Minoru Shimizu

Mobilization of CD34-Positive Bone Marrow–Derived Cells After Coronary Stent Implantation Impact on Restenosis

Background— Recently, accumulating evidence has indicated that bone marrow–derived stem cells are capable of differentiating into vascular cells. It has been hypothesized that the inflammatory response after vascular injury triggers the mobilization of endothelial and smooth muscle progenitor cells from bone marrow. Methods and Results— We measured circulating CD34-positive mononuclear cells, activation of integrin Mac-1 on the surface of neutrophils, and plasma granulocyte-colony stimulating factor levels in 40 patients undergoing coronary stenting. After bare-metal stenting, CD34-positive cells increased, reaching a maximum on day 7 after stenting. The maximum change compared with baseline before stenting was more striking in patients with restenosis than without restenosis (332±108% versus 148±49%; P<0.05). In contrast, CD34-positive cells decreased after sirolimus-eluting stenting (72±21% on day 7). The change in CD34-positive cells on day 7 relative to baseline was closely correlated with that in activated Mac-1 at 48 hours (R=0.52, P<0.01) and that in granulocyte-colony stimulating factor levels at 24 hours (R=0.42, P<0.05). Cell culture assay on day 7 showed that mononuclear cells differentiated into CD31-positive endothelium-like cells after bare-metal stenting. In patients with restenosis, mononuclear cells differentiating into α-smooth muscle actin–positive smooth muscle–like cells also were observed. Implantation of sirolimus-eluting stents suppressed both types of differentiation. Conclusions— Stent implantation may induce differentiation of bone marrow cells into endothelial or smooth muscle cells. Endothelial cells may participate in reendothelialization, a protective reaction against vascular injury, whereas smooth muscle cells may participate in neointimal thickening and restenosis. Sirolimus-eluting stents appear to inhibit the mobilization and differentiation of bone marrow cells.

Effect of Enalapril Maleate on Cerebral Blood Flow in Patients with Chronic Heart Failure

The effect of enalapril on cerebral blood flow (CBF) was studied in 11 patients with chronic heart failure (NYHA II or III, dilated cardiomyopathy in 6 and old myocardial infarction in 5). CBF was evaluated by analyzing the Patlak-Plot curve obtained from radionuclide angiography with technetium-99m hexamethylpropylene amine oxime (99mTc-HM-PAO). Cardiac index (CI) and stroke volume (SV) were simultaneously measured by impedance cardiography. These measurements were performed before and at four weeks after daily administration of 5 mg enalapril. The stroke volume, cardiac index, and heart rate were not significantly changed after four weeks of enalapril admin istration. However, CBF was increased by 6.5% from 36.72 ±4.66 to 39.13 ±5.65 mL/ 100g/min (P<0.05). These results suggest that enalapril increased cerebral blood flow, which was not related to increased cardiac output in congestive heart failure. Patlak-Plot analysis of radionuclide angiography using 99m Tc-HM-PAO may be available for quantitative assessment of brain perfusion.

Effects of losartan on serum total and high-molecular weight adiponectin concentrations in hypertensive patients with metabolic syndrome

High-molecular weight (HMW) adiponectin may have the most biologic activity among several isoforms. We investigated long-term effects of losartan on serum concentrations of total and HMW adiponectin in hypertensive patients with metabolic syndrome (MS) by serial measurements over 6 months. Forty hypertensive patients first received 50 mg of losartan. Upward titration of the losartan dose was implemented to reach a target blood pressure of less than 140/90 mm Hg. Serum total adiponectin and HMW adiponectin were measured at study entry (baseline), the 3-month treatment time point, and the end of the 6-month period. Non-HMW adiponectin (ie, medium- and low-molecular weight adiponectin) was calculated as total adiponectin--HMW adiponectin. Diagnosis of MS was done by current standard criteria. In hypertensive patients without MS (n = 21), the serum total adiponectin increased from 9.8 +/- 5.4 microg/mL at baseline to 11.1 +/- 6.2 microg/mL at 6 months (P < .01). Furthermore, the serum total adiponectin was significantly higher at 6 months than at 3 months (P < .01). Serum HMW adiponectin also increased from 5.7 +/- 3.9 microg/mL at baseline to 6.6 +/- 4.4 microg/mL at 6 months (P < .01). In hypertensive patients with MS, the serum total adiponectin increased from 6.0 +/- 2.7 mug/mL at baseline to 6.7 +/- 3.3 microg/mL at 3 months and to 7.0 +/- 3.1 microg/mL at 6 months (P < .01 for both). Furthermore, the serum HMW adiponectin concentration was significantly higher at 6 months than at 3 months (P < .001). However, the serum non-HMW adiponectin concentration did not change during treatment in either group. In conclusion, serum total and HMW adiponectin concentrations increase after 6 months of losartan treatment in hypertensive patients, irrespective of the presence or absence of MS.

A novel method for angiography of the left internal thoracic artery from a right arm approach using a YUMIKO-LITA catheter

