小林 欣夫

Background: There is limited information about Optimal management of drug-eluting stent (DES) restenosis. This Study evaluated the incidences of re-restenosis and re-target lesion revascularization (TLR) after the treatment of sirolimus-eluting stent (SES.) restenosis. Methods and Results: A total of 102 lesions in 10 1 patients who underwent TLR for SES restenosis were classified according to: (1) focal (lesion length <= 10mm) or non-focal restenosis (>10mm); and (2) use of DES for TLR: ( 1) focal restenosis treated with DES (focal-DES, n=40); (2) focal restenosis treated by balloon angioplasty by (focal-balloon, n=31); (3) non-focal restenosis with DES (non-focal-DES, n=17); and (4) non-focal restenosis by balloon angioplasty (non-focal-balloon, n=14). Re-restenosis and re-TLR were observed in 6 (19.4%) and 5 lesions (12.5%) of the focal-DES group, in 13 (65.0%) and 11 (35.5%) of the focal-balloon group, in 7 (50.0%) and 6 (35.3%) of the non-focal-DES group, and in 8 (61.5%) and 7 (50.0%) of the non-focal-balloon group, respectively (P<0.05 for restenosis and TLR between the focal-DES group and other group). Conclusions: Re-DES implantation for focal DES restenosis results in lower re-restenosis and re-TLR rates compared to re-DES implantation for non-focal DES restenosis or conventional balloon angioplasty either for focal or non-focal DES restenosis. (Circ J 2009; 73: 867-871)

Background: Large-scale randomized trials demonstrate a high proportion of focal restenosis after drug-eluting stent (DES) implantation. On the other hand, recent reports have shown that in real-world practice a significant proportion of the restenosis is non-focal when DESs are used in unselected lesions. The present study evaluated angiographic patterns of restenosis after sirolimus-eluting stent (SES) implantation in Japan. Methods and Results: Angiographic restenosis patterns of all consecutive restenotic lesions (n=124) after SES implantation were evaluated and classified according to the following scheme: focal (<= 10mm in length), diffuse (restenosis >10mm within the stent), proliferative (restenosis >10mm in length extending outside the stent), and occlusive. There were 98 focal (79.0%), 15 diffuse (12.1%), and 5 proliferative restenoses (4.0%) and 6 total occlusions (4.8%). Focal intrastent restenosis was most dominant (42.7%). Proximal edge restenosis occurred in 22 lesions (17.7%). Multivariate analysis demonstrated diabetes mellitus (P<0.01) as an independent predictor of non-focal restenosis. Conclusions: Focal restenosis is predominant after SES implantation in real-world practice in Japan. (Circ J 2009; 73: 508-511)

To investigate intravascular ultrasound predictors of long-term clinical outcome in patients with acute coronary syndrome, 94 patients with a first acute coronary syndrome with both preintervention intravascular ultrasound imaging and long-term follow-up were enrolled in this study. Remodeling index was defined as external elastic membrane cross-sectional area at the target lesion divided by that at the proximal reference. Arterial remodeling was defined as either positive (PR: remodeling index > 1.05) or intermediate/negative remodeling (remodeling index <= 1.05). Clinical events were death, myocardial infarction, and target-lesion revascularization. Patients were followed up for a mean of 3 years. PR was observed in 50 (53%), and intermediate/negative remodeling, in 44 (47%). During the 3-year follow-up, there were 20 target-lesion revascularization events and 5 deaths (2 cardiac and 3 noncardiac), but no myocardial infarctions. Patients with PR showed significantly lower major adverse cardiac event (MACE; death, myocardial infarction, and target-lesion revascularization)-free survival (log-rank p = 0.03). However, patients with plaque rupture showed a nonsignificant trend toward lower MACE-free survival (p = 0.13), but there were no significant differences in MACE-free survival between those with single versus multiple plaque ruptures. Using multivariate logistic regression analysis, only culprit lesion PR was an independent predictor of MACEs (p = 0.04). In conclusion, culpri-tension remodeling rather than the presence or absence of culprit-lesion plaque rupture was a strong predictor of long-term (3-year) clinical outcome in patients with acute coronary syndrome. (C) 2009 Elsevier Inc. (Am J Cardiol 2009;103:791-795)

The polymer of paclitaxel-eluting stents (PES) plays an important role in controlling the release of paclitaxel. Damage to the polymer of a PES that is used in a patient has not been demonstrated, although in-vitro studies report disruption of it. The present case report describes damage to a PES as delivery through a calcified coronary artery was being attempted. (Circ J 2008; 72: 1907-1908)

