小林 欣夫

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.

Background-It is not clear why some plaque ruptures lead to acute coronary syndromes (ACS) but others do not. Methods and Results-We analyzed 80 plaque ruptures in 74 patients and compared culprit lesions of ACS patients with nonculprit lesions of ACS patients and lesions of non-ACS patients; both culprit and nonculprit plaque ruptures were studied in 6 of 54 ACS patients. Intravascular ultrasound findings suggesting thrombus were observed more frequently in culprit lesions of ACS patients (n=35) compared with nonculprit lesions of ACS patients (n=19) and lesions of non-ACS patients (n=26): 60% versus 32% versus 8% (P&lt;0.001). At the minimal lumen site, smaller lumen areas (3.3&PLUSMN;1.5 versus 5.4&PLUSMN;2.6 versus 6.1&PLUSMN;2.0 mm(2), P&lt;0.001) and greater area stenosis (61+/-15% versus 50+/-14% versus 46+/-18%, P=0.002) and plaque burden (80+/-8% versus 71+/-8% versus 69+/-10%, P&lt;0.001) were observed in culprit lesions of ACS patients compared with nonculprit lesions of ACS patients and lesions of non-ACS patients. Lesions were longer (18.7&PLUSMN;6.4 versus 154.9&PLUSMN;6.1 versus 12.0&PLUSMN;4.9 mm, P&lt;0.001) and rupture site remodeling indices were greater (1.26+/-0.21 versus 1.24+/-0.21 versus 1.09+/-0.05, P=0.002). Independent predictors of culprit plaque ruptures in ACS patients were smaller minimum lumen areas (P=0.02) and presence of thrombus (P=0.01). Conclusions-Ruptured plaques in culprit lesions of ACS patients have smaller lumens; greater plaque burdens, area stenosis, and remodeling indices; and more thrombus. Plaque rupture itself does not lead to symptoms. The association of plaque rupture with a smaller lumen area and/or thrombus formation causes lumen compromise and leads to symptoms.

The present study evaluated in-hospital and 1-year outcomes after multivessel stenting in patients aged greater than or equal to80 (75 patients, 241 lesions) and &lt;80 years (894 patients, 2,678 lesions). Despite a high technical success rate of multivessel stenting, octogenarians had higher in-hospital cardiac and noncardiac complication rates and a higher mortality rate at 1-year clinical follow-up compared with their younger counterparts. (C)2003 by Excerpta Medica, Inc.

Percutaneous coronary intervention (PCI) devices are much more expensive in Japan than in the United States, but their prices were reduced in April 2002. This study evaluated the impact of that change in the price of PCI devices on medical expenses. In-hospital costs of 22 consecutive patients who underwent elective single-vessel PCI without a debulking procedure before April 2002 were collected and the in-hospital cost of each patient was recalculated by applying the current prices of the PCI devices and those in the USA. For patients treated with PCI before April 2002, the in-hospital cost was Y1,456,375+/-358,781, but when the current price is used, the in-hospital cost is estimated to be Y1,355,812+/-313,237 (7% reduction). If the prices of the devices were reduced to those in USA, there would be a 53% reduction (Y689,417+/-99,139). Although the change in the price of PCI devices in April 2002 has reduced in-hospital costs, the devices are still much more expensive in Japan than in the USA. Further reduction of the price is required to make PCI more cost-effective.

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 2 vs. 13.7 +/- 3.4 vs 14.5 +/- 5.6 mm, 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 re-modeling 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. (C) 2003 by Excerpta Medica, Inc.

Transforming growth factor-beta (TGF-beta) has been implicated in the development of diabetic glomerulopathy. In order to evaluate a role of Smad3, one of the major signaling molecules downstream of TGF-beta, in the pathogenesis of diabetic glomerulopathy, Smad3-null mice were made diabetic with streptozotocin injection and analyzed 4 weeks after induction of diabetes. Electron microscopy revealed that the thickness of glomerular basement membrane (GBM) in wild-type diabetic mice was significantly higher than that in non-diabetic mice, whereas no appreciable GBM thickening was found in Smad3-null diabetic mice. Urinary albumin excretion was dramatically increased in wild-type diabetic mice, whereas Smad3-null diabetic mice did not show any overt albuminuria. Northern blotting revealed that mRNA levels of fibronectin and alpha 3 chain of type IV collagen (alpha 3Col4) in renal cortex of wild-type diabetic mice were approximately twice as much as those of non-diabetic mice, whereas their mRNA levels were not increased in Smad3-null diabetic mice. Real-time polymerase chain reaction (PCR) also confirmed diabetes-induced upregulation of fibronectin and alpha 3Col4 in glomeruli of wild-type mice. Glomerular expression of TGF-beta 1, as assessed by real-time PCR, was enhanced to a similar degree in wild-type and smad3-null diabetic mice, indicating that the observed differences between wild-type and Smad3-null mice are not attributable to difference in the expression of TGF-beta 1. These data clearly demonstrate a critical role of Smad3 in the early phase of diabetic glomerulopathy. This may be due at least partly to the present findings that diabetes-induced upregulation of fibronectin and alpha 3Col4 is dependent on Smad3 function.

