Satoru Otsuji

Prediction of Progression of Coronary Artery Disease and Clinical Outcomes Using Vascular Profiling of Endothelial Shear Stress and Arterial Plaque Characteristics: The PREDICTION Study

Background— Atherosclerotic plaques progress in a highly individual manner. The purposes of the Prediction of Progression of Coronary Artery Disease and Clinical Outcome Using Vascular Profiling of Shear Stress and Wall Morphology (PREDICTION) Study were to determine the role of local hemodynamic and vascular characteristics in coronary plaque progression and to relate plaque changes to clinical events. Methods and Results— Vascular profiling, using coronary angiography and intravascular ultrasound, was used to reconstruct each artery and calculate endothelial shear stress and plaque/remodeling characteristics in vivo. Three-vessel vascular profiling (2.7 arteries per patient) was performed at baseline in 506 patients with an acute coronary syndrome treated with a percutaneous coronary intervention and in a subset of 374 (74%) consecutive patients 6 to 10 months later to assess plaque natural history. Each reconstructed artery was divided into sequential 3-mm segments for serial analysis. One-year clinical follow-up was completed in 99.2%. Symptomatic clinical events were infrequent: only 1 (0.2%) cardiac death; 4 (0.8%) patients with new acute coronary syndrome in nonstented segments; and 15 (3.0%) patients hospitalized for stable angina. Increase in plaque area (primary end point) was predicted by baseline large plaque burden; decrease in lumen area (secondary end point) was independently predicted by baseline large plaque burden and low endothelial shear stress. Large plaque size and low endothelial shear stress independently predicted the exploratory end points of increased plaque burden and worsening of clinically relevant luminal obstructions treated with a percutaneous coronary intervention at follow-up. The combination of independent baseline predictors had a 41% positive and 92% negative predictive value to predict progression of an obstruction treated with a percutaneous coronary intervention. Conclusions— Large plaque burden and low local endothelial shear stress provide independent and additive prediction to identify plaques that develop progressive enlargement and lumen narrowing. Clinical Trial Registration— URL: http:www.//clinicaltrials.gov. Unique Identifier: NCT01316159.

Impact of Cilostazol on Restenosis After Percutaneous Coronary Balloon Angioplasty

BACKGROUND Restenosis after percutaneous transluminal coronary (balloon) angioplasty (PTCA) remains a major drawback of the procedure. We previously reported that cilostazol, a platelet aggregation inhibitor, inhibited intimal proliferation after directional coronary atherectomy and reduced the restenosis rate in humans. The present study aimed to determine the effect of cilostazol on restenosis after PTCA. METHODS AND RESULTS Two hundred eleven patients with 273 lesions who underwent successful PTCA were randomly assigned to the cilostazol (200 mg/d) group or the aspirin (250 mg/d) control group. Administration of cilostazol was initiated immediately after PTCA and continued for 3 months of follow-up. Quantitative coronary angiography was performed before PTCA and after PTCA and at follow-up. Reference diameter, minimal lumen diameter, and percent diameter stenosis (DS) were measured by quantitative coronary angiography. Angiographic restenosis was defined as DS at follow-up >50%. Eligible follow-up angiography was performed in 94 patients with 123 lesions in the cilostazol group and in 99 patients with 129 lesions in the control group. The baseline characteristics and results of PTCA showed no significant difference between the 2 groups. However, minimal lumen diameter at follow-up was significantly larger (1.65+/-0.55 vs 1.37+/-0.58 mm; P<0.0001) and DS was significantly lower (34.1+/-17.8% vs 45.6+/-19. 3%; P<0.0001) in the cilostazol group. Restenosis and target lesion revascularization rates were also significantly lower in the cilostazol group (17.9% vs 39.5%; P<0.001 and 11.4% vs 28.7%; P<0. 001). CONCLUSIONS Cilostazol significantly reduces restenosis and target lesion revascularization rates after successful PTCA.

Coronary angioplasty of chronic total occlusions with bridging collateral vessels: immediate and follow-up outcome from a large single-center experience.