Chronic active Epstein-Barr virus (CAEBV) infection is characterized by chronic or recurrent infectious mononucleosis-like symptoms and the prognosis of CAEBV infection is quite poor. The incidence of myocarditis as a complication of EBV infection is not so high and it is unusual that heart failure appears as the initial symptom. However, it is very important to detect and treat chronic active myocarditis in the early phase of CAEBV infection because chronic active myocarditis disorganizes and decreases cardiomyocytes, resulting in the progression to heart failure. We report a case of a 45-year-old man with CAEBV infection for 5 years. Echocardiography revealed moderate left ventricular systolic dysfunction with mild pericardial effusion. Endomyocardial biopsies demonstrated massive lymphocytic infiltration with adjacent myocytolysis and necrosis of cardiomyocytes suggesting active myocarditis. Immunohistological analysis of biopsies revealed that the infiltrating cells were mainly T lymphocytes. And some of the infiltrating cells showed a positive signal for the EBV-encoded small nuclear RNA by in situ hybridization. Positron emission tomography using (18)F-fluoro-2-deoxyglucose ((18)F-FDG) performed revealed increased uptake of (18)F-FDG of whole left ventricular wall with mild heterogeneity. (C) 2007 Elsevier Ireland Ltd. All rights reserved.

Background A lower maintenance dose of clopidogrel may be appropriate in Japanese patients because the maintenance dose of ticlopidine is lower in Japan than that used in the United States. Methods and Results A total of 126 patients with 153 lesions who consented to take 50-mg clopidogrel to prevent stern thrombosis were enrolled. There was 1 case of early stent thrombosis (0.65%). Side-effects of clopidogrel occured in 5 patients (4.0%). Conclusion This preliminary Study shows that 50mg clopidogrel may be acceptable in Japanese patients.

Werner syndrome (WS) is an autosomal recessive progeroid disorder caused by mutations in RecQ DNA helicase. Ectopic soft tissue calcification is one of the well known symptoms in WS. However, the prevalence, clinical outcome, and mechanism of such calcification remain to be elucidated. The clinical features and mechanism of ectopic calcification were examined in seven patients with WS whose diagnosis were confirmed by a genomic DNA analysis. X-ray examinations revealed subcutaneous calcification in 35 of 41 major joints (85.3%). The patients complained of dermal pain at 23 joints among 35 joints (65.7%) with calcification. Refractory skin ulcers were found at the area of the skin overlaying the calcification in 16 joints (45.7%). In contrast, no pain or ulcers were observed in the joints without calcification. The presence of ectopic calcification could not be explained by a systemic hormonal abnormality. Cultured fibroblasts from WS patients underwent spontaneous mineralization in vitro in the normal phosphate condition, and overexpressed Pit-1, a transmembrane type III Na-Pi cotransporter both at the mRNA and protein levels. Phosphonophormic acid, a specific inhibitor for Pit-1, inhibited mineralization in the WS fibroblasts. Both calcification and Pit-1 overexpression were detected in the skin of WS in situ. WS showed a high prevalence of ectopic calcification, which was associated with dermal pain and refractory skin ulcers. An overexpression of Pit-1 therefore seems to play a key role in the formation of soft tissue calcification in this syndrome.

Background The loading dose of ticlopidine is 500mg in both the US and Europe and 200mg in Japan. A lower loading dose of clopidogrel might achieve adequate platelet inhibition in Japanese patients. Methods and Results Platelet aggregation was serially measured at baseline, and 2, 4, 6, and 8h after 150-mg (n=20) and 300-mg (n=20) clopidogrel loading. Platelets were stimulated with 5 and 20 mu mol/L adenosine diphosphate (ADP) and aggregation was assessed by optical aggregometry. Pretreatment ADP-induced platelet aggregation in the 150-mg clopidogrel group did not differ from that of the 300-mg group. The administration of 300-mg clopidogrel loading dose resulted in lower platelet aggregation 2h after the administration (5 mu mol/L ADP: 53 +/- 9% vs 61 +/- 12%, p<0.05 and 20 mu mol/L ADP: 61 +/- 10% vs 68 +/- 9%, p<0.05). A lower platelet aggregation induced with 20 mu mol/L ADP was still observed 4h after the 300-mg clopidogrel loading (58 +/- 10% vs 65 +/- 9%, p<0.05). Conclusions The 150-mg clopidogrel loading does not achieve rapid platelet inhibition. The 300-mg loading dose should be used to suppress platelet function rapidly even in Japanese patients undergoing coronary stent placement.

We report the case of a 38-year-old Asian man with a pericardial hemangioma on the left main coronary artery. The patient presented initially at our hospital after cardiopulmonary resuscitation following an episode of ventricular fibrillation (VF). Because of spontaneous coved-type ST segment elevation on the higher intercostal space V1 to V2 in a 12-lead electrocardiogram, documented VF in the absence of structural heart disease, and a family history of sudden death, he was diagnosed with Brugada syndrome. Transesophageal echocardiography showed a smooth-surfaced mass with well-demarcated borders, directly above the left main coronary artery. Computed tomography confirmed the presence of the mass, which showed no enhancement at early phase, but did demonstrate homogenous enhancement at delay phase by contrast material. There were no findings from either the nuclear medicine or the tumor marker investigations which indicated that the mass located just above the main coronary arteries was malignant. Therefore, taken together, these findings suggested that the tumor might be a pericardial hemangioma. The relationship between the location of the hemangioma just above the left main coronary artery and the occurrence of VF was not clear, i.e. whether the presence of the hemangioma caused the stimulation of the left main coronary artery and as a result, led to the spasm of the left main coronary artery and the occurrence of VF. Furthermore, as the tumor did not extend into any of the adjacent structures, such as the coronary arteries or the right ventricular outflow tract, surgical resection was not performed; instead, the patient received a dual chamber implantable cardioverter-defibrillator. (C) 2007 Published by Elsevier Ireland Ltd.