Correlations between baseline hemodynamic and oximetric variables during an invasive exercise test and an improvement in peak oxygen uptake (peak (V) over circle o2) after exercise training (ET) were examined in 20 patients who participated in a cardiac rehabilitation program after acute myocardial infarction (AMI). Peak (V) over circle o2 significantly increased by 23+/-21% (p&lt;0.01) after ET and the improvement best correlated with the change in O-2 extraction fraction ([arterial O-2 content-venous O-2 content] /arterial O-2 content) during an exercise test before ET (r=-0.61, p&lt;0.01). Exercise capacity was improved to a greater extent by ET in patients with a smaller increase in O-2 extraction fraction during an exercise test before ET. Thus, O-2 extraction fraction during an exercise test before ET may be a useful predictor of the improvement in exercise capacity after ET in post-AMI patients.

Angiographic criteria to select patients for optimal balloon angioplasty.

The present study evaluated the effect of stent overdilatation on lumen size and intimal hyperplasia at follow-up. Stent overdilatation results in larger follow-up lumens despite larger late lumen loss due to greater intimal hyperplasia.

Although previous randomized trials 1-2 have demonstrated lower restenosis rates in selected lesions with coronary stents than with conventional balloon angioplasty. in-stent restenosis remains an important clinical problem.(3,4) Previous serial angiographic studies(5,6) showed that lumen loss after stenting occurred within 6 months. On the other hand, improvements in lumen dimensions between 6 months and 2 to 3 years have been demonstrated by angiography.(6-9) Serial (postintervention and at 6-month follow-up) intravascular ultrasound (IVUS) studies(10,11) have demonstrated that coronary stenting eliminates negative arterial remodeling, and thus intimal hyperplasia is solely responsible for in-stent restenosis. However, little has been reported about changes in intimal hyperplasia that occur beyond this 6-month period. This serial IVUS study evaluated the changes in intimal hyperplasia between 6 and 12 months after stent placement.

We identified 1,215 patients (322 women, 26.5%) who received glycoprotein (GP) IIb/IIIa inhibitors during 1,852 coronary artery stenting procedures. Compared with men, women had similar rates of in-hospital ischemic events and vascular complications, and similar 1-month major adverse cardiac events rates. Therefore. use of the GP Ilb/IIIa inhibitors appears to eliminate the previously noted "disadvantages" in women with respect to early clinical outcome after interventional procedures.

Objectives The purpose of this study, was to evaluate the approach of intravascular ultrasound (IVUS)-guided percutaneous transluminal coronary, angioplasty (PTCA) with spot stenting (SS) for the treatment of long coronary, lesions. Background Treating long coronary lesions with balloon angioplasty, results in suboptimal short- and long-term outcomes. Full lesion coverage with traditional stenting (TS) has been associated with a high restenosis rate. Methods We prospectively evaluated a consecutive series of 130 long lesions (&gt;15 mm) in 101 patients treated with IVUS-guided PTCA and SS. The results were compared with those of TS int a matched group of patients. Coronary angioplasty was performed with a balloon to vessel ratio of 1:1, according to the IVUS media-to-media diameter of the vessel at the lesion site, to achieve prespecified IVUS criteria: lumen cross-sectional area (CSA) greater than or equal to5.5 mm(2) or greater than or equal to 50% of the vessel CSA at the lesion site. The stents were implanted only, in the vessel segment where the criteria were not met. Results In the SS group, stents were implanted in 67 of 130 lesions, and the mean stent length was shorter than that of lesions in the matched TS group (10.4 +/- 13 mm vs. 32.4 +/- 13 mm, p&lt;0.005). The 30-day major adverse cardiac event (MACE) rate was similar (5%) for both groups. Angiographic restenosis was 25% with IVUS-guided SS, as compared with 39% in the TS group (p&lt;0.05). Follow-up MACE and target lesion revascularization rates were lower in the SS group than in the TS group (22% vs. 38% [p&lt;0.05] and 19% vs. 34% [p&lt;0.05], respectively). Conclusions Intravascular ultrasound-guided SS for the treatment of long coronary, lesions is associated with good acute outcome. Angiographic restenosis and follow-up MACE rates were significantly lower than those with TS. (J Am Coll Cardiol 2001;38:1427-33) (C) 2001 by the American College of Cardiology.

We report five cases treated with brachytherapy through the internal mammary artery (IMA) for in-stent restenosis at the distal anastomosis (n = 3) and in the left anterior descending coronary artery beyond the distal anastomosis (n = 2). After angioplasty, catheter-based gamma radiation was performed. There was no delivery failure of the radiation system. All cases had angiographic success and no procedural or in-hospital complications. (C) 2001 Wiley-Liss, Inc.

In 382 de novo lesions in native coronary arteries, clinical and angiographic predictors of a large discrepancy in vessel diameter between intravascular ultrasound and quantitative angiography were evaluated. The discrepancy was highest in diabetics, in vessels &lt;3.0 mm on angiography, and in the proximal segments of the coronary tree.

We report treatment of a lesion with coronary stent underexpansion due to heavily calcified plaque. Conventional balloon angioplasty was attempted for in-stent restenosis, but the lesion was undilatable despite 25-atm inflation pressure. Intravascular ultrasound (IVUS) revealed stent underexpansion due to heavily calcified plaque. Rotational atherectomy was performed using a stepped burr approach, after which repeat IVUS revealed marked ablation of the stent-calcium complex. Adjunctive balloon angioplasty then easily resulted in full balloon and stent expansion, with an excellent angiographic and IVUS result. The patient's hospital course was uneventful. Cathet Cardiovasc Intervent 2001; 52:208-211. (C) 2001 Wiley-Liss, Inc.