Kazuki Tobita

Co-Existence of Carotid Artery Disease, Renal Artery Stenosis, and Lower Extremity Peripheral Arterial Disease in Patients With Coronary Artery Disease

In atherosclerosis, carotid artery stenosis (CAS), renal artery stenosis (RAS), lower extremity peripheral arterial disease (PAD), and coronary artery disease (CAD) are common pathologic lesions; their interrelationship is, however, unclear. We studied concomitant multiple atherosclerotic lesions in patients with CAD to understand their prevalence and relations. A cross-sectional analysis was performed on data from consecutive patients who underwent nonemergent coronary angiography. Simultaneous carotid and renal artery Doppler studies and ankle-brachial systolic pressure measurements were reviewed to diagnose concomitant lesions and their severity. The study included 1,734 patients (aged 71 ± 9 years; 70% men), with prevalences of CAS, RAS, lower extremity PAD, and CAD of 6%, 7%, 13%, and 72%, respectively. In patients with CAD (n = 1,253), the prevalences of CAS, RAS, and lower extremity PAD were 7%, 9%, and 16%, respectively; 24% CAD patients had ≥1 additional atherosclerotic lesion. Significant interactions among the prevalences of these lesions were found. In addition, the extent of CAD and the prevalences of CAS, RAS, and lower extremity PAD were significantly correlated. Multivariate analysis supported these relationships. In conclusion, the prevalences of CAS, RAS, lower extremity PAD, and CAD were strongly interrelated in the study population; CAD severity was related to that of other atherosclerotic lesions. Additional systematic screening of other concomitant atherosclerotic lesions is recommended, especially in CAD patients having multivessel disease, left main disease, and/or already diagnosed with other concomitant atherosclerotic lesions.

Comparison of Short- and Long-Term Outcomes of Percutaneous Coronary Intervention for Chronic Total Occlusions Between Patients Aged ≥75 Years and Those Aged <75 Years

Few reports are available on the safety and efficacy of percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) in older patients. In the present study, 284 patients who underwent PCI for CTOs were retrospectively evaluated by comparing the characteristics of 67 patients aged ≥75 years (the older group) and 217 patients aged <75 years (the younger group). Technical success was achieved in 77% of the patients in the older group and 79% of those in the younger group (p = 0.66). No significant differences were observed between the 2 groups in terms of the incidence of procedural complications. In the older group, a comparison between the patients with successful and failed PCI revealed significantly superior 3-year cardiac survival (97.6% vs 76.9%, p = 0.005). The 3-year cardiac survival of those with successful PCI was similar to that observed in the younger group. On multivariate analysis, successful PCI was found to be associated with a lower incidence of cardiac death in the older group (hazard ratio 0.09, 95% confidence interval 0.01 to 0.91, p = 0.042). In conclusion, this single-center, observational study suggests that PCI for CTOs can be performed with a high rate of procedural success and acceptably low mortality and morbidity in older patients, resulting in improved cardiac survival. Thus, PCI for CTO lesions should be included among the treatment strategies for older patients.

Prehospital Transfer Pathway and Mortality in Patients Undergoing Primary Percutaneous Coronary Intervention

BACKGROUND It is recommended that not only door-to-balloon time but also prehospital delay for primary percutaneous coronary intervention (PCI) should be improved. We investigated the effect of prehospital transfer pathway on onset-to-balloon time and prognosis in patients with ST-segment elevation myocardial infarction (STEMI) in Japan. METHODSANDRESULTS We analyzed data from 540 consecutive patients with primary PCI for STEMI. Patient clinical data and mortality were compared between patients who visited the family physician or non-PCI-capable hospitals and were then transferred to PCI-capable centers (indirect transfer patients), and those who directly visited PCI-capable centers (direct transfer patients). Onset-to-balloon time was longer in indirect transfer patients than in direct transfer patients (mean, 270 min; range, 180-480 min vs. 180 min, 120-240 min; P<0.001). In addition, patient prognosis was evaluated on Cox proportional regression analysis. Cardiac death and all-cause death were significantly higher in indirect transfer patients (odds ratios [OR], 2.17; 95% confidence intervals [95% CI]: 1.17-4.01, P=0.01; OR, 1.71; 95% CI: 1.09-2.68, P=0.02). These results were confirmed using propensity score matching for adjusted analyses. CONCLUSIONS Patients with indirect transfer to regional emergency departments of PCI centers had longer onset-to-balloon time and worse prognosis than those with direct transfer.

Comparison of long‐term patency after endovascular therapy for superficial femoral artery occlusive disease between patients with and without hemodialysis

To compare long‐term patency after endovascular therapy (EVT) for superficial femoral artery (SFA) occlusive disease between patients with hemodialysis (HD; HD+) and those without HD (HD−).

