Directional Coronary Atherectomy Research Articles

Effectiveness of directional coronary atherectomy in treating recurrent in-stent restenosis: A case report

Effectiveness of directional coronary atherectomy in treating recurrent in-stent restenosis: A case report

Single-Cell RNA Sequencing Reveals an Immune Landscape of CD4+ T Cells in Coronary Culprit Plaques With Acute Coronary Syndrome in Humans-Brief Report.

Acute coronary syndrome (ACS) involves plaque-related thrombosis, causing primary ischemic cardiomyopathy or lethal arrhythmia. We previously demonstrated a unique immune landscape of myeloid cells in the culprit plaques causing ACS by using single-cell RNA sequencing. Here, we aimed to characterize T cells in a single-cell level, assess clonal expansion of T cells, and find a therapeutic target to prevent ACS. We obtained the culprit lesion plaques from 4 patients with chronic coronary syndrome (chronic coronary syndrome plaques) and the culprit lesion plaques from 3 patients with ACS (ACS plaques) who were candidates for percutaneous coronary intervention with directional coronary atherectomy. Live CD45+ immune cells were sorted from each pooled plaque samples and applied to the 10× platform for single-cell RNA sequencing analysis. We also extracted RNA from other 3 ACS plaque samples and conducted unbiased TCR (T-cell receptor) repertoire analysis. CD4+ T cells were divided into 5 distinct clusters: effector, naive, cytotoxic, CCR7+ (C-C chemokine receptor type 7) central memory, and FOXP3 (forkhead box P3)+ regulatory CD4+ T cells. The proportion of central memory CD4+ T cells was higher in the ACS plaques. Correspondingly, dendritic cells also tended to express more HLAs (human leukocyte antigens) and costimulatory molecules in the ACS plaques. The velocity analysis suggested the differentiation flow from central memory CD4+ T cells into effector CD4+ T cells and that from naive CD4+ T cells into central memory CD4+ T cells in the ACS plaques, which were not observed in the chronic coronary syndrome plaques. The bulk repertoire analysis revealed clonal expansion of TCRs in each patient with ACS and suggested that several peptides in the ACS plaques work as antigens and induced clonal expansion of CD4+ T cells. For the first time, we revealed single cell-level characteristics of CD4+ T cells in patients with ACS. CD4+ T cells could be therapeutic targets of ACS. URL: https://upload.umin.ac.jp/cgi-open-bin/icdr_e/ctr_view.cgi?recptno=R000046521; Unique identifier: UMIN000040747.

Intralesional pentraxin 3 increases with atherosclerotic disease progression, but may protect from thrombosis: Friend or foe?

AimTo investigate the role of pentraxin 3 (PTX3) in atherosclerotic disease progression and plaque destabilization, as well as in coronary restenosis after directional coronary atherectomy (DCA). Materials and methodsPTX3 contents of early and advanced atherosclerotic lesions of the aorta obtained at autopsy were determined by ELISA and Western blot. Also, coronary plaques of patients with acute coronary syndrome (ACS) or stable angina pectoris (SAP) obtained by DCA were analyzed by immunohistochemistry for PTX3. The effects of PTX3 on smooth muscle cells (SMCs) and thrombogenesis were investigated with cultured human coronary artery SMCs and a flow chamber system, respectively. ResultsAdvanced atherosclerotic lesions contained a significantly larger amount of PTX3 than early lesions (ELISA: 9.96 ± 2.77 ng/100 mg tissue, n = 8 vs 0.24 ± 0.18 ng/100 mg tissue, n = 6, P = 0.0097). Also, ACS plaques contained a significantly larger amount of PTX3 than SAP plaques (PTX3 immunohistochemistry–positive area percentage: 2.88 ± 0.53 %, n = 22 vs 0.67 ± 0.27 %, n = 23, P = 0.0009). Curiously, the patients who would remain free of post-DCA restenosis (n = 19) had plaques with a significantly higher PTX3 immunohistochemistry–positive area percentage than those who would develop restenosis (n = 12) (2.32 ± 0.49 % vs 0.49 ± 0.17 %, P = 0.002). In the mechanistic part of the study, PTX3 inhibited SMC proliferation and migration. PTX3 also inhibited platelet thrombus formation in the condition simulating arterial blood flow. ConclusionsPTX3 is increased in advanced (vs early) atherosclerotic lesions and unstable (vs stable) coronary plaques. The inhibitory effects of PTX3 on SMCs and thrombogenesis suggest that intraplaque PTX3 might have atheroprotective effects.

