Distal Vessel Diameter Research Articles

Silk vista baby flow diversion beyond the circle of Willis: A single-center experience with long-term outcomes.

There is a lack of evidence of flow diversion (FD) safety for aneurysms treatment beyond the circle of Willis. Therefore, we provide a single-center real-world experience with the Silk Vista Baby (SVB). A single-center database was retrospectively reviewed for aneurysms treated with SVB flow diverters. Demographic information, clinical presentation, radiographic characteristics, procedural complications, and outcomes were assessed. About 57 patients (66.7% female, mean age 54.3 ± 13.2) encompassing 57 aneurysms were included. Overall, 40.4% were ruptured: 68.4% saccular, 17.5% blister, 8.7% fusiform, and 5.3% dissecting. The majority were in the anterior circulation (68.4%), and in 48.2% of cases, the distal vessel diameter was inferior to 2 mm. The symptomatic ischemic rate was 5.2%, with one case due to in-stent thrombosis (1.8%). There were no hemorrhagic complications. Complication rates did not differ between ruptured and unruptured lesions (p = 0.356). There were no cases of delayed aneurysm rupture, and overall mortality was 1.8%. The median follow-up time was 18 ± 12 months. In-stent stenosis rate was 10.5% (6/57), all of which were asymptomatic. At the last follow-up, 70.2% of cases had an adequate occlusion (OKM C and D), and 96.5% had an mRS of 0-2. In our series, SVB was shown to be a safe device in the treatment of not only distal anterior circulation aneurysms but also in the management of complex posterior fossa and ruptured blister aneurysms. Multicenter studies are needed to confirm and generalize these results.

Distal normal vessel diameter might be associated with silent brain infarcts after stenting for symptomatic carotid stenosis

BackgroundCarotid artery stenting (CAS) has been the standard treatment for carotid stenosis because it is less invasive; however, the risk of periprocedural thromboembolism is high. We investigated the predictors for silent brain infarcts (SBIs), focusing on embolic protection in CAS. MethodsThis study was single-center retrospective study, and we obtained baseline demographics and clinical, laboratory, and periprocedural variables of patients who underwent CAS. Also, methods used for embolic protection (no EPD, distal EPD, or proximal balloon guiding catheter) during CAS were obtained. Distal normal vessel diameter was defined as the diameter of cervical internal carotid artery where the artery wall becomes parallel. Diffusion-weighted imaging was performed before and after procedure to detect SBIs. The primary outcome was stented territory SBIs, and the secondary outcomes were any territories SBIs and stented territory SBIs in cases with EPD. ResultsA total of 196 CAS procedures with mean age 69.1 ± 9.9 years were included. After CAS, stented territory SBIs occurred in 53 (27.0 %) cases and any territories SBIs in 60 (30.6 %) cases. Univariable analyses revealed that distal normal vessel diameter (odds ratio = 1.71, 95 % confidence interval = 1.20–2.43, P = 0.003) was associated with the occurrence of stented territory SBIs after CAS. After adjusting for potential variables, larger distal normal vessel diameter (1.61 [1.10–2.36], P = 0.014) increased the occurrence of SBIs after CAS. Consistent results were obtained when the outcome was any territories SBIs or stented territory SBIs in cases with EPD. ConclusionsDistal normal vessel diameter was a predictor for the occurrence of SBI after CAS. The passable pore size of EPDs may vary depending on vessel diameter, and may impact the occurrence of SBIs.

Impact of vessel morphology on CT-derived fractional-flow-reserve in non-obstructive coronary artery disease in right coronary artery