Long-term risks for patency loss in patients with hemodialysis after bare self-expandable nitinol stent implantation to femoropopliteal artery occlusive lesions

BACKGROUND Although patients receiving hemodialysis (HD+) have significantly different backgrounds, including a history of progressive atherosclerotic disease, compared with those not receiving hemodialysis (HD-), there are no studies evaluating the risks for loss of primary patency (PP) and need for target lesion revascularization (TLR) in HD+ patients following bare self-expandable nitinol stent (BSNS) implantation to femoropopliteal (FP) artery occlusive lesions, after adjusting for differences using propensity score (PS) analysis in observed characteristics between groups. METHODS We studied 531 limbs of 432 Japanese patients (HD+, n=107; HD-, n=325) who received BSNS implantation to FP lesions between 2004 and 2014. Patients were followed-up for an average of 44.3±33.6months. We compared the long-term results between HD+ and HD- patients using the Cox-proportional hazard model with adjustment for inverse probability treatment weight (IPTW) of PS, which was calculated for covariates with HD as a dependent variable. RESULTS PP rate in HD+ vs. HD- patients at 9years after the procedure was 19.1% vs. 47.9%, with a freedom from TLR rate of 47.6% vs. 62.9%, respectively. Adjusted HRs in HD+ patients with 95% confidence intervals (CIs) were as follows: loss of PP: HR 1.64, 95% CI 1.052-2.557, P=0.03; TLR: HR 1.862, 95% CI 1.104-3.139, P=0.02. CONCLUSIONS The present study suggests that HD+ patients have an increased risk for loss of PP and need for TLR after BSNS implantation to FP lesions.

Intravascular Ultrasound-Assisted Crosser System Through the Retrograde Approach to Treat a Trans-Atlantic Inter-Society Consensus D Lesion in the Superficial Femoral Artery After Graft Failure

BACKGROUND The crosser system is useful to treat chronic total occlusion (CTO) lesions refractory to guidewire recanalization. However, the Inter-Society Consensus for the Management of Peripheral Arterial Disease recommends bypass graft surgery for Trans-Atlantic Inter-Society Consensus (TASC) type D femoropopliteal (FP) lesions. This approach may not be practical in patients with previous graft failure. In these patients, endovascular therapy with the crosser system may be appropriate. However, there are few reports of the crosser system to treat CTO after failure of FP bypass grafts. CASE REPORT A 74-year-old man with a history of 2 FP bypass grafts presented with left lower-limb ischemic rest pain. Ankle-brachial pressure index (ABPI) in the left leg was 0.45. Angiography revealed a TASC type D lesion in the left superficial femoral artery (SFA). A bidirectional approach was used, but the very stiff dedicated CTO guidewire could not pass through the lesion. Therefore, after confirming that the guidewire was in the true lumen by intravascular ultrasound (IVUS), we used a CROSSER(®) 14S catheter (Bard Peripheral Vascular Inc., Tempe, AZ) through the retrograde route in the popliteal artery. The lesion was crossed, and a stent was successfully implanted. The patients symptoms of rest pain resolved with an improved ABPI in the left leg of 0.82 after the procedure. CONCLUSIONS The crosser system assisted by IVUS through the retrograde approach was useful to treat CTO in the SFA after failure of FP bypass grafts.

The COFFEE Trial (COmparison of Fractional Flow Reserve Measurements through 4 FrEnch versus 6 FrEnch Diagnostic Catheter)

Fractional flow reserve (FFR) measurement is a well-established pressure wire-based procedure that is used to assess the functional severity of coronary lesions [(1)][1]. Various randomized trials have demonstrated that FFR-guided revascularization improves clinical outcomes in patients with

Modified jailed balloon technique for bifurcation lesions

We propose a new systematic approach in bifurcation lesions, modified jailed balloon technique (M‐JBT), and report the first clinical experience.

Reply : Slender Sheaths Have the Potential to Expand the Use of Transradial Access for Complex CTO-PCI

We would like to thank Dr. Aminian and colleagues for their interest in our study [(1)][1] that assessed whether the transradial approach can be used to treat complex chronic total occlusion (CTO) and that attempted to determine the predictors of transradial percutaneous coronary intervention (PCI)

Diagnostic performance of 320-slice computed tomography coronary angiography for symptomatic patients in clinical practice

OBJECTIVE Multi-slice computed tomography (MSCT) coronary angiography has been reported as an effective alternative to invasive conventional coronary angiography (CCA) for the diagnosis of coronary artery disease (CAD). However, in previous reports, the diagnostic accuracy of MSCT has not been significant enough to be of benefit in symptomatic patients. The aim of this study was to identify the usefulness of 320-slice computed tomography coronary angiography (320-CTA) for symptomatic patients in terms of the diagnostic accuracy of 320-CTA and the prevalence of vasospastic angina pectoris (VSAP) within the study cohort. METHODS We retrospectively analyzed 513 consecutive symptomatic patients with suspected CAD who had undergone 320-CTA and CCA. We determined the diagnostic accuracy of 320-CTA using CCA as the reference standard. Ergonovine provocation tests were performed on patients without significant coronary artery stenosis on CCA. RESULTS Of the total cohort of 513 symptomatic patients, 39% had obstructive CAD. The patient based analysis of the accuracy of 320-CTA showed a sensitivity of 91.0%, a specificity of 71.0%, a positive predictive value of 66.5%, and a negative predictive value of 92.5%. Of the 314 symptomatic patients who did not have significant coronary artery stenosis on CCA, 58 (18%) were diagnosed with VSAP using ergonovine provocation tests. DISCUSSION The negative and positive predictive values indicate that 320-CTA cannot replace CCA for symptomatic patients. Indeed, a combination of CCA and ergonovine provocation tests should be taken into consideration for symptomatic patients.