Hideo Takebayashi

Contribution of Stent Underexpansion to Recurrence After Sirolimus-Eluting Stent Implantation for In-Stent Restenosis

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) <5.0 mm2 versus 5 of 19 nonrecurrent lesions (P =0.003); 7 of 11 recurrent lesions had an MSA <4.0 mm2 versus 4 of 19 nonrecurrent lesions (P =0.02); and 4 of 11 recurrent lesions had an MSA <3.0 mm2 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.

Intravascular ultrasound assessment of ulcerated ruptured plaques: a comparison of culprit and nonculprit lesions of patients with acute coronary syndromes and lesions in patients without acute coronary syndromes.

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 <0.001). At the minimal lumen site, smaller lumen areas (3.3±1.5 versus 5.4±2.6 versus 6.1±2.0 mm2, P <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 <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±6.4 versus 154.9±6.1 versus 12.0±4.9 mm, P <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.

Nonuniform Strut Distribution Correlates With More Neointimal Hyperplasia After Sirolimus-Eluting Stent Implantation

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 mm2; P<0.01), larger maximum interstrut angle (135±39° versus 72±23°; P<0.01), larger IH area (3.4±1.5 versus 0.6±1.1 mm2; P<0.01) and thickness (0.7±0.3 versus 0.1±0.2 mm; P<0.01) at maximum interstrut angle, and fewer stent struts (4.9±1.0 versus 6.0±0.5; P<0.01) even when normalized for the number of stent cells (0.78±0.15 versus 0.97±0.07; P<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<0.01 and P<0.01), minimum lumen area (P<0.01 and P<0.01), and IH thickness (P<0.01 and P<0.01). Conclusions—The number and distribution of stent struts affect the amount of neointima after SES implantation.

Restenosis due to underexpansion of sirolimus-eluting stent in a bifurcation lesion.

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. Catheter Cardiovasc Interv 2003;60:496–499.

Calcification analysis by intravascular ultrasound to define a predictor of left circumflex narrowing after cross-over stenting for unprotected left main bifurcation lesions

OBJECTIVES The aim of this study was to identify predictors of significant LCx-ostium compromise after distal unprotected left main coronary artery (ULMCA) stenting on the basis of baseline intravascular ultrasound (IVUS). BACKGROUND Provisional single-stenting is considered as the default strategy for non-true bifurcation lesions in ULMCA. However, in certain cases, left circumflex artery (LCx)-ostium stenting is necessary. METHODS A total of 77 patients underwent percutaneous coronary intervention with drug-eluting stents for non-true bifurcation lesions in ULMCA and had IVUS evaluation. Pre-procedural IVUS was performed to measure cross-sectional areas at the following segments: left main trunk, left anterior descending artery (LAD)-ostium. Post-stenting-narrowing at the circumflex ostium (PSN-LCx) was defined as the presence of more than 50% diameter stenosis at the LCx-ostium as determined by quantitative coronary angiography analysis. RESULTS PSN-LCx occurred in 27 (35%) patients. The presence of calcified plaque at the culprit lesion as identified by IVUS was more frequently observed in the PSN-LCx group as compared to the non-PSN-LCx group (81.5% vs. 22.0%, p<0.001). Calcium arc in the PSN-LCx group was significantly greater than that in the non-PSN-LCx group (118.1°±69.9° vs. 36.9°±63.0°, p<0.001). On multivariable analysis, a calcium arc>60° was an independent predictor of PSN-LCx (odds ratio: 5.12, 95% confidence interval: 1.21-25.01, p=0.03). CONCLUSIONS The presence of calcified plaque at the culprit lesion appears to be one of the factors involved in LCx-ostial compromise in non-true bifurcation ULMCA lesions, especially when the calcium arc is >60°.

Acute Myocardial Infarction Caused by Left Main Coronary Artery Compression as a Result of a Mycotic Aneurysm of the Sinus of Valsalva.

An 83-year-old woman with a history of fever presented with severe chest pain progressing to cardiogenic shock. Her electrocardiogram showed evidence of anteroseptal myocardial infarction (MI). Urgent coronary angiography, with intra-aortic balloon pump support, indicated total occlusion of the left

The role of integrated backscatter intravascular ultrasound in characterizing bare metal and drug-eluting stent restenotic neointima as compared to optical coherence tomography.

BACKGROUND To evaluate the role of integrated backscatter intravascular ultrasound (IB-IVUS) in assessing the morphology of neointima in bare-metal stent (BMS) and drug-eluting stent (DES) restenosis as compared to the gold-standard, optical coherence tomography (OCT). METHODS A total of 120 cross-sections were evaluated by IB-IVUS and OCT at five cross-sections from 24 patients (24 lesions): at the minimal lumen area (MLA) and at 1 and 2mm proximal and distal to the MLA site in 24 lesions (9 treated with DES and 15 treated with BMS). IB-IVUS and OCT findings were analyzed according to the time at which restenosis was identified (early <12 months and late ≥12 months) and the stent type. RESULTS IB-IVUS was found to correctly characterize the neointima of both BMS and DES in-stent restenosis (ISR) as compared to OCT. The overall agreement between the pattern of ISR neointima by IB-IVUS and that by OCT was excellent (kappa=0.85, 95% CI 0.76-0.94). Late DES ISR was characterized by more non-homogeneous, low backscatter and lipid-laden neointima, as compared to the BMS equivalent (BMS vs. DES, 45.0% vs. 80.0%, p<0.01; 51.7% vs. 85.0%, p=0.008; 33.3% vs. 65.0%, p<0.01, respectively). CONCLUSIONS IB-IVUS assessment of the ISR neointima pattern appears to provide similar information as the gold-standard OCT in patients with stable angina. Both modalities suggested that late DES restenosis is characterized by a non-homogeneous lipid-laden neointima.

COMPARISON OF THE PROGNOSTIC UTILITIES OF CREATININE-BASED AND CALCULATED CREATININE CLEARANCE-BASED MID-TERM RENAL INSUFFICIENCY UNDERGOING PERCUTANEOUS CORONARY INTERVENTION

Contrast-induced acute kidney injury derived from creatinine value for 3-days, as well as persistent renal damage derived from calculated creatinine clearance (CCC) at 3-months has impact on worse clinical outcomes after percutaneous coronary intervention (PCI). While, there is little data regarding

Unintentional extraction of a platinum–chromium everolimus-eluting stent by entanglement with a covered stent

Urgent angiography in a 76-year-old male with acute coronary syndrome revealed calcified tortuous stenosis in the left anterior descending coronary artery (LAD) ( Panel A ). Coronary perforation occurred at the mid-LAD during rotational atherectomy ( Panel B ). Intravascular ultrasound (IVUS) revealed that rotational atherectomy created a false lumen. For the bailout of perforation, a 2.5 × 28 mm everolimus-eluting stent (EES) (Promus Premier, Boston Scientific, Natick, MA, USA) was deployed in the mid-LAD. However, there …

TCT-572 Impact of calcium-deposit for left circumflex ostium narrowing after crossover stenting in distal left main bifurcation: An Intravascular Ultrasound Study in the Milan and Fukuyama Registry.

A provisional single-stenting is considered a default strategy for non-true bifurcation lesion in distal unprotected left main coronary artery (ULMCA). However, in certain cases, left circumflex artery (LCx)-ostium stenting may be necessary. The aim of this study was to evaluate predictors of