Koki Shishido

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.

In Vitro and Human Studies of a 4F Double-Coaxial Technique (“Mother-Child” Configuration) to Facilitate Stent Implantation in Resistant Coronary Vessels

Background— We recently developed a 4F child catheter that can be inserted into 6F or larger conventional guiding catheters. The use of 4F mother-child technique may improve the delivery of coronary stents to complex lesions. Accordingly, we sought to determine the potential of using a 4F mother-child technique to treat complex coronary lesions. Methods and Results— The support power and the trackability of the mother-child technique of 4-in-6 were evaluated using a coronary artery tree model. In addition, the results of 51 lesions treated by using a 4F child catheter were retrospectively analyzed. The in vitro experiment demonstrated that backup support of the 4-in-6 system was increased when the child catheter was advanced into the coronary tree ≥5 cm (P⩽0.01); further, the 4F child catheter was associated with superior trackability as compared with a 5F child catheter (15.0 cm [15.0 to 15.0] versus 13.0 cm [12.8 to 13.0], P<0.005). A total of 51 lesions, in which conventional techniques had been unsuccessful, were treated using the 4F mother-child technique. Lesion success was achieved in 48 (94%) lesions. Stent deployment was attempted in 44 (86%) and was successful in 40 of 44 (91%). There were 2 instances of stent dislodgment. Conclusions— With the superior trackability of the 4F child catheter and with increased backup support of the mother-child system, the 4F mother-child system provided >90% success rate for lesions in which conventional techniques had failed. The 4F mother-child system may become a viable alternative to conventional techniques in treating complex coronary lesions.

How do we prevent the vulnerable atherosclerotic plaque from rupturing? Insights from in vivo assessments of plaque, vascular remodeling, and local endothelial shear stress.

Coronary atherosclerosis progresses both as slow, gradual enlargement of focal plaque and also as a more dynamic process with periodic abrupt changes in plaque geometry, size, and morphology. Systemic vasculoprotective therapies such as statins, angiotensin-converting enzyme inhibitors, and antiplatelet agents are the cornerstone of prevention of plaque rupture and new adverse clinical outcomes, but such systemic therapies are insufficient to prevent the majority of new cardiac events. Invasive imaging methods have been able to identify both the anatomic features of high-risk plaque and the ongoing pathobiological stimuli responsible for progressive plaque inflammation and instability and may provide sufficient information to formulate preventive local mechanical strategies (eg, preemptive percutaneous coronary interventions) to avert cardiac events. Local endothelial shear stress (ESS) triggers vascular phenomena that synergistically exacerbate atherosclerosis toward an unstable phenotype. Specifically, low ESS augments lipid uptake and catabolism, induces plaque inflammation and oxidation, downregulates the production, upregulates the degradation of extracellular matrix, and increases cellular apoptosis ultimately leading to thin-cap fibroatheromas and/or endothelial erosions. Increases in blood thrombogenicity that result from either high or low ESS also contribute to plaque destabilization. An understanding of the actively evolving vascular phenomena, as well as the development of in vivo imaging methodologies to identify the presence and severity of the different processes, may enable early identification of a coronary plaque destined to acquire a high-risk state and allow for highly selective, focal preventive interventions to avert the adverse natural history of that particular plaque. In this review, we focus on the role of ESS in the pathobiologic processes responsible for plaque destabilization, leading either to accelerated plaque growth or to acute coronary events, and emphasize the potential to utilize in vivo risk stratification of individual coronary plaques to optimize prevention strategies to preclude new cardiac events.

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.

Arterial Remodeling and Endothelial Shear Stress Exhibit Significant Longitudinal Heterogeneity Along the Length of Coronary Plaques

Atherosclerosis is determined by both systemic risk factors and local vascular mechanisms. The arterial remodeling in response to plaque development plays a key role in atherosclerosis. Compensatory expansive remodeling is an adaptive mechanism that maintains lumen patency as a plaque develops. In

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−).

The 4 Fr mother-child technique with side-branch protection for treatment of complex bifurcation lesions

Description A 4 Fr child catheter (KIWAMI ST01; Terumo Corp., Tokyo, Japan) can be used in combination with a conventional 6 Fr mother guiding catheter to deliver stents into complex coronary lesions without difficulties1. Four Fr child catheters can be inserted into 6 Fr or 7 Fr guiding catheters with a second guidewire for side-branch protection. In this report, we introduce a new technique for delivering stents into complex bifurcation lesions with side-branch protection.

Renin–angiotensin system blockade therapy after transcatheter aortic valve implantation

Objective The persistence of left ventricular (LV) hypertrophy is associated with poor clinical outcomes after transcatheter aortic valve implantation (TAVI) for aortic stenosis. However, the optimal medical therapy after TAVI remains unknown. We investigated the effect of renin−angiotensin system (RAS) blockade therapy on LV hypertrophy and mortality in patients undergoing TAVI. Methods Between October 2013 and April 2016, 1215 patients undergoing TAVI were prospectively enrolled in the Optimized CathEter vAlvular iNtervention (OCEAN)-TAVI registry. This cohort was stratified according to the postoperative usage of RAS blockade therapy with angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs). Patients with at least two prescriptions dispensed 180 days apart after TAVI and at least a 6-month follow-up constituted the RAS blockade group (n=371), while those not prescribed any ACE inhibitors or ARBs after TAVI were included in the no RAS blockade group (n=189). Results At 6 months postoperatively, the RAS blockade group had significantly greater LV mass index regression than the no RAS blockade group (−9±24% vs −2±25%, p=0.024). Kaplan-Meier analysis revealed a significantly lower cumulative 2-year mortality in the RAS blockade than that in the no RAS blockade group (7.5% vs 12.5%; log-rank test, p=0.031). After adjusting for confounding factors, RAS blockade therapy was associated with significantly lower all-cause mortality (HR, 0.45; 95% CI 0.22 to 0.91; p=0.025). Conclusions Postoperative RAS blockade therapy is associated with greater LV mass index regression and reduced all-cause mortality. These data need to be confirmed by a prospective randomised controlled outcome trial.

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.