ObjectivesComputed tomography (CT)–derived fractional flow reserve (FFRCT) decreases continuously from proximal to distal segments of the vessel due to the influence of various factors even in non-obstructive coronary artery disease (NOCAD). It is known that FFRCT is dependent on vessel-length, but the relationship with other vessel morphologies remains to be explained.PurposeTo investigate morphological aspects of the vessels that influence FFRCT in NOCAD in the right coronary artery (RCA).MethodsA total of 443 patients who underwent both FFRCT and invasive coronary angiography, with < 50% RCA stenosis, were evaluated. Enrolled RCA vessels were classified into two groups according to distal FFRCT: FFRCT ≤ 0.80 (n = 60) and FFRCT > 0.80 (n = 383). Vessel morphology (vessel length, lumen diameter, lumen volume, and plaque volume) and left-ventricular mass were assessed. The ratio of lumen volume and vessel length was defined as V/L ratio.ResultsWhereas vessel-length was almost the same between FFRCT ≤ 0.80 and > 0.80, lumen volume and V/L ratio were significantly lower in FFRCT ≤ 0.80. Distal FFRCT correlated with plaque-related parameters (low-attenuation plaque, intermediate-attenuation plaque, and calcified plaque) and vessel-related parameters (proximal and distal vessel diameter, vessel length, lumen volume, and V/L ratio). Among all vessel-related parameters, V/L ratio showed the highest correlation with distal FFRCT (r = 0.61, p < 0.0001). Multivariable analysis showed that calcified plaque volume was the strongest predictor of distal FFRCT, followed by V/L ratio (β-coefficient = 0.48, p = 0.03). V/L ratio was the strongest predictor of a distal FFRCT ≤ 0.80 (cut-off 8.1 mm3/mm, AUC 0.88, sensitivity 90.0%, specificity 76.7%, 95% CI 0.84–0.93, p < 0.0001).ConclusionsOur study suggests that V/L ratio can be a measure to predict subclinical coronary perfusion disturbance.Clinical relevance statementA novel marker of the ratio of lumen volume to vessel length (V/L ratio) is the strongest predictor of a distal CT-derived fractional flow reserve (FFRCT) and may have the potential to improve the diagnostic accuracy of FFRCT.Key Points• Physiological FFRCT decline depends not only on vessel length but also on the lumen volume in non-obstructive coronary artery disease in the right coronary artery.• FFRCT correlates with plaque-related parameters (low-attenuation plaque, intermediate-attenuation plaque, and calcified plaque) and vessel-related parameters (proximal and distal vessel diameter, vessel length, lumen volume, and V/L ratio).• Of vessel-related parameters, V/L ratio is the strongest predictor of a distal FFRCT and an optimal cut-off value of 8.1 mm3/mm.

Assessment of 3-Year Patency after Endoluminal versus Surgical Bypass Therapy for Complex Femoropopliteal Artery Disease

PurposeTo compare the 3-year clinical outcomes of endoluminal bypass with those of surgical bypass for complex femoropopliteal (FP) arterial lesions. Materials and MethodsIn this retrospective multicenter study, 530 patients with symptomatic peripheral artery disease (Rutherford classification 1–3, 66.0%; 4–6, 34.0%) who underwent either endoluminal bypass with Viabahn stent grafts (n = 276) or surgical bypass (n = 254) (with saphenous vein grafts, 74.4%; prosthetic grafts, 25.6%) for FP arterial lesions between 2010 and 2018 were analyzed. The propensity score-matched analysis was performed to compare the 3-year clinical outcomes of endoluminal bypass with those of surgical bypass. The primary end point was primary patency (freedom from restenosis). The secondary end points were secondary patency, freedom from target lesion revascularization (TLR), limb salvage, and overall survival. The interaction effect of baseline characteristics on the association of the revascularization strategy with the risk of restenosis was analyzed using the Poisson mixed-effect model. ResultsThe propensity score-matched analysis extracted 107 pairs. After propensity score matching, the primary patency rate at 1, 2, and 3 years was 84.5%, 75.1%, and 70.9%, respectively, for the endoluminal bypass group versus 78.6%, 73.3%, and 72.0%, respectively, for the surgical bypass group (P = .65). There was no significant difference in secondary patency, freedom from TLR, limb salvage, and overall survival (all P > .05). The subsequent interaction analysis revealed that the involvement of popliteal lesions, small distal reference vessel diameters, and long lesions favored surgical bypass over endoluminal bypass because of improved primary patency (all P for interaction < .05). ConclusionsThe 3-year clinical outcomes after endoluminal bypass or surgical bypass for FP arterial lesions were similar.