Stent thrombosis is an infrequent event but a potentially fatal complication of coronary stenting. Adherence to long-term antiplatelet therapy plays an important role in the prevention of late stent thrombosis after drug-eluting stent (DES) implantation. Poor glycemic control due to nonadherence to diabetic treatments is likely to result in severely diffuse coronary atherosclerosis and diabetic microvascular complications. This case report describes fatal very late stent thrombosis in a Young diabetic patient, which teaches us about the potential risk of DES in patients with acute myocardial infarction and the importance of patient education about long-term dual antiplatelet therapy after DES implantation. Furthermore, it demonstrates severely diffuse atherosclerosis in a young diabetic patient with nonadherence to diabetic treatments. (Int Heart J 2008 49: 507-513)

Background. Damage to the polymer coating on sirolimus-eluting stents (SES) may occur when it is delivered through complex lesions such as calcified lesions. The present study evaluated damage to the polymer of SES that could not be delivered into lesions. Methods. SES that could not be delivered into lesions were prospectively collected and examined using a scanning electron microscope. Results. There were 5 undelivered SES. In all cases, moderate or severe calcification with and without vessel tortuosity were reasons for unsuccessful delivery. Scanning electron microscopy demonstrated damage to the polymer of 4 out of the 5 undelivered SES. Conclusion. Damage to the polymer coating of SES may occur when delivered through a calcified coronary artery.

Background Antiplatelet therapy in patients with sirolimus-eluting stents (SES) may be stopped because of bleeding or an invasive procedure. Methods and Results In 254 patients with SES, the incidence of discontinuation of antiplatelet therapy and subsequent adverse cardiac events was evaluated. Follow-up was complete for 97.2% of the population and mean follow-up was 15.6 8.9 months. Discontinuation of antiplatelet therapy occurred for 46 patients (18.1%): 1 case of late stent thrombosis (2.2%) occurred 10 days after cessation of therapy because of pulmonary hemorrhage 7 months after SES deployment. Conclusion Discontinuation of antiplatelet therapy in patients with SES is not infrequent.

Background There is little information about the efficacy of ticlopidine plus aspirin after sirolimus-eluting stent (SES) implantation. Methods and Results The incidence of stent thrombosis was evaluated in 1,029 patients receiving ticlopidine and aspirin after SES deployment. Clinical follow-up was obtained in 98.9% (mean follow-up 17.0 +/- 7.9 months). Early stent thrombosis was observed in 5 patients (0.49%). There was 1 case each of late (0.1%) and very late stent thrombosis (0.1%). Conclusion Late and very late stent thrombosis in Japanese patients receiving ticlopidine and aspirin after SES deployment occurs infrequently.

Primary cardiac tumors are rare. In this report, using fusion images of multislice computed tomography (MSCT) and positron emission tomography (PET) using F-18 Fluoro-Deoxyglucose, we could diagnose, morphologically, the location, size and extent of the tumor, and degree of blood flow from the feeding artery (by MSCT) and establish that this cardiac tumor was malignant (by PET) before surgical operation. Histologically, the tumor was diagnosed as a cardiac angiosarcoma. (C) 2007 Published by Elsevier Ireland Ltd.

Background: This study examined feasibility and safety of granulocyte colony- stimulating factor ( G- CSF) treatment for patients with acute myocardial infarction ( AMI). Methods: Forty patients with AMI related with the left anterior descending coronary artery, who underwent successful percutaneous coronary intervention ( PCI), were randomized into G- CSF group ( n= 18) or Control group ( n= 22). G- CSF treatment was started within 24 h after PCI. Tc-99m- tetrofosmin single- photon emission computed tomography ( SPECT) was performed at 4 days and 6 months after AMI. SPECT data was analyzed for LV end- diastolic volume ( LVEDV), LV end- systolic volume ( LVESV), LV ejection fraction ( LVEF) and myocardial perfusion. Results: LVEF at 6 months was significantly better than that at 4 days in G- CSF group ( p= 0.013), but not changed in Control group ( p= 0.245). Although no significant difference was observed for LVEDV between the two groups, LVESV tended to be decreased only in G-CSF group. In G- CSF group, defect score ( DS) was significantly decreased from 4 days to 6 months after AMI. Restenosis rate at 6 months after AMI was not significantly different between the two groups. Conclusions: G- CSF treatment for patients with AMI was effective and did not have any clinical and angiographic adverse effects. (C) 2006 Elsevier Ireland Ltd. All rights reserved.