One-year outcomes of patients undergoing percutaneous coronary intervention with the revived directional coronary atherectomy catheter: Insights from the J-PCI OUTCOME registry.

We sought to investigate the 1-year outcomes, including all-cause and cardiovascular mortality, major adverse cardiovascular events (MACEs), and major bleeding, of patients undergoing percutaneous coronary intervention (PCI)with or without the revived directional coronary atherectomy (DCA)catheter in a Japanese nationwide registry. Clinical data regarding the midterm outcomes of patients undergoing PCI with DCA are scarce in contemporary real-world practice. We analyzed the data of 74,764 patients who underwent PCI at 179 hospitals from January 2017 to December 2018. The baseline characteristics and 1-year outcomes of patients with stable coronary artery disease or unstable angina who underwent PCI with or without DCA were assessed. Overall, 431 patients (0.6%) underwent PCI with DCA. Patients in the DCA group were younger and predominantly male, with fewer comorbidities than patients in the non-DCA group. Stentless PCI with DCA following additional drug-coated balloon (DCB) angioplasty was the dominant strategy in the DCA group (43.6%). One-year outcomes, including all-cause mortality (1.2% in the DCA group vs. 2.5% in the non-DCA group, respectively, p = 0.075), cardiovascular death (0.9% vs. 1.0%, p = 0.69), MACEs (1.9% vs. 1.8%, p = 0.96), and nonfatal major bleeding requiring readmission (1.2% vs. 1.4%, p = 0.62), were comparable between the two groups. In the DCA group, 1-year outcomes were comparable, regardless of whether the stent or DCB was used. One-year clinical outcomes after PCI with DCA in patients with stable coronary artery disease or unstable angina are acceptable, regardless of stent use.

Optical coherence tomographic patterns of restenosis in patients treated with directional coronary atherectomy and drug-coated balloon therapy.

Optical coherence tomographic patterns of restenosis in patients treated with directional coronary atherectomy and drug-coated balloon therapy.

Intentional Thromboatherectomy Using Directional Coronary Atherectomy for Massive Subacute Intracoronary Thrombus

Intentional Thromboatherectomy Using Directional Coronary Atherectomy for Massive Subacute Intracoronary Thrombus

Early-phase restenosis following directional coronary atherectomy and paclitaxel-coated balloon angioplasty: a histopathological analysis.

A 58-year-old man with hypertension and dyslipidaemia was hospitalized for angina pectoris. He underwent directional coronary atherectomy (DCA) followed by dilatation with a 3.5 × 15 mm paclitaxel-coated balloon (PCB) for severe stenosis in the proximal segment of the left anterior descending coronary artery (LAD) (Panels A–C). Intravascular ultrasound (IVUS) demonstrated a large, layered, and mostly highly echoic plaque (Panel E). The lesion was successfully resected (Panels B and F), and sufficient coronary blood flow was achieved (Panels C and G). Histopathological analysis of the retrieved DCA specimen showed smooth muscle cell (SMC)-rich fibrous plaque (α-smooth muscle actin) without macrophages (CD68) (Panels I1–4). The patient was re-admitted 6 months later for chest pain. Coronary angiography identified restenosis in the proximal LAD (Panel D). We decided to repeat DCA and then implant a drug-eluting stent. IVUS of the restenotic lesion showed a plaque with iso and high echogenicity (Panel H). Histopathological analysis of the DCA specimens revealed the proliferation of numerous stellate cells and a proteoglycan-rich matrix. Immunostaining also demonstrated that these cells were mostly SMCs, with very few macrophages (Panels J1–4).

Multimodality Imaging of Possible Healed Plaque Erosion Pathologically Validated by Directional Coronary Atherectomy Specimens

Multimodality Imaging of Possible Healed Plaque Erosion Pathologically Validated by Directional Coronary Atherectomy Specimens

In Vivo Assessment of In-Stent Restenosis After Resolute Zotarolimus-Eluting Stent Implantation: Multimodality Imaging with Directional Coronary Atherectomy.

