Takuya Haraguchi

Incidence and Clinical Impact of Stent Fracture After Everolimus-Eluting Stent Implantation

Background—Stent fracture (SF) after drug-eluting stent implantation has recently become an important concern because of its potential association with in-stent restenosis and stent thrombosis. However, the incidence and clinical impact of SF after everolimus-eluting stent implantation remain unclear. Methods and Results—A total of 1035 patients with 1339 lesions undergoing everolimus-eluting stent implantation and follow-up angiography 6 to 9 months after index procedure were analyzed. SF was defined as complete or partial separation of the stent, as assessed by plain fluoroscopy or intravascular ultrasound during follow-up. We assessed the rates of SF and major adverse cardiac events, defined as cardiac death, myocardial infarction, stent thrombosis, and clinically driven target lesion revascularization within 9 months. SF was observed in 39 of 1339 lesions (2.9%) and in 39 of 1035 patients (3.8%). Ostial stent location and lesions with hinge motion, tortuosity, or calcification were independent predictors of SF. The rate of myocardial infarction and target lesion revascularization were significantly higher in the SF group than in the non-SF group (5.1% versus 0.4%; P=0.018 and 25.6% versus 2.0%; P<0.001, respectively). Stent thrombosis was more frequently observed in the SF group than in the non-SF group (5.1% versus 0.4%; P=0.018). Major adverse cardiac events within 9 months were significantly higher in the SF group than in the non-SF group (25.6% versus 2.3%; P<0.001). Conclusions—SF after everolimus-eluting stent implantation occurs in 2.9% of lesions and is associated with higher rate of major adverse cardiac events, driven by higher target lesion revascularization and stent thrombosis.

Anterolateral Popliteal Puncture Technique: A Novel Retrograde Approach for Chronic Femoropopliteal Occlusions

Purpose: To describe the feasibility and safety of an anterolateral popliteal puncture technique as a retrograde access to chronic total occlusions (CTOs) in the femoropopliteal segment. Methods: Twenty consecutive patients (mean age 75.1±10.9 years; 13 women) with symptomatic femoropopliteal occlusive disease underwent endovascular therapy via a retrograde access using the anterolateral popliteal puncture technique. With the patient supine, the P3 segment of the popliteal artery was accessed with a sheathless technique intended to provide minimally invasive access. Subsequent to a wire rendezvous technique in the CTO, the antegrade guidewire was advanced to the below-the-knee artery. Hemostasis across the P3 segment was secured with balloon inflation alone or combined with thrombin-blood patch (TBP) injection. Results: Both the anterolateral popliteal puncture technique and subsequent revascularization were successful in all patients. Mean hemostasis time for balloon inflation only was 7.73±4.03 vs 4.78±0.78 minutes for balloon inflation with TBP injection. There were no in-hospital deaths or complications, including pseudoaneurysms, arteriovenous fistulas, hematomas, embolic complications, or nerve damage. Conclusion: The anterolateral popliteal puncture technique is useful as an alternative retrograde access vs a conventional transpopliteal approach for CTOs in the femoropopliteal segment if antegrade recanalization has failed. This technique may become one option for retrograde access in patients with severe below-the-knee lesions or with CTOs that extend to the P2 segment of the popliteal artery. Furthermore, this technique has the added benefit of allowing patients to remain in the supine position throughout treatment.

Comparison of Angiographic Dissection Patterns Caused by Long vs Short Balloons During Balloon Angioplasty of Chronic Femoropopliteal Occlusions

Purpose: To describe the feasibility of balloon angioplasty using a long balloon for chronic femoropopliteal occlusions by evaluating angiographic dissection patterns for optimization of outcomes in balloon angioplasty. Methods: A retrospective, single-center analysis examined 101 symptomatic patients (mean age 75.6±9.9 years; 65 men) with single de novo femoropopliteal occlusive lesions treated with balloon angioplasty between August 2012 and October 2016. The patients were classified into 2 groups for comparison of angiographic dissection patterns: 51 patients were treated with balloon angioplasty using long balloons (L-BA; defined as ≥220 mm in length) and 50 patients were treated with short balloon angioplasty (S-BA; defined as <150-mm-long balloons). Results: Severe vessel dissection patterns, defined as type C or higher, were fewer in the L-BA group (47.1% vs 70.0% in the S-BA group, p=0.019) and the total dissection length was shorter (92.7±72.6 vs 160.4±84.6 mm in the S-BA group, p<0.001). Although the results showed no significant differences between the two groups regarding the length of chronic total occlusions (L-BA: 228.6±73.2 vs S-BA: 226.0±53.8 mm, p=0.83), inflation pressure (L-BA; 8.2±2.6 vs S-BA: 8.1±2.9 atm, p=0.86), and the other lesion characteristics, inflation time was significantly longer in the L-BA group (161.2±68.7 seconds vs 51.1±54.0 seconds in the S-BA group, p<0.001). Multivariate analysis identified a balloon length ≥220 mm as an independent negative predictor of severe vessel dissection (odds ratio 0.29, 95% confidence interval 0.11 to 0.83, p=0.02). Conclusion: Using long balloons for balloon angioplasty may help prevent severe vessel dissection in chronic femoropopliteal occlusions.