Cardiac amyloidosis is generally a progressive disease with a poor prognosis, so early diagnosis and appropriate treatments are important. Although cardiac amyloidosis can be diagnosed definitively by endomyocardial biopsy, non- invasive methods of diagnosis are desired because of a great risk in biopsy. In ECG- gated enhanced multislice computed tomography, not only clear images of the cardiac morphology but also the character of myocardium indicating fibrosis can be identified. We demonstrate two patients with cardiac amyloidosis who showed marked thickening of left ventricular wall with partial fibrotic changes by enhanced multislice computed tomography. (C) 2006 Elsevier Ireland Ltd. All rights reserved.

Background It remains unclear whether sirolimus-eluting stents (SES) have an advantage over bare metal stents (BMS) in patients on dialysis. Methods and Results Percutaneous coronary intervention (PCI) using SES was performed in 54 dialysis patients with 69 lesions. A control group for comparison comprised 54 consecutive dialysis patients with 58 lesions who underwent PCI using BMS. Angiographic and clinical follow-ups were scheduled at 9 months. After the procedure, minimum lumen diameter (MLD) was similar between the 2 groups. At follow-up, the SES group had a higher NILD than the BMS group (1.98 +/- 0.83 mm vs 1.50 +/- 0.78 mm, p < 0.01). In-stent restenosis rate was lower in lesions treated with SES than in those with BMS (22% vs 40%, p=0.048). However, there was no significant difference between the 2 groups for in-segment restenosis (31% vs 43%, p=0.3). During follow-up, there was no significant difference in the incidence of death, myocardial infarction or target lesion revascularization (TLR) (14% vs 21 %, p=0.4) between the SES and BMS groups. Conclusions In this retrospective study, SES, in comparison with BMS, reduced in-stent restenosis in patients on dialysis. However, in-segment restenosis and TLR were not statistically different between lesions treated with SES and those with BMS.

This case report describes multivessel coronary artery spasm refractory to oral nifedipine, intravenous isosorbide dinitrate, diltiazem and nicorandil, and intracoronary nitroglycerin. Intracoronary administration of nicorandil only transiently relieved coronary artery spasm. Prednisolone was effective in preventing coronary artery spasm.

We describe as case of a 70-year-old man who underwent a percutaneous coronary intervention with stenting, for a severe stenosis complicated by a coronary aneurysm just distal to the stenotic site. Notably, coronary angiogram showed an immediate and progressive reduction in the size of coronary aneurysm. Curved planar reconstruction images of the enhanced CT showed no thrombus and no dissection of the coronary aneurysm. We speculate that coronary stenting might decrease the velocity of coronary flow through the stenosis. Consequently, stenting might attenuate the hydrodynamic wall stress on the aneurysm, and, in addtion, improve the degradation of the extracellular matrix structure through the regulation of matrix metalloproteinases. Regression of coronary aneurysm after stenting requires further investigations, because stenting may become a potential means for treating post-stenotic aneurysms. (c) 2006 Elsevier Ireland Ltd. All rights reserved.

We observed a 63-year old male with cardiac amyloidosis who presented with the clinical symptoms of sick sinus syndrome and dyspnea and abnormal thickening of the right atrial wall, which extended to the junction of the superior vena cava. This may explain the relationship of abnormal thickening of the right atrium which extends to the junction of the superior vena cava and right atrium with amyloid deposits in the sinus node and occurrence of sick sinus syndrome. (c) 2006 Elsevier Ireland Ltd. All rights reserved.

We report here a 75-year-old male with hypertrophic obstructive cardiomyopathy of de novo sustained monomorphic ventricular tachycardia (VT) after successful percutaneous transluminal alcohol septal myocardial ablation (PTSMA). In this case history, the necrotic induced by the PTSMA procedure might represent a region of slow conduction that is a circuit of re-entry and therefore stimulation might be spread around. Therefore, the basis of the sustained monomorphic VT was thought to be the presence of a focal necrotic area, itself a complication arising from the PTSMA procedures. In conclusion, the PTSMA procedure may have caused a de novo episode of ventricular arrhythmia. (C) 2006 Elsevier Ireland Ltd. All rights reserved.

