: In patients with AF and significant functional MR occurring despite their preserved LV systolic function, the left atrium and mitral annulus were dilated and the anterior leaflet was flattened along the mitral annular plane, whereas the posterior leaflet was bent toward the LV cavity.

Real-time transesophageal echocardiography facilitates antegrade balloon aortic valvuloplasty.

We report two cases of severe aortic stenosis (AS) where antegrade balloon aortic valvuloplasty (BAV) was performed under real-time transesophageal echocardiography (TEE) guidance. Real-time TEE can provide useful information for evaluating the aortic valve response to valvuloplasty during the procedure. It was led with the intentional wire-bias technique in order to compress the severely calcified leaflet, and consequently allowed the balloon to reach the largest possible size and achieve full expansion of the aortic annulus.

[Evaluation of 38 cases of employing aortic occlusion balloon catheter].

BACKGROUND: Aortic occlusion balloon catheter (AOBC), which occludes the descending aorta without thoracotomy, is expected to prevent further blood loss and raise blood pressure (BP). We investigated the effects of AOBC retrospectively. METHOD: AOBC was used in 38 patients for perioperative management only if the BP responded insufficiently despite rapid resuscitation due to massive hemorrhage below the diaphragm. There were 33 trauma cases, and five cases of ruptured abdominal aortic aneurysm. We inserted AOBC via the femoral artery or left common carotid artery in the emergency room(ER) or in the operating room (OR). RESULTS: BP increased for 38.7 +/- 33.9 mmHg following AOBC, with a survival rate of 36%. CONCLUSIONS: In our experience, AOBC was effective for raising BP in patients in hemorrhagic shock.

Preferential Conduction Properties Along The Left Lateral Ridge And The Arrhythmogenicity Of The Left Pulmonary Veins In Patients With Atrial Fibrillation.

PURPOSE: In this study, we examined the hypothesis that the preferential conduction property along left lateral ridge (LLR) might affect the arrhythmogenicity of left pulmonary veins (LPVs). METHODS: The study population included 40 consecutive AF patients. Radiofrequency energy (RF) was sequentially delivered along the LLR from a lower to upper manner during postero-lateral CS pacing during an isoproterenol infusion. RESULTS: The conduction time during pacing from the CS was significantly prolonged during radiofrequency (RF) deliveries (before vs. after, upper; 91±26ms vs. 127±38ms, p<0.001, lower; 86±21ms vs. 103±22ms, p<0.001). Remarkable prolongation of more than 30ms was observed in 19 of 40 patients (48%) (both LPVs, 6; only the upper LPVs, 12; and only the lower LPV, 1). Sites with a remarkable prolongation were observed at the carina between the LPVs,[4] anterior site of the upper LPV carina,[10] anterior wall of the lower LPV,[3] and bottom of the lower LPVs [2] Thirty-three arrhythmogenic foci (AMF) from the LPVs were observed in 23/40 patients (56%). The conduction time during pacing from the LPVs during the RF delivery was significantly longer in the patients with AMF from the upper LPV than in those patients without (107±36ms vs. 146±40ms, p<0.01). CONCLUSION: The LLR includes the preferential conduction properties between the CS and LPVs, and the observation of the serial changes during the RF delivery could provide us information about the LPVs arrhythmogenicity.

Features of intrinsic ganglionated plexi in both atria after extensive pulmonary isolation and their clinical significance after catheter ablation in patients with atrial fibrillation.

BACKGROUND: The features of intrinsic ganglionated plexi (GP) in both atria after extensive pulmonary vein isolation (PVI) and their clinical implications have not been clarified in patients with atrial fibrillation (AF). OBJECTIVE: The purpose of this study was to assess the features of GP response after extensive PVI and to evaluate the relationship between GP responses and subsequent AF episodes. METHODS: The study population consisted of 216 consecutive AF patients (104 persistent AF) who underwent an initial ablation. We searched for the GP sites in both atria after an extensive PVI. RESULTS: GP responses were determined in 186 of 216 patients (85.6%). In the left atrium, GP responses were observed around the right inferior GP in 116 of 216 patients (53.7%) and around the left inferior GP in 57 of 216 (26.4%). In the right atrium, GP responses were observed around the posteroseptal area: inside the CS in 64 of 216 patients (29.6%), at the CS ostium in 150 of 216 (69.4%), and in the lower right atrium in 45 of 216 (20.8%). The presence of a positive GP response was an independent risk factor for AF recurrence (hazard ratio 4.04, confidence interval 1.48-11.0) in patients with paroxysmal, but not persistent, AF. The incidence of recurrent atrial tachyarrhythmias in patients with paroxysmal AF with a positive GP response was 51% vs 8% in those without a GP response (P = .002). CONCLUSION: The presence of GP responses after extensive PVI was significantly associated with increased AF recurrence after ablation in patients with paroxysmal AF.