OBJECTIVES The purpose of the present study was to assess the effect of bridging collateral vessels on the success of coronary angioplasty of chronic total occlusions in the context of state of the art technology and operator skill. BACKGROUND Coronary angioplasty of chronic total occlusions has been associated with relatively low success rates. Because the presence of bridging collateral vessels in chronic total occlusion has been reported to be the major predictive factor in procedural failure, angioplasty is often not recommended in patients with such vessels. METHODS Three hundred ninety-seven consecutive patients undergoing coronary angioplasty for chronic total occlusion were classified into two groups. Patients in group I had chronic total occlusion with bridging collateral vessels (97 patients, 109 total occlusions), and patients in group II had chronic total occlusion without such vessels (300 patients, 324 total occlusions). RESULTS The mean +/- SD duration of occlusion was 46 +/- 66 months (range 2 to 170) in group I and 27 +/- 39 months (range 2 to 112) in group II (p < 0.05, high power value 0.83, group I vs. group II). Angioplasty for single-vessel disease was performed in a smaller proportion of patients in group I than in group II (22% vs. 36%, p < 0.05; power value 0.77). Procedural success was achieved in 82 chronic total occlusions in group I and 270 chronic total occlusions in group II (75% vs. 83%, p = 0.07; power value 0.53). The rates of restenosis and reocclusion were 54% and 16%, respectively, for group I and 56% and 13%, respectively, for group II (p = 0.76, 0.46; power value 0.51, 0.47). Complications were minor with no Q wave infarction or requirement for urgent bypass surgery in either group. Of 81 patients with unsuccessful coronary angioplasty, 1 patient from group I (1%) and 3 patients from group II (1%) required pericardiocentesis because of cardiac tamponade. Guide wire manipulation did not impair the flow of bridging collateral channels in group I. CONCLUSIONS Coronary angioplasty can open chronic total occlusions, with or without bridging collateral channels, for safe and effective recanalization without major complications.

Impact of cilostazol on intimal proliferation after directional coronary atherectomy

Cilostazol, a novel platelet aggregation inhibitor, inhibits intimal proliferation in animal models. We randomly assigned 41 patients with lesions suitable for directional coronary atherectomy to the cilostazol group (200 mg/day) or the aspirin (250 mg/day) group. Medication was started before directional coronary atherectomy and was continued to a 6-month follow-up. Serial quantitative coronary angiography and intravascular ultrasound study were performed. Baseline characteristics were not different between the two groups. However, the minimal lumen diameter at follow-up was larger (2.33 +/- 0.60 mm vs 1.81 +/- 0.68 mm, p = 0.016) and the percent diameter stenosis (24.5% +/- 16.6% vs 40.9% +/- 21.0%, p = 0.010) was smaller in the cilostazol group. The change in vessel area was not different, but the percent plaque area at follow-up was smaller in the cilostazol group (55.7% +/- 11.2% vs 64.5% +/- 14.5%, p = 0.044). The restenosis rate was significantly lower in the cilostazol group (0% vs 26%, p = 0.020). We conclude that cilostazol appears to have an inhibitory effect on intimal proliferation after directional coronary atherectomy and may reduce restenosis.

Final results of the STent versus directional coronary Atherectomy Randomized Trial (START)

OBJECTIVES This study was designed to compare primary stenting with optimal directional coronary atherectomy (DCA). BACKGROUND No previous prospective randomized trial comparing stenting and DCA has been performed. METHODS One hundred and twenty-two lesions suitable for both Palmaz-Schatz stenting and DCA were randomly assigned to stent (62 lesions) or DCA (60 lesions) arm. Single or multiple stents were implanted with high-pressure dilation in the stent arm. Aggressive debulking using intravascular ultrasound (IVUS) was performed in the DCA arm. Serial quantitative angiography and IVUS were performed preprocedure, postprocedure and at six months. The primary end point was restenosis, defined as > or =50% diameter stenosis at six months. Clinical event rates at one year were also assessed. RESULTS Baseline characteristics were similar. Procedural success was achieved in all lesions. Although the postprocedural lumen diameter was similar (2.79 vs. 2.90 mm, stent vs. DCA), the follow-up lumen diameter was significantly smaller (1.89 vs. 2.18 mm; p = 0.023) in the stent arm. The IVUS revealed that intimal proliferation was significantly larger in the stent arm than in the DCA arm (3.1 vs. 1.1 mm ; p < 0.0001), which accounted for the significantly smaller follow-up lumen area of the stent arm (5.3 vs. 7.0 mm2; p = 0.030). Restenosis was significantly lower (32.8% vs. 15.8%; p = 0.032), and target vessel failure at one year tended to be lower in the DCA arm (33.9% vs. 18.3%; p = 0.056). CONCLUSIONS These results suggest that aggressive DCA may provide superior angiographic and clinical outcomes to primary stenting.

Attenuation of acetylcholine-induced vasoconstriction by L-arginine is related to the progression of atherosclerosis

To determine if L-arginine, a precursor of the endothelium-derived relaxing factor, restores endothelium-dependent dilation in human coronary arteries, we studied 21 patients in whom the lumina of the coronary arteries were angiographically smooth or slightly irregular and in whom there was a constrictor response to acetylcholine (ACh) in the left anterior descending coronary artery or the circumflex coronary artery. We examined the response to intracoronary ACh before and after infusion of L-arginine by measuring coronary diameter with quantitative angiography. Intracoronary injection of ACh produced vasoconstriction in the majority of patients with coronary risk factors. The percentage diameter change in smooth segments in patients with entirely smooth coronary arteries (group 1, n = 44) from baseline was -20.7% +/- 17.4%. During systemic infusion of L-arginine, the constrictor response to ACh in these segments was significantly attenuated (-2.2% +/- 15.1% from baseline, p < 0.01, ACh alone vs ACh during L-arginine infusion). In smooth segments in patients with luminal irregularities in the other coronary arteries (group 2, n = 19), ACh produced a marked constriction (-32.5% +/- 22.5% from baseline, p < 0.05, group 1 vs group 2). Infusion of L-arginine also attenuated ACh-induced vasoconstriction in these segments (-9.7% +/- 14.1% from baseline, p < 0.01, ACh vs ACh during L-arginine infusion). In segments with irregular lumina (group 3, n = 26), ACh produced more prominent vasoconstriction. The percentage diameter change was -40.9% +/- 26.5% from baseline (p < 0.01 vs group 1).(ABSTRACT TRUNCATED AT 250 WORDS)