Impact of vessel morphology on computed tomography derived fractional flow reserve (FFRCT) in normal coronary artery disease: a novel marker for the predictor of FFRCT changes

Abstract Background Computed tomography (CT) derived fractional flow reserve (FFRCT) decreases continuously from the proximal to the distal segments of the vessel even in normal coronary arteries. It has been empirically proved that the degree of FFRCT decline varies based on vessel morphology even in the same vessel length. Purpose To investigate the vessel morphological factors that influence FFRCT in normal coronary arteries. Methods A total of 1402 outpatients with suspected CAD who underwent CT angiography (CTA) with FFRCT analysis between January 2017 and October 2021 were evaluated. Among them, 234 consecutive patients who underwent both CT angiography including FFRCT and invasive coronary angiography, resulting in &amp;lt;20% stenosis in right coronary artery (RCA) were evaluated. RCA vessels from ostium to just proximal site of the posterior descending branch were analysed and divided into two groups according to distal FFRCT: FFRCT &amp;gt;0.80 (n=219) and FFRCT ≤0.80 (n=15). FFRCT was measured at proximal and distal segments of the RCA. Vessel morphology (vessel length, lumen diameter and volume, and plaque volume) and left ventricular mass were assessed. The ratio of lumen volume and vessel length was defined as the V/L ratio. Results Whereas vessel length was almost the same between FFRCT &amp;gt;0.80 and ≤0.80 (&amp;gt;0.80 vs. ≤0.80, 115.9±17.3 vs. 119.6±28.7 mm), lumen volume (1135.2±369.3 vs. 906.2±362.6 mm3, p&amp;lt;0.05) and V/L ratio (9.8±2.6 vs. 7.5±2.3, p&amp;lt;0.01) were significantly higher in FFRCT &amp;gt;0.80. Distal FFRCT correlated with plaque-related parameters [low-attenuation plaque, intermediate-attenuation plaque, and calcified plaque (CP)] and vessel-related parameters (proximal and distal vessel diameter, vessel length, lumen volume, and V/L ratio). Among all vessel-related parameters, V/L ratio showed the highest correlation with distal FFRCT (r=0.44, p&amp;lt;0.0001) (Figure 1). Multivariable analysis showed that CP volume was the strongest predictor of distal FFRCT (β-coefficient = −0.38, p&amp;lt;0.0001), followed by V/L ratio (β-coefficient = 0.95, p=0.007). V/L ratio was the strongest predictor of a distal FFRCT ≤0.80 (cut-off 8.2, AUC 0.73, sensitivity 66.7%, specificity 69.3%, 95% CI 0.60–0.86) (Figure 2). Conclusions Our study findings suggest that the V/L ratio can be a measure to predict subclinical coronary perfusion disturbance. Funding Acknowledgement Type of funding sources: None.

A novel initial wiring technique for chronic total occlusion of the superficial femoral artery using the structural features of a polymer jacket guidewire

BackgroundTo evaluate the efficacy of the GLadIus MG drilLINg technique (GLIMGLIN), a novel initial wiring technique using the Gladius MG™ structural features, for crossing the superficial femoral artery (SFA) with chronic total occlusion (CTO).MethodsThis retrospective, single-center study enrolled 27 symptomatic patients (mean age 77.4 ± 8.5 years; 20 men) with de novo SFA CTO (mean CTO length 16.1 ± 8.9 cm) who underwent GLIMGLIN as the initial wiring between January 2020 and December 2021. The success of GLIMGLIN was defined when the wire crossing was completed using a Gladius MG™ and a microcatheter without any additional devices and techniques.ResultsThe success rate of GLIMGLIN was 48.1%. Intravascular ultrasound findings showed complete true lumen passage in the GLIMGLIN success group. Compared to the failure group, the proximal (6.3 ± 0.8 vs. 5.5 ± 0.9 mm, p = 0.02) and distal (5.9 ± 0.5 vs. 5.4 ± 0.6 mm, p = 0.02) reference vessel diameters were significantly larger, and the rate of calcium angle > 180° was significantly lower (30.8 vs. 71.4%, p = 0.04) in the success group. No significant difference was shown in the CTO length between two groups. Total wiring time, total procedure time, and fluoroscopic time were significantly shorter in the success group.ConclusionsGLIMGLIN may enable operators to perform CTO wiring easily and efficiently in selected cases.