Background Previous intravascular ultrasound (IVUS) studies have shown that calcification can be quantified by the determination of the arc on one cross-section. However, because calcium levels change along the length of lesions, it is important to assess the length of calcium using serial cross-sectional images. The correlation between the largest arc and length of each calcium deposit in patients with coronary artery disease (CAD) has not been determined. The present study was performed to determine this correlation. Methods and Results Preinterventional IVUS images of 194 patients with CAD were studied. The largest arc and length of all calcium within the 10-mm-long culprit lesion segment were quantified using serial cross-sectional images. One hundred and ninety-four patients had 277 calcium deposits. In all patients, the length of each calcium exhibited a strong correlation with the largest arc of calcium (R=0.750, p<0.0001). Conclusions Our findings revealed the quantitative characteristics of each calcium within the culprit lesion segment. They will be useful in interpreting results of previous and future IVUS studies, which deal only with the arc of calcium, as well as studies using new modalities such as computed tomography that assess calcium mainly along the long axis of the coronary artery. (Circ J 2007; 71: 530 - 535)<br>

Background Because of its side-effects, long-term administration of ticlopidine limits the use of the sirolimuseluting stent (SES) in Japan. Methods and Results Side-effects of ticlopidine occurred in 41 (9.3%) of 440 patients who underwent SES implantation. The majority were liver dysfunction (4.5%) and rash (3.6%). One patient died from severe liver dysfunction. Neutropenia occurred in 3 patients (0.7%). It is remarkable that 28% of side-effects occurred &gt; 8 weeks after the initiation of ticlopidine. Conclusions Ticlopidine has a relative high rate of side-effects. Clopidogrel should be approved for prevention of stent thrombosis as soon as possible.

Serial (baseline and 9-month follow-up) intravascular ultrasound analysis was performed at 5-mm reference segments immediately proximal and distal to the sirolimus-eluting stent (SES) in 33 lesions. Proximal and distal reference segments were divided into 1-mm subsegments. Between postintervention and follow-up intravascular ultrasound studies, there were significant decreases in the lumen and increases in plaque & media areas in the subsegment closest to the distal edge, with no change in external elastic membrane area. There was no significant change in external elastic membrane, lumen, and plaque & media areas within the other subsegments. At the nearest 1-mm subsegment from the proximal and distal edges, baseline plaque & media area was associated with subsequent vessel remodeling. In conclusion, a large amount of plaque at the SES edge may be a risk of negative remodeling at follow-up (stent edge restenosis). It supports the importance of "normal-to-normal" SES deployment. (c) 2006 Elsevier Inc. All rights reserved.

Previous studies have shown that coronary stents have radial strength above the pressure induced by coronary artery spasm. This case report describes a stent deformity caused by coronary artery spasm during percutaneous coronary intervention.

The discovery of bone marrow - derived endothelial progenitors in the peripheral blood has promoted intensive studies on the potential of cell therapy for various human diseases. Accumulating evidence has suggested that implantation of bone marrow mononuclear cells effectively promotes neovascularization in ischemic tissues. It has also been reported that the implanted cells are incorporated not only into the newly formed vessels but also secrete angiogenic factors. However, the mechanism by which cell therapy improves tissue ischemia remains obscure. We enrolled 29 " no- option" patients with critical limb ischemia and treated ischemic limbs by implantation of peripheral mononuclear cells. Cell therapy using peripheral mononuclear cells was very effective for the treatment of limb ischemia, and its efficacy was associated with increases in the plasma levels of angiogenic factors, in particular interleukin- 1 beta ( IL- 1 beta). We then examined an experimental model of limb ischemia using IL- 1 beta - deficient mice. Implantation of IL- 1 beta - deficient mononuclear cells improved tissue ischemia as efficiently as that of wild- type cells. Both wild- type and IL- 1 beta - deficient mononuclear cells increased expression of IL- 1 beta and thus induced angiogenic factors in muscle cells of ischemic limbs to a similar extent. In contrast, inability of muscle cells to secrete IL- 1 beta markedly reduces induction of angiogenic factors and impairs neovascularization by cell implantation. Implanted cells do not secret angiogenic factors sufficient for neovascularization but, instead, stimulate muscle cells to produce angiogenic factors, thereby promoting neovascularization in ischemic tissues. Further studies will allow us to develop more effective treatments for ischemic vascular disease.

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 defected 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 (I to 3 times the upper limit of normal CK-MB, 35% vs 10%, p &lt;0.001; &gt;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. (C)2005 by Excerpta Medica Inc.

Intravascular ultrasound (IVUS) evaluation was performed in 33 lesions with sirolimus-eluting stent (SES) failure: 4 thromboses; 26 in-stent restenoses (including 6 edge stenoses), 4 new stenoses &gt;5 mm proximal to the stent, and 1 patient with no evidence of the implanted SES (presumably because of embolization): A minimum stent area &lt;5.0 mm(2) (stent underexpansion) was observed in 67% of all SES failures (in particular, 67% of intrastent restenosis); negative remodeling was observed in 4 of 6 stent edge restenoses, and new lesions were secondary to an increase in plaque area. (C) 2005 by Excerpta Medica Inc.