Incidence and impact on midterm outcome of controlled subintimal tracking in patients with successful recanalisation of chronic total occlusions: J-PROCTOR registry.

AIMS To assess the incidence and impact on clinical outcomes of subintimal tracking in patients undergoing percutaneous coronary intervention for chronic total occlusion (CTO). Patients at 27 centres were consecutively enrolled when guidewire crossing of the CTO by either the antegrade or the retrograde approach was confirmed by intravascular ultrasound (IVUS). IVUS images were examined to identify the course of the wire. Clinical follow-up at one year and angiographic follow-up at nine months were performed after everolimus-eluting stent implantation. Among a total of 163 patients (59 antegrade and 104 retrograde), subintimal tracking was more frequent with the retrograde approach (24.2% vs. 12.3%, p=0.10). Although there was no difference in the one-year target vessel revascularisation rate between intimal and subintimal tracking with either the antegrade or the retrograde approach, angiographic follow-up revealed greater late loss in the subintimal group compared with the intimal group. Multivariate analysis identified the pre-procedural reference diameter as a predictor of subintimal tracking. Subintimal tracking was more frequent with the retrograde approach. After medium-term follow-up, no negative clinical impact of subintimal tracking was observed in this small study. However, further evaluation of the angiographic impact is needed.

Debulking and stenting versus debulking only of coronary artery disease in patients treated with cilostazol (final results of ESPRIT)

Stenting inhibits vascular constrictive remodeling after directional coronary atherectomy (DCA). Cilostazol has been reported to control neointimal proliferation after stenting. This studys aim was to examine the effect of debulking and stenting with antirestenotic medication on restenosis. After optimal DCA, 117 lesions were randomly assigned to either the DCA with stent (DCA-stent) (58 lesions) group or the DCA only (59 lesions) group. Multilink stents were implanted in the DCA-stent group. Cilostazol (200 mg/day) without aspirin was administered to both groups for 6 months. Ticlopidine (200 mg/day) was given to the DCA-stent group for 1 month. Serial quantitative angiography and intravascular ultrasound (IVUS) were performed at the time of the procedure and at 6-month follow-up. The primary end point was 6-month angiographic restenosis. Clinical event rates at 1 year were also assessed. Baseline characteristics were similar. All procedures were successful. No adverse effects to cilostazol were observed. Postprocedural lumen diameter was significantly larger (3.27 vs 2.92 mm; p <0.0001) in the DCA-stent group. However, the follow-up lumen diameter was not significantly different (2.53 vs 2.41 mm, DCA-stent vs DCA). IVUS revealed that intimal proliferation was significantly larger in the DCA-stent group (4.2 vs 1.5 mm(2); p <0.0001), which accounted for the similar follow-up lumen area (6.5 vs 7.1 mm(2)). The restenosis rate was low in both groups (5.4% vs 8.9%), and the difference was not significant. Clinical event rates at 1 year were also not significantly different. These results suggest that optimal lesion debulking by DCA does not always need adjunctive stenting if cilostazol is administered.

Percutaneous myocardial ablation in double‐chamber right ventricle

Double‐chamber right ventricle (DCRV) exhibits intracavitary outflow obstruction. We report the first case of percutaneous myocardial ablation of DCRV in a 73‐year‐old patient. An alcohol‐induced conus branch occlusion provided the reduction of pressure gradient from 81 to 48 mm Hg and clinical improvement. This strategy may be an alternative therapy to surgery in the adult patients with DCRV. Cathet. Cardiovasc. Intervent. 49:97–101, 2000.

PROMUS STENT TREATMENT OF CHRONIC TOTAL OCCLUSIONS USING TWO DIFFERENT RECANALIZATION TECHNIQUES IN JAPAN– J–PROCTOR REGISTRY: A MULTICENTER REGISTRY TO EVALUATE CLINICAL OUTCOME OF DRUG ELUTING STENT IN SUBINTIMAL AREA AFTER CTO REVASCULARIZATION USING ANTEGRADE OR RETROGRADE APPROACH

Since the current retrograde approach for percutaneous coronary interventions in chronic total occlusions (CTO) was introduced in 1995, this approach has continued to increase PCI success rates in CTOs. Despite the increased success rate, short and long term Drug Eluting Stent (DES) clinical