Impact of Cardiac Function on Loss of Patency in Patients With Peripheral Artery Disease Presenting the Femoropopliteal Lesions Endovascularly Treated With New-Generation Devices

Purpose: The current study sought to investigate the impact of cardiac condition on loss of patency after endovascular therapy (EVT) using new-generation devices for femoropopliteal (FP) lesions. Materials and Methods: We retrospectively studied 547 lesions (chronic limb-threatening ischemia: 44%, TASC II C/D lesion: 61%, chronic total occlusion: 37%, in-stent restenosis: 13%, involving popliteal arterial lesion: 45%) belonging to 416 patients (average age: 75±9 years, male: 69%, diabetes mellitus: 62%, hemodialysis: 33%) who underwent EVT with new-generation FP-specific devices (polymer-free paclitaxel-eluting stent, n=186; stent graft, n=119; fluoropolymer-based paclitaxel-eluting stent, n=29; interwoven stent, n=17; drug-coated balloon, n=196) from June 2012 to May 2019. Cardiac function was evaluated using echocardiography. The primary outcome measure was primary patency, which was defined as free from peak systolic velocity ratio (PSVR) >2.5 assessed by duplex ultrasound. Predictors for loss of patency were evaluated using Cox proportional hazards regression analysis. Results: Overall 12 primary patency were 80.0±1.8%. After the multivariate analysis, reduced stroke volume evaluated by echocardiography (hazard ratio [HR]=0.99, 95% confidence interval [CI]=0.97-0.99, p=0.03), chronic heart failure (HR=1.76, 95% CI=1.05-2.97, p=0.03), and a smaller distal reference vessel diameter (HR=0.73, 95% CI=0.55-0.97, p=0.03) were significantly associated with loss of 12-month primary patency, whereas lesion length (HR=1.01, 95% CI=0.99–1.03, p=0.33) and presence of chronic total occlusion (CTO; HR=0.92, 95% CI=0.61-1.40, p=0.70) were not statistically significant. Conclusion: The current study revealed that cardiac function represented by reduced stroke volume and presence of chronic heart failure as well as a smaller distal reference vessel diameter were significantly associated with loss of 12-month primary patency in patients with peripheral artery disease (PAD) presenting FP lesions endovascularly treated with new-generation devices.

Clinical outcomes and predictors of restenosis in patients with femoropopliteal artery disease treated using polymer-coated paclitaxel-eluting stents or drug-coated balloons.

Both polymer-coated paclitaxel-eluting stents (PC-PESs) and drug-coated balloons (DCBs) are used in conjunction with endovascular therapy (EVT) for the treatment of peripheral artery disease (PAD). We aimed to identify the risk factors for the loss of patency following the use of PC-PES and DCB in a real clinical setting. We assessed the multi-center registry data of 151 lesions from 151 patients who underwent EVT for symptomatic PAD in the superficial femoral and proximal popliteal arteries using PC-PES or DCB. One-year primary patency (PP) and clinically driven target lesion revascularization (CD-TLR) were evaluated using Kaplan-Meier analysis. The predictive risk factors for 1-year outcomes were analyzed using the random survival forest method. PC-PES and DCB were used in 65 (43.0%) and 86 (57.0%) cases, respectively. There were no significant differences in 1-year PP or freedom from CD-TLR between PC-PES and DCB. PP occurred in 85.4% and 80.2% of cases in the PC-PES and DCB groups, respectively (log-rank p = 0.65), while freedom from CD-TLR was noted in 92.7% and 94.1% of cases in the PC-PES and DCB groups, respectively (log-rank p = 0.73). In order of importance, a Clinical Frailty Scale score ≥ 6, female sex, lower proximal vessel diameter, lower body mass index, and younger and older age were identified as predictive risk factors of restenosis in the PC-PES group. Peripheral artery calcification scoring system grade of ≥ 2, post-dissection pattern ≥ D, lower proximal and distal vessel diameter, and lesion length ≥ 100mm were identified as predictive risk factors of restenosis, in order of importance, in the DCB group. Both PC-PES and DCB were associated with favorable clinical outcomes within 1year in patients with femoropopliteal artery disease. Furthermore, several factors that could predict restenosis within 1year following the use of each device were detected.

Three-Year Clinical Outcomes Following Implantation of LifeStent Self-Expanding Nitinol Stents in Patients With Femoropopliteal Artery Lesions.