Background - Little is known about causes of intimal hyperplasia (IH) after sirolimus-eluting stent (SES) implantation. Methods and Results - Intravascular ultrasound was performed in 24 lesions with intra-SES restenosis and a comparison group of 25 nonrestenotic SESs. To assess stent strut distribution, the maximum interstrut angle was measured with a protractor centered on the stent, and the visible struts were counted and normalized for the number of stent cells. In SES restenosis patients, minimum lumen site was compared with image slices 2.5, 5.0, 7.5, and 10.0 mm proximal and distal to this site. The minimum lumen site had a smaller IVUS lumen area at follow-up (2.7 +/- 0.9 versus 6.2 +/- 1.9 mm(2); P &lt; 0.01), larger maximum interstrut angle ( 135 +/- 39&DEG; versus 72 +/- 23&DEG;; P &lt; 0.01), larger IH area (3.4 +/- 1.5 versus 0.6 +/- 1.1 mm(2); P &lt; 0.01) and thickness (0.7 +/- 0.3 versus 0.1 +/- 0.2 mm; P &lt; 0.01) at maximum interstrut angle, and fewer stent struts (4.9 +/- 1.0 versus 6.0 +/- 0.5; P &lt; 0.01) even when normalized for the number of stent cells (0.78 +/- 0.15 versus 0.97 +/- 0.07; P &lt; 0.01). Compared with nonrestenotic SES, the restenosis lesions also had a smaller minimal lumen area, larger IH area, thicker IH at maximum interstrut angle, fewer stent struts, and larger maximum interstrut angle. Multivariate analysis identified the number of visualized stent struts normalized for the number of stent cells and maximum interstrut angle as the only independent IVUS predictor of IH cross-sectional area ( P &lt; 0.01 and P &lt; 0.01), minimum lumen area ( P &lt; 0.01 and P &lt; 0.01), and IH thickness ( P &lt; 0.01 and P &lt; 0.01). Conclusions - The number and distribution of stent struts affect the amount of neointima after SES implantation.

Coronary remodeling and plaque composition were compared between focal and diffuse coronary lesions. Negative remodeling and fibrous and calcified plaque compositions contribute to stenosis development in diffuse lesions more frequently than in focal lesions. (C)2004 by Excerpta Medica, Inc.

The treatment of in-stent restenosis using balloon angioplasty alone often produces excellent early results, but is associated with high rate of recurrence. Previous studies have demonstrated significant tissue reintrusion shortly after the treatment of in-stent restenosis with balloon angioplasty. The study was designed to elucidate the contribution of early lumen loss 6 hr after balloon angioplasty to lumen loss at follow-up. We prospectively performed quantitative coronary angiography and intravascular ultrasound in 12 patients with in-stent restenosis before intervention, after the final procedure, 6 hr later (5.6 +/- 1.4 hr), and at follow-up (7.7 +/- 2.3 months). Compared with immediately after balloon angioplasty, by 6 hr postintervention, the minimum lumen diameter (MLD) and lumen cross-sectional area had decreased significantly (2.48 +/- 0.44 to 2.01 +/- 0.57 mm, P = 0.01, and 7.0 +/- 1.2 to 5.5 +/- 1.4 mm(2), p = 0.004, respectively). Furthermore, the MILD decreased further between 6 hr postintervention and long-term follow-up (2.01 +/- 0.57 to 1.55 +/- 0.64 mm; P = 0.001). Patients who showed recurrence of restenosis at follow-up had greater early lumen loss than patients without recurrence of restenosis (0.71 +/- 0.31 vs. 0.23 +/- 0.13 mm; P = 0.006). Diffuse lesions had greater early lumen loss compared to focal lesions (0.75 +/- 0.35 vs. 0.28 +/- 0.13 mm; P = 0.008). Early lumen loss is common after the treatment of in-stent restenosis by balloon angioplasty. Within the first 6 hr postintervention, 32% +/- 29% of acute lumen gain is lost, and early lumen loss contributed to 42% +/- 18% of total lumen loss at follow-up. (C) 2004 Wiley-Liss, Inc.

Background In a previous study the adjusted thresholds at which the diameters of coronary arteries determined by enhanced electron-beam computed tomography (CT) scans are equal to the corresponding quantitative coronary angiography measurements were analyzed, and their correlation with maximum CT values for the vessel short axes was determined. A rapid accurate method for such measurements was sought by substituting maximum CT values for the descending aorta in the corresponding axial images for those for the short axes. Methods and Results In 8 patients, 179 sites were measured. Means (+/-SD) of adjusted thresholds and the maximum CT values for vessel short axes and the descending aorta in the corresponding axial images for all vessels were 108+/-66, 227+/-80, and 363+/-75 Hounsfield Unit (HU), respectively. Adjusted thresholds correlated with the maximum CT values for the corresponding vessel short axes and the descending aorta in the corresponding axial images, with R-2=0.55, 0.33, p&lt;0.01, respectively. An abbreviated formula for use of maximum CT values for the descending aorta in the corresponding axial images was y=0.5x-75 (HU) (y = adjusted threshold, x = maximum CT value for the descending aorta in the corresponding axial image). Conclusions The abbreviated formula provided a rapid, accurate method for measurements independent of arterial enhancement.

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. (C) 2004 Wiley-Liss, Inc.