O the basis of the current use of coronary angiographic techniques, the right brachial or right radial approach is widely performed. With these approaches, catheters of smaller sizes (5Fr to 6Fr) are mainly used. These techniques are less invasive and enable reduction of both the hospitalization period and adverse events caused by the catheterization procedure. Coronary artery bypass surgery using the left internal thoracic artery (LITA) graft has also been advanced because of its long-term patency. Thus, angiography of the LITA is important for follow-up study after bypass surgery. However, angiography of the LITA performed by a right arm approach is considered difficult, so it is frequently performed by the femoral or left arm approach. Currently, the RLIMA catheter (Caudis Corp., Miami, Florida, 5Fr) or the BMI catheter (Caudis, 8Fr) are used to performed LITA angiography from a right arm approach. However, there have never been established techniques or specific catheters for right arm LITA angiography. We designed a novel YUMIKO-LITA catheter for angiography of the LITA by the right brachial or radial approach. We report our experience with its use. • • • The YUMIKO-LITA catheter (Goodman Inc., Nagoya, Japan) is a 5.4 Fr, 110-cm-long catheter that we designed for angiography of the LITA by the right brachial or right radial approach by modifying the Simmons catheter (Mallinckrodt, St. Louis, Missouri) for cerebral angiography (Figure 1). The first curve is a 7-cm-long soft tip made of nylon to minimize vessel wall injury. The shape of the second curve was repeatedly reformed so the tip could be easily inserted into the left subclavian artery from the aortic arch. The shaft is made of polyurethane and nylon and strengthened with stainless steel. The inner diameter of the catheter is 1.13 mm. Two independent techniques (ascending and descending) are used to advance the YUMIKO-LITA catheter into the LITA for 3 operators. We usually performed the ascending approach technique. This technique is depicted in Figure 2. First, the catheter is advanced to the ascending aorta using a guidewire. After the guidewire is removed, the catheter is rotated to direct the tip toward the left subclavian artery. The tip easily selects the left subclavian artery by a slight clockwise rotation. By pulling the catheter with a slight counterclockwise rotation, the tip is advanced to the distal subclavian artery. Further pulling of the catheter enables the tip to be inserted into the LITA. An alternative approach technique is shown in Figure 3. This technique shows the catheter advancing into the descending aorta using a guidewire. After guidewire removal, the catheter is turned, hanging the tip on the side branch of the descending aorta on the celiac trunk or renal artery. By pulling the catheter tip to be directed to left, the tip is advanced toward the left subclavian artery. Further pulling enables the tip to be inserted into the LITA. Fifty-five patients underwent the ascending approach, and 3 patients underwent both the ascending and descending approaches. The study included 58 patients with coronary artery disease who underwent LITA angiography by the right transbrachial approach using the YUMIKOLITA catheter. Patients were aged between 40 and 84 years (mean 63.1; 47 men and 11 women). All patients in this study had chest pain symptoms and severe stenosis of the left anterior descending artery. No patient had renal dysfunction or other complications. Preoperative evaluation of the LITA in 54 patients who were scheduled to undergo coronary artery bypass surgery, or postoperative evaluation of the LITA graft in 4 patients who had already undergone surgery was performed. Written informed consent was obtained from each patient. To evaluate the efficacy of the catheter, we investigated the total period of fluoroscopy during its engagement into the LITA, the quality of angiographic From the Department of Cardiology, Koshigaya Hospital, Dokkyo University School of Medicine, Saitama, Japan; and Division of Cardiovascular Medicine, Kasukabe Central General Hospital, Saitama, Japan. Dr. Miyake’s address is: Division of Cardiology, Columbia University, PH 9-941, 630 West 168th Street, New York, New York, 10032. E-mail: ymmiyake@hotmail.com. Manuscript received September 7, 2001; revised manuscript received and accepted December 28, 2001. FIGURE 1. YUMIKO-LITA catheter (right) shown in comparison with the Simonds catheter for cerebral angiography (left).

TCTAP C-089 Bidirectional Approach to Chronic Total Occlusion of the Left Circumflex Artery with Single Guiding Catheter Using the Wire Rendezvous Technique and Chasing Wire Technique

### Patient Initials or Identifier Number YT ### Relevant Clinical History and Physical Exam A 78-year-old-man with heart failure and low ejection fraction was transferred to our institution. Angiography after compensation of heart failure revealed hypoplasty of the right coronary artery, severe

The 0.035-Inch Wire Externalization Technique for Overcoming a Severely Angled and Calcified Aortic Bifurcation

A 61-year-old man with end-stage renal disease presented to receive endovascular therapy for bilateral intermittent claudication. The target lesion was located in the right common femoral artery and superficial femoral artery. We inserted a 6-F guiding sheath from the left common femoral artery.

Simple percutaneous coronary interventions using the modification of complex coronary lesion with excimer laser

Excimer laser coronary atherectomy (ELCA), a unique percutaneous coronary intervention (PCI) device, comprises a monorail-type system and is compatible with any standard 0.014-inch guidewire. ELCA is the only device that vaporizes the atherosclerotic plaques or modifies underlying plaque located underneath to a hard tissue, such as severe calcification or a stent. Therefore, ELCA differs from other coronary atherectomy devices and is useful for patients with acute coronary syndrome, chronic total occlusion or under-expanded stents. This case series reports on patients treated using ELCA to simplify complex PCI procedures. Furthermore, we review and discuss ELCA in several situations.

Utility of a 0.035″ compatible rapid-exchange balloon (Metacross RX™) as a perfusion balloon in endovascular therapy compared with conventional percutaneous coronary intervention: A mini-review

Since endovascular treatment for peripheral artery disease has been rapidly and widely adopted as the preferred strategy, interventionists sometimes experience complications such as vessel perforation and severe dissections. We have a long-time inflation strategy for perfusion balloon catheters, which could be a solution for vessel complications in coronary sections, but not in peripheral sections. We invented a simple device for application as a perfusion balloon in peripheral sections, using a 0.035″ wire compatible rapid-exchange balloon Metacross RX™ (TERUMO, Tokyo, Japan) and reviewed this strategy using three cases as examples and compared them with the coronary perfusion balloon. TABLE OF CONTENTS SUMMARY Metacross RX (TERUMO, Tokyo, Japan) is being used as a rapid exchange balloon and can be potentially used as a perfusion balloon. We report a series of cases in which patients were treated using the Metacross RX at a single-center for endovascular treatment of peripheral artery disease. We review and discuss the use of this device in comparison with the conventional coronary perfusion balloon catheter.