In Vivo Assessment of In-Stent Restenosis After Resolute Zotarolimus-Eluting Stent Implantation: Multimodality Imaging with Directional Coronary Atherectomy.

A Rare Presentation of Coronary Aneurysm following Bare-metal Stent

We present a case of post-percutaneous transluminal coronary angioplasty with a bare-metal stent to the right coronary artery (RCA). He presented with acute ST-elevation inferior wall myocardial infarction. Coronary angiography showed an aneurysm of proximal RCA extending from the proximal end of the stent to the distal end. There was a 90% discrete lesion beyond the stent with TIMI III flow. The development of coronary artery aneurysms (CAAs) was reported even before the era of stents. CAA can develop after plain balloon angioplasty, after directional coronary atherectomy, and after bare-metal and drug-eluting stents also but not after coronary angiography. Kachru et al. reported an incidence of 0.2% (4 of 2408) per DES without routine angiographic follow-up and Rha et al. reported an incidence of 1.7% (five out of 296) per patient at 6-month routine angiographic follow-up. CAA is an uncommon and often accidental finding, we report a case of CAA which presented as acute myocardial infarction mimicking stent thrombosis.

Pathological findings of honeycomb-like structure resected by directional coronary atherectomy.

Pathological findings of honeycomb-like structure resected by directional coronary atherectomy.

Overview of in-hospital outcomes in patients undergoing percutaneous coronary intervention with the revived directional coronary atherectomy.

We sought to provide clinical insights on the usage rate, indications, and in-hospital outcomes of the revived directional coronary atherectomy (DCA) catheter (Atherocut™) in a Japanese nationwide percutaneous coronary intervention (PCI) registry. Debulking devices such as the revived DCA catheter have become increasingly important in the era of complex PCI. However, little is known about PCI outcomes using a novel DCA catheter in contemporary real-world practice. We analyzed 188,324 patients who underwent PCI in 1112 hospitals from January to December 2018. Baseline characteristics and in-hospital outcomes of patients with stable coronary artery disease or unstable angina who underwent PCI with or without the DCA were analyzed. Overall, 1696 patients (0.9%) underwent PCI with the DCA during the study period, predominantly for left main trunk or proximal left anterior descending artery lesions under a transfemoral approach. Patients in the DCA group were younger and had fewer comorbidities such as hypertension, diabetes mellitus, and chronic kidney disease than patients in the non-DCA group. Stentless PCI using the DCA with drug-coated balloon angioplasty was a preferred treatment strategy in the DCA group (50.0%). Predefined in-hospital adverse outcomes, including mortality (0.2% vs. 0.3%, p = 0.446) and periprocedural complications (1.8% vs. 1.7%, p = 0.697), were comparable between the two groups, whereas the fluoroscopy time was longer and the total contrast volume was higher in the DCA group. In Japan, PCI using the revived DCA catheter is safely performed with low complication rates in patients with stable coronary artery disease or unstable angina.

Involvement of enhanced expression of classical complement C1q in atherosclerosis progression and plaque instability: C1q as an indicator of clinical outcome.

Activation of the classical complement pathway plays a major role in regulating atherosclerosis progression, and it is believed to have both proatherogenic and atheroprotective effects. This study focused on C1q, the first protein in the classical pathway, and examined its potentialities of plaque progression and instability and its relationship with clinical outcomes. To assess the localization and quantity of C1q expression in various stages of atherosclerosis, immunohistochemistry, western blotting, and real-time polymerase chain reaction (PCR) were performed using abdominal aortas from eight autopsy cases. C1q immunoreactivity in relation to plaque instability and clinical outcomes was also examined using directional coronary atherectomy (DCA) samples from 19 patients with acute coronary syndromes (ACS) and 18 patients with stable angina pectoris (SAP) and coronary aspirated specimens from 38 patients with acute myocardial infarction. C1q immunoreactivity was localized in the extracellular matrix, necrotic cores, macrophages and smooth muscle cells in atherosclerotic lesions. Western blotting and real-time PCR illustrated that C1q protein and mRNA expression was significantly higher in advanced lesions than in early lesions. Immunohistochemical analysis using DCA specimens revealed that C1q expression was significantly higher in ACS plaques than in SAP plaques. Finally, immunohistochemical analysis using thrombus aspiration specimens demonstrated that histopathological C1q in aspirated coronary materials could be an indicator of poor medical condition. Our results indicated that C1q is significantly involved in atherosclerosis progression and plaque instability, and it could be considered as one of the indicators of cardiovascular outcomes.