Larger final lumen dimensions after percutaneous coronary interventions in native coronary arteries lead to lower restenosis rates. We sought to determine the impact of stent expansion, as assessed by intravascular ultrasound, on clinical results of stent implantation in saphenous vein grafts (SVGs). We identified 226 consecutive patients who underwent intravascular ultrasound-guided stenting of 234 de novo SVG lesions. Patients were divided into 2 groups based on the final stent cross-sectional area (CSA): group I (stent CSA &lt;100% of the reference lumen CSA, n = 176 patients, 182 lesions) and group II (stent CSA greater than or equal to100% of the reference lumen CSA, In = 50 patients, 52 lesions). Baseline patient characteristics were similar between the 2 groups with the exception of smaller lesions in group II. More aggressive stent expansion (group 11) was associated with (1) increased rates of in-hospital non-Q-wave myocardial infarction (29% vs 17%, p = 0.05), (2) any myocardial infarction (26% vs 8%, p = 0.003) at 1-year follow-up, and (3) no improvement in target vessel revascularization at 1 year (31% vs; 26%, p = 0.3). Aggressive stent expansion in SVG lesions resulted in higher myocardial infarction rates and, unlike native arteries, no improvement in target vessel revascularization rate at 1 year. A less aggressive stent implantation strategy in SVGs than in native coronary lesions appears prudent. (C) 2004 by Excerpta Medica, Inc.

OBJECTIVES The present study evaluated clinical outcomes in diabetic patients after multivessel stenting. BACKGROUND Multivessel angioplasty studies have reported decreased survival in diabetic patients undergoing conventional balloon angioplasty compared with coronary artery bypass graft surgery (CABG). However, several studies have demonstrated excellent procedural success and acceptable clinical outcomes after multivessel stenting. METHODS Multivessel stenting was performed in 689 patients with 1,639 native coronary lesions. Patients were classified into three groups according to diabetes mellitus (DM) status: 1) no DM (501 patients/1,200 lesions); 2) DM treated with oral agents (102 patients/235 lesions); and 3) DM treated with insulin (86 patients/204 lesions). RESULTS Procedural success was high overall. In-hospital CABG was higher in diabetics treated with insulin compared with the other two groups (3.5% vs. 0.4% vs. 1.0%, p = 0.02). There were no significant differences in the incidence of in-hospital cardiac death and myocardial infarction. Diabetic patients treated with oral agents or insulin had higher one-year target lesion revascularization rates than non-diabetic patients (25% vs. 35% vs. 16%, p &lt; 0.001). Lower one-year survival was observed in diabetic patients treated with either oral agents or insulin, compared with non-diabetic patients (85% vs. 86% vs. 95%, p &lt; 0.001). On multivariable analysis, DM was an independent predictor of one-year mortality, myocardial infarction, and target lesion revascularization after multivessel stenting. CONCLUSIONS Despite a high technical success rate of multivessel stenting, diabetic patients, especially those treated with insulin, have higher in-hospital CABG, higher subsequent revascularization rates, and lower one-year survival than non-diabetic patients. (C) 2004 by the American College of Cardiology Foundation

Background - We used intravascular ultrasound (IVUS) to evaluate recurrence after sirolimus-eluting stent (SES) implantation treatment of in-stent restenosis (ISR). Methods and Results - Forty-eight ISR lesions ( 41 patients with objective evidence of ischemia) were treated with SES. Recurrent ISR was identified in 11 lesions ( all focal); repeat revascularization was performed in 10. These were compared with 16 patients ( 19 lesions) without recurrence as documented by angiography. Nine of 11 recurrent lesions had a minimum stent area (MSA) &lt; 5.0 mm(2) versus 5 of 19 nonrecurrent lesions ( P = 0.003); 7 of 11 recurrent lesions had an MSA &lt; 4.0 mm(2) versus 4 of 19 nonrecurrent lesions (P = 0.02); and 4 of 11 recurrent lesions had an MSA &lt; 3.0 mm(2) versus 1 of 19 nonrecurrent lesions ( P = 0.03). A gap between SESs was identified in 3 of 11 recurrences versus 1 of 19 nonrecurrent lesions. Conclusions - Stent underexpansion is a significant cause of failure after SES implantation treatment of ISR.