The aim of this study was to evaluate midterm clinical outcomes after implantation of LifeStent self-expanding nitinol stents for the treatment of femoropopliteal lesions. This retrospective, multicenter, non-randomized study examined 260 femoropopliteal lesions in 250 consecutive patients with peripheral artery disease implanted with LifeStents from April 2016 to April 2017. The prevalence of chronic total occlusion (CTO), lesion length ≥25cm, and distal reference vessel diameter (RVD) <5mm was 58%, 35%, and 50%, respectively. The 3-year restenosis rate in the overall population was estimated to be 72.9% and a major adverse limb event was observed in 36.9%. Multivariate analysis revealed that chronic limb-threatening ischemia (CLTI) (odds ratio [OR]: 8.04; 95% confidence interval [CI]: 1.86-34.7), CTO (OR: 4.87; 95% CI: 1.43-16.6), lesion length ≥25cm (OR: 5.95; 95% CI: 1.11-32.0), and distal RVD <5mm (OR: 4.43; 95% CI: 1.34-14.6) were independent risk factors for 3-year restenosis. The present study demonstrated the midterm clinical outcomes and risk factors for restenosis after implantation of the LifeStent in femoropopliteal artery lesions. CLTI, CTO, lesion length ≥25cm, and distal RVD <5mm predicted decreased patency after a 3-year follow-up.

Prevalence of pathological FFRCT values without coronary artery stenosis in an asymptomatic marathon runner cohort

ObjectivesTo evaluate computed tomography fractional flow reserve (FFRCT) values in distal parts of the coronaries in an asymptomatic cohort of marathon runners without any coronary stenosis for potentially false-positive values.MethodsNinety-eight asymptomatic male marathon runners (age 53 ± 7 years) were enrolled in a prospective monocentric study and underwent coronary computed tomography angiography (CCTA). CCTA data were analyzed for visual coronary artery stenosis. FFRCT was evaluated in 59 participants without coronary artery stenosis in proximal, mid, and distal coronary sections using an on-site software prototype.ResultsIn participants without coronary artery stenosis, abnormal FFRCT values ≤ 0.8 in distal segments were found in 22 participants (37%); in 19 participants in the LAD; in 5 participants in the LCX; and in 4 participants in the RCA. Vessel diameters in participants with FFRCT values > 0.80 compared to ≤ 0.80 were 1.6 ± 0.3 mm versus 1.5 ± 0.3 mm for distal LAD (p = 0.025), 1.8 ± 0.3 mm versus 1.6 ± 0.5 mm for distal LCX (p = 0.183), and 2.0 ± 0.4 mm versus 1.5 ± 0.2 mm for distal RCA (p < 0.001).ConclusionsAbnormal FFRCT values of ≤ 0.8 frequently occurred in distal coronary segments in subjects without any anatomical coronary artery stenosis. This effect is only to some degree explainable by small distal vessel diameters. Therefore, the validity of hemodynamic relevance evaluation using FFRCT in distal coronary artery segment stenosis is reduced.Key Points• Abnormal FFRCT values (≤ 0.8) occurred in over a third of the subjects in the distal LAD despite the absence of coronary artery stenosis..• Therefore, the validity of hemodynamic relevance evaluation in distal coronary artery segment stenosis is reduced.• Decision-making based on abnormal FFRCT values in distal vessel sections should be performed with caution and only in combination with visual assessment of the grade of stenosis..

Flow Diverter Apposition in Patients with Large or Giant Intracranial Aneurysms Evaluated on Three-Dimensional Fusion Images Acquired by High-Resolution Cone-Beam Computed Tomography and Digital Subtraction Angiography

To investigate flow diverter (FD) apposition on fused images acquired by high-resolution cone-beam computed tomography (CBCT) and 3-dimensional (3D) digital subtraction angiography. Patients with large or giant internal carotid artery aneurysms treated with Pipeline FDs who underwent CBCT imaging at our institution between October 2016 and May 2019 were included. Two neurosurgeons measured the maximum malapposition between FDs and vessel walls on 3D fusion images of high-resolution CBCT images displaying the FD and 3D digital subtraction angiography images displaying the vessels. Associations between the relative malapposition, FD diameter, vessel diameter, proximal and distal vessel diameter discrepancy, and siphon angle were evaluated by linear regression analysis. Inter-rater and intermethod (3D and 2D image) agreements of the malapposition measurements were assessed by Bland-Altman analysis and by interclass correlation coefficients. Images of 2 patients were excluded because of image artifacts or fusion errors, and 3D fusion images were acquired in the remaining 26 patients. Our results did not suggest that relative malapposition was associated with vessel diameter (P= 0.12), vessel diameter discrepancy