Impact of directional coronary atherectomy followed by drug-coated balloon strategy to avoid the complex stenting for bifurcation lesions.

Although the simple single stenting rather than complex double stenting is recommended on percutaneous coronary intervention (PCI) for bifurcation lesions, double stenting cannot always be avoided. We investigated the impact of directional coronary atherectomy (DCA), followed by drug-coated balloon (DCB) treatment to reduce the number of stents and avoid complex stenting in PCI for bifurcation lesions and short-term patency. DCA treatment without stents was attempted for 27 bifurcation lesions in 25 patients, of those, 26 bifurcation lesions in 24 patients were successfully treated and 3-month follow-up angiography and optical coherence tomography (OCT) were performed. Sixteen lesions (59.3%) were related to left main trunk distal bifurcations, and 7 (25.9%) were true bifurcation lesions. Among the true bifurcation lesions, 4 lesions (57.1%) needed 1 stent, and the other 3 lesions (42.9%) needed no stents. Among the non-true bifurcation lesions, 1 lesion (5.0%) needed bailout stent and other lesions (95.0%) needed no stents. According to DCA followed by DCB treatment, the angiographic mean diameter stenosis improved from 65.5 ± 15.0% to 7.8 ± 9.8%, and the mean plaque area in intravascular ultrasound improved from 80.4 ± 10.5% to 39.0 ± 11.5%, respectively. Angiographic and OCT late lumen loss values were 0.2 ± 0.6mm and 1.4 ± 1.9mm, respectively. No patient had in-hospital major adverse cardiac events (MACE) and 3-month MACE. In conclusion, compared with standard provisional side branch stenting strategy, DCA followed by DCB treatment might reduce the number of stents, avoid complex stenting for major bifurcation lesions and provide good short-term outcomes.

Chlamydia pneumoniae is Prevalent in Symptomatic Coronary Atherosclerotic Plaque Samples Obtained From Directional Coronary Atherectomy, but its Quantity is Not Associated With Plaque Instability: An Immunohistochemical and Molecular Study.

Aim:To clarify whether there is any association between the extent of Chlamydia pneumoniae (C. pneumoniae) infection and plaque instability or post–directional coronary atherectomy (DCA) restenosis, we determined the frequency of C. pneumoniae infection and its localization in symptomatic coronary atherosclerotic plaques using specimens obtained from DCA.Methods and results:Immunohistochemistry (IHC) and real-time polymerase chain reaction (RT-PCR) revealed the existence of C. pneumoniae in all 50 specimens of coronary atherosclerotic plaques obtained by DCA. C. pneumoniae–positive cell ratio determined with IHC or copy numbers of C. pneumoniae DNA detected by RT-PCR did not differ significantly between patients with stable angina pectoris and those with acute coronary syndrome (IHC: 16.4 ± 7.6% vs 18.0 ± 7.1%, P = .42; RT-PCR: no. of cases with high copy numbers 12/25 vs 10/25, P = .78), or between patients with subsequent post-DCA restenosis and those without (IHC: 17.1 ± 8.0% vs 18.0 ± 7.4%, P = .74; RT-PCR: 5/12 vs 10/21, P = 1.00).Conclusions:C. pneumoniae was highly prevalent in coronary atherosclerotic plaques of patients who underwent DCA. However, the extent of C. pneumoniae infection in coronary atherosclerotic plaques was not associated with plaque instability or post-DCA restenosis.

Vascular Response after Directional Coronary Atherectomy for Left Main Bifurcation Lesion.