Possible roles of angiotensin II-forming enzymes, angiotensin converting enzyme and chymase-like enzyme, in the human aneurysmal aorta.

Aortic aneurysm is a chronic degenerative condition associated with atherosclerosis. Recent studies have revealed that angiotensin (Ang) II plays important roles in atherosclerosis. In this study, to investigate the relationship between aortic aneurysm and Ang II, we measured the activities of the angiotensin (Ang) II-forming enzymes, angiotensin converting enzyme (ACE) and chymase-like enzyme, in human aneurysmal and control aortae. Aneurysmal aortic specimens were obtained from 16 aneurysm patients and control aortic specimens were obtained from 16 patients who underwent coronary artery bypass surgery (8 patients in each group were administered ACE inhibitors). The ACE and chymase-like enzyme activities were determined using extracts from vascular tissues. Both the ACE and chymase-like enzyme activities in the aneurysmal aortae were significantly higher than those in the control aortae (p < 0.01). In the patients treated with ACE inhibitors, the ACE activity in the aneurysmal aortae tended to be low, but the chymase-like enzyme activity tended to be high. In the aneurysmal aortae, the chymase-like enzyme activity in the adventitia was significantly higher than that in the intimal or medial layers (p < 0.01), while differences in ACE activity were not observed. Our results suggest that increases in local Ang II formation induced by chymase-like enzymes may play important roles in the pathogenesis of aneurysmal formation.

Increased local angiotensin II formation in aneurysmal aorta.

We investigated the levels and locations of angiotensin II-forming enzymes, angiotensin converting enzyme (ACE) and chymase, in aneurysmal and normal aortas. Aneurysmal aortic specimens (n = 14) were obtained at the time of operative aneurysm repair from 14 patients ranging in age from 57 to 84 y. Normal aortic specimens (n = 16) were obtained from 16 patients (48 to 72 y) who underwent coronary artery bypass surgery. The ACE and chymase activities were determined using each specimen. Sections of each specimen were immunostained with antibodies for ACE and chymase. The ACE activities in the aneurysmal and normal aortas were 0.82 +/- 0.10 and 0.14 +/- 0.05 mU/mg protein, respectively, and this difference was significant. The chymase activities in the aneurysmal and normal aortas were 17.9 +/- 2.40 and 1.02 +/- 0.18 mU/mg protein, respectively, and this difference was also significant. In the aneurysmal aorta, ACE-positive cells were detected with macrophages in the intima and media and chymase-positive cells were detected with mast cells in the media and adventitia, whereas positive ACE and chymase cells in the normal aorta were located only in the endothelium and adventitia, respectively. Angiotensin II-forming enzymes, chymase and ACE, were significantly increased in the aneurysmal aorta, and increased angiotensin II may be associated with the development of aneurysmal formations.

Surgical treatment of traumatic thoracic aorta rupture: a 7-year experience.