Thrombectomy Using Myocardial Biopsy Forceps in Acute Limb Ischemia Patients

PURPOSE To evaluate the efficacy and safety of thrombectomy using myocardial biopsy forceps for the treatment of acute limb ischemia (ALI). MATERIALS AND METHODS A retrospective review of 11 ALI patients (12 affected limbs, 18 affected vessels) who underwent thrombectomy using biopsy forceps between November 2011 and April 2016 was performed. Of the 12 affected limbs, 2 limbs had stent thrombosis, 1 limb had thrombotic occlusion at a de novo stenosis site, and 9 limbs had embolic ALI. Biopsy forceps were used for angiographically limited arterial flow that persisted after the use of an aspiration catheter and conventional balloon angioplasty. The general technique for use of the biopsy forceps included advancement in parallel to a guidewire to the thrombus site, grasping of the thrombus with the forceps, and confirmation of grasping the thrombus with injection of a contrast medium prior to thrombus extraction. RESULTS Partial or total retrieval of the thrombus was angiographically confirmed in 12 of the 18 affected vessels, with restoration of normal blood flow in 11 vessels. Unsuccessful results in the remaining 6 affected vessels appeared to be due to friction at the aortoiliac bifurcation caused by the contralateral approach, small vessel size, or curvature of the anterior tibial artery. None of the 18 treated vessels had any complications such as dissection or perforation of the target vessel wall and distal emboli. None of the surviving patients required major or minor amputation. CONCLUSIONS Thrombectomy using biopsy forceps is a feasible technique for removal of an arterial thrombus in patients with ALI.

Treatment for in-stent restenosis requiring rotational atherectomy

OBJECTIVES This study aimed to evaluate the outcomes of patients with in-stent restenosis (ISR) who underwent rotablation (RA) followed by balloon angioplasty (BA), drug-eluting stent (DES) implantation, or drug-coated balloon (DCB) angioplasty. BACKGROUND Interventional treatment of ISR is occasionally challenging. Despite the availability of various percutaneous treatments, the optimal solution remains unclear. METHODS AND RESULTS A total of 200 patients with ISR who underwent RA were retrospectively identified from our institutional database. Clinical outcomes at 12 months and independent predictors of target lesion revascularization (TLR) were assessed. Of patients, 90, 55, and 55 underwent BA, DES implantation, and DCB angioplasty, respectively. The incidence of all-cause death, cardiac death, and hospitalization due to heart failure was low in all groups. Moreover, no definite stent thrombosis was observed in the three groups. The TLR rate of BA, DES implantation, and DCB angioplasty following RA for ISR were 40.7%, 35.0%, and 27.3%, respectively. The adjusted outcomes for TLR using the inverse probability of treatment weighting method based on propensity scores indicated that DCB angioplasty following RA was superior to BA after RA. Intraprocedural complications, which could be successfully managed with interventional treatment, were identified in only three cases. CONCLUSIONS TLR at 12 months is dismal. RA is not effective for ISR requiring RA. In unfavorable settings, DCB angioplasty following RA is the most effective treatment option in patients with ISR requiring debulking strategy.

Response to Letter Regarding Article, “Incidence and Clinical Impact of Stent Fracture After Everolimus-Eluting Stent Implantation”

We thank Dr Paul D. Williams, Dr Mama A. Mamas, and Dr Douglas G. Fraser for their interest in our article.1 First, we investigated the stent fracture after Xience V (Abbott Vascular) and Promus (Boston Scientific). As they note, our results, therefore, do not apply to all everolimus-eluting stents. Second, they suggest that double stent strut layer shown in Figure 4 is the consequence of stent fracture rather than longitudinal stent deformation. Actually, it may well be that there is considerable overlap between …