Background Various autopsy and intravascular ultrasound (IVUS) studies have shown neointimal proliferation as the main mechanism of in-stent restenosis (ISR) responsible for &gt;95% of luminal narrowing-while stent struts are not compressed. ISR of diffuse type has a high incidence of recurrence (up to 70%) after balloon angioplasty (PTCA). Tissue ablation with percutaneous rotational coronary atherectomy (PRCA) may be more efficacious compared to tissue compression or extrusion after PTCA for the interventional treatment of diffuse ISR. Methods The Rotational. Atherectomy Versus Balloon Angioplasty for Diffuse In-Stent Restenosis (ROSTER) trial is a single-center, randomized trial comparing PRCA to PTCA (both with IVUS guidance) in the treatment of diffuse ISR in 200 patients. In the PRCA group (n = 100), rotablation was performed using a burr-to-artery ratio &gt;0.7 followed by adjunctive balloon dilatation at low pressure (4-6 atm). In the PTCA group (n = 100), high-pressure (&gt; 12 atm) balloon dilatation was performed using an optimal size balloon. The study's primary end point was target lesion revascularization (TLR) at 9 months and secondary end points included clinical events at 1 year and angiographic restenosis in a substudy of the last 75 patients enrolled. Results Baseline clinical and angiographic variables were comparable between the 2 groups with similar procedural and angiographic success, but a higher rate of repeat stenting occurred in the PTCA group (31% vs 10%; P &lt;.001). Although the angiographic acute luminal gain was similar between the 2 groups, IVUS analysis revealed lower residual intimal hyperplasia area after PRCA versus PTCA (2.1 &PLUSMN; 0.9 mm(2) vs. 3.3 &PLUSMN; 1.8 mm(2); P = .005). At a mean follow-up of 12 &PLUSMN; 2 months, there were 2 deaths, 3 myocardial infarctions, and 3 coronary artery bypass graft procedures in each group. TLR incidence was 32% in the PRCA group and 45% in the PTCA group (P = .042), with a similar trend noted in the angiographic substudy. Conclusion The ROSTER trial for diffuse ISR revealed both PRCA and PTCA to be safe and effective, but PRCA resulted in less residual intimal hyperplasia, lower repeat stent use, and decreased TLR.

Even in the drug-eluting stent era, percutaneous coronary intervention in bifurcation lesions is complex and technically demanding, and considerable expertise is required. This case report describes in-stent restenosis due to stent underexpansion after kissing stents using sirolimus-eluting stents. (C) 2003 Wiley-Liss, Inc.

OBJECTIVES We sought to determine the impact of aggressive stent expansion on creatine kinase-MB isoenzyme (CK-MB) release and clinical restenosis. BACKGROUND Elevation of CK-MB after percutaneous coronary interventions has been associated with late mortality. METHODS We identified 989 consecutive patients who underwent intravascular ultrasound-guided stenting of 1,015 coronary lesions. Patients were divided into three groups according to stent expansion, defined as the ratio of final lumen over the reference lumen cross-sectional areas: Group 1 (ratio &lt;70%, n = 117 patients with 126 lesions); Group 2 (ratio 70% to 100%, n = 551 patients with 562 lesions); Group 3 (ratio &gt;100%, n = 321 patients with 327 lesions). RESULTS The peak CK-MB values increased significantly with increasing stent expansion: CK-MB = 3 to 5 X normal occurred 16%, 18%, and 25% in Groups 1, 2, and 3, respectively, p = 0.02; CK-MB &gt;5 times normal occurred 9%, 13%, and 16% respectively, p = 0.02. Conversely, at one year follow-up there was a stepwise decrease in target lesion revascularization (11% vs. 19% and 17%, respectively, p = 0.04) and major adverse cardiac events with increasing stent expansion. In addition, there was a trend toward lower mortality in Group 3 (9% vs. 4.4% vs. 4.0%, p = 0.07). CONCLUSIONS Intravascular ultrasound-guided stent overexpansion (final lumen greater than reference lumen cross-sectional area) is accompanied by a higher periprocedural CK-MB release but a lower target lesion revascularization and a trend toward lower mortality. at one year. Increased periprocedural CK-MB release appears as a trade-off for optimal stent implantation and lower clinical restenosis. (C) 2003 by the American College of Cardiology Foundation

Despite similar early clinical events, patients who undergo treatment of small vessels are at an increased risk for target lesion revascularization (TLR) after coronary artery stenting. We sought to determine predictors of TLR after stent implantation in small coronary arteries. We identified 423 consecutive patients who underwent intravascular ultrasound (IVUS)-guided small vessel stenting procedures in 465 coronary lesions with an angiographic reference vessel diameter of &lt;2.75 mm. Patients were divided into 2 groups based on a final IVUS lumen area of less than or equal to6.0 mm(2) (n = 345 lesions, group I) and &gt;6.0 mm(2) (n = 115, group II). Baseline patient characteristics and in-hospital outcomes were similar between the 2 groups, except for a higher rate of restenotic lesions in group I and bifurcation lesions in group II. Group I had higher TLR rates at 1 year compared with group II patients (39% vs 26%, p = 0.02). The TLR rate appeared to decrease with greater stent expansion, especially at &gt;90% of the reference vessel area, as assessed by IVUS. By multivariate analysis, an IVUS final stent area of less than or equal to6 mm(2), diabetes, absence of prior myocardial infarction, and history of intervention were independent predictors of 1-year TLR in this population. Final stent area of &gt;6.0 mm(2) and greater stent expansion were associated with a decrease in TLR. Therefore, there does not appear to be any "downside" to aggressive stent implantation strategies in small vessels. In contrast, IVUS allows maximization of final lumen dimensions to minimize clinical restenosis. (C)2003 by Excerpta Medica, Inc.