OBJECTIVES: Traumatic aortic rupture is highly lethal and an ongoing therapeutic challenge. We review our 7-year experience with traumatic aortic disruption. METHODS: We treated 12 cases of traumatic rupture of the thoracic aorta (TRTA) from December 1994 to June 2001 at our institution. Of these, 9 were male, and the average age 26 years. Injuries were caused by traffic accidents in 9 cases and falls in 3. Contrast-enhanced helical computed tomography was used to diagnose10 cases and digital subtraction angiography to diagnose 2 at other hospitals. Six of 12 (50%) disruptions were located in the aortic isthms. All surgery was conducted under cardiopulmonary bypass. A percutaneous cardiopulmonary support system (heparin-bonded artificial lung and centrifugal pump) was used in 6 cases since 1998. RESULTS: Among the 12 patients, 6 had early surgical repair within 2 days after the accident, and all survived free of neurological problems. Six other had repair delayed more than 2 days and all were doing well. CONCLUSION: Immediate repair of aortic lesions should be the rule because the majority of deaths from TRTA occur within 24 hours. We believe, however, that immediate surgery may not be necessary for some patients with severe, multiple associated lesions who survive initial traumatic aortic disruption of the aorta.

Direct aspiration of large thrombi in acute myocardial infarction using a standard 6 Fr guide catheter via the transradial approach.

A large thrombus load on the culprit coronary artery of patients with acute myocardial infarction (MI) is associated with increased procedural complications and adverse coronary events following angioplasty. This case series describes effective removal of large, occlusive thrombi in acute MI via direct aspiration using a standard 6 Fr guide catheter, following failed conventional catheter aspiration. This procedure is a simple and rapid alternative for challenging thrombi-containing coronary lesions when current thrombectomy catheters fail.

Asymptomatic acute ischemic stroke after primary percutaneous coronary intervention in patients with acute coronary syndrome might be caused mainly by manipulating catheters or devices in the ascending aorta, regardless of the approach to the coronary artery.

BACKGROUND: Asymptomatic acute ischemic stroke (aAIS) following primary percutaneous coronary intervention (p-PCI) in patients with acute coronary syndrome (ACS) has not been studied in detail. METHODS AND RESULTS: Of 75 patients who underwent p-PCI, 26 (34.7%) developed aAIS as determined by diffusion-weighted magnetic resonance imaging (MRI). Including the approach to the coronary artery (via lower limb or right upper limb), 23 factors were compared between patients with (n=26) and without (n=49) aAIS. Age, hypertension, smoking, plasma glucose levels, Killip grade, right coronary artery (RCA) as culprit vessel, percutaneous coronary intervention (PCI) time, and the frequency of device insertion into the coronary artery differed in a statistically significant manner. However, multivariate analysis showed that the RCA (odds ratio 3.477) and the frequency of device insertion (1.375) were independent factors linked to the incidence of aAIS. Moreover, anterior or posterior location and left or right cerebral circulation of aAIS were equivalent in both approaches. CONCLUSIONS: Cranial MRI images following emergency PCI revealed that 34.7% of the patients with ACS had aAIS that might be caused by manipulating the catheter or devices in the ascending aorta, micro-air bubble embolism during injection, or micro-thrombus embolism derived from the ACS lesions during the PCI procedure.

Young adult patients with short dissection length and thrombosed false lumen without ulcer-like projections are liable to have false-negative results of D-dimer testing for acute aortic dissection based on a study of 113 cases.

BACKGROUND: Previous reports indicate that D-dimer testing (DT) for acute aortic dissection (AAD) has a sensitivity of 100%, but each study comprised less than 30 patients. The aim of this study was to evaluate the positive rate and factors related to the results of DT for AAD in a larger population. METHODS AND RESULTS: DT (cutoff; upper normal limit) was performed for 113 consecutive AAD patients within 24 h of symptom onset. In total, 104 (92%) patients exhibited positive DT. The positive rate of DT showed a low tendency in patients aged less than 70 years and for a time interval from symptom onset to admission within 120 min, and there were significant differences between those with and without a thrombosed false lumen (TFL) (86.4% (n=59) vs 98.1% (n=54), p=0.033), complete TFL (excluding patients with ulcer-like projection (ULP) from those with a TFL) (81.1% (n=37) vs 97.4% (n=76), p=0.005) and length score (1 (n=28); 78.6%, 2 (n=40); 95.0%, 3 (n=45); 97.8%, p=0.005). Multivariate analysis demonstrated age (odds ratio =1.164, p=0.013), complete TFL (0.048, 0.030) and length score (6.271, 0.033) as independent factors. CONCLUSIONS: Physicians should be aware that younger patients with short dissection length and a TFL without ULP are liable to have false-negative DT results.