Aims To evaluate the vascular response after directional coronary atherectomy (DCA) for left main (LM) bifurcation lesion. Methods This study was a retrospective, single-center study enrolling 31 patients who underwent stentless therapy using DCA followed by drug-coated balloon (DCB) angioplasty for LM bifurcation lesion. We compared intravascular ultrasound (IVUS) findings before and after DCA. Results After DCA, the lumen and vessel areas significantly increased, whereas the plaque area (PA) and %PA were significantly reduced. When the lesions were divided into small vessel and large vessel groups using the median value of the vessel area, the maximum balloon pressure of the DCA catheter was greater in the large vessel group. Changes in the lumen and vessel areas were also significantly greater in the large vessel group. On the other hand, the changes in PA and %PA were similar between groups. Conclusions The main vascular responses associated with lumen enlargement after DCA were plaque reduction and vessel expansion. Contribution of vessel expansion to lumen enlargement was larger than the effect of plaque reduction in large vessel lesions.

Accurate directional coronary atherectomy procedure using the tip detection method and intelligent 3D wiring pro software.

Accurate directional coronary atherectomy procedure using the tip detection method and intelligent 3D wiring pro software.

Directional coronary atherectomy using dual catheter system via bilateral transradial approach.

Directional coronary atherectomy using dual catheter system via bilateral transradial approach.

Why high intensity plaque is bright on MRI?

Although CT is an excellent imaging modality for detecting lipid pools and calcification in the atherosclerotic plaque, it cannot distinguish hemorrhage from fibrous tissue. MRI has a unique capability of identifying subacute hemorrhage as high signal intensity area on T1-weighted MRI. Non-contrast T1-weighted MRI has been used to demonstrate high intensity plaque (HIP) in the coronary arterial wall. HIP was shown to be an important feature of a vulnerable plaque that increases the risk of future cardiac events. However, due to the lack of histopathological analysis of in vivo tissue samples from patients with HIP, the pathological features of HIP are still unknown. In the current issue of American Heart Journal Plus, Ehara et al. investigated the association between the PMR on non-contrast T1-weighted MRI and coronary intraplaque hemorrhage by analyzing plaque specimen obtained by directional coronary atherectomy. An antibody against glycophorin A was used to identify sites of previous plaque hemorrhage. They found a strong positive correlation between PMR and glycophorin A score. The results in the current study by Ehara reinforce the importance and implications of non-contrast T1-weighted MRI for the evaluation of HIP from a pathological perspective. Recent technical advances in MRI such as goldenangle radial sampling, self-gating, compressed sensing with deep learning reconstruction, and simultaneous acquisition of anatomical reference images and T1 weighted images may substantially reduce the total imaging time of coronary plaque MRI.

Relationship of high-intensity plaques on T1-weighted magnetic resonance imaging with coronary intraplaque hemorrhage: A directional coronary atherectomy study

BackgroundAlthough intraplaque hemorrhage (IPH) has been identified as a key feature of rupture-prone plaques, noninvasive imaging-based features for its detection in coronary artery have not been clearly established. The aim of this study was to investigate the relationship of the ratio between the signal intensities of coronary plaque and cardiac muscle (PMR) on non-contrast T1-weighted imaging (T1WI) in magnetic resonance with IPH in the directional coronary atherectomy (DCA) specimens. MethodsFifteen lesions from 15 patients, who underwent DCA and T1WI, were prospectively enrolled. The snap-frozen samples obtained by DCA were used for immunohistochemical staining against a protein specific to erythrocyte membranes (glycophorin A) and macrophages. The percentage of glycophorin A and macrophages was graded using a scale from 0 to 4, with higher scores indicating higher percentages. ResultsPMR showed a strong positive correlation with glycophorin A scores (ρ = 0.772, p < 0.001), whreas, there was a weak correlation between the PMR and macrophage scores (ρ = 0.626, p < 0.05). The receiver-operating characteristic curve analysis showed that the optimal PMR cutoff value for predicting glycophorin A scores ≥grade 2 (glycophorin A-positive area ≥5% of the plaque) was 1.2 (area under the curve; 0.91, 95% confidence interval; 0.73–1.00), and this PMR value had a sensitivity of 8/9 (89%), specificity of 6/6 (100%), positive predictive value of 8/8 (100%), and negative predictive value of 6/7 (86%). ConclusionsIn patients with ischemic heart disease, a high PMR on T1WI is a predictor of coronary IPH as assessed by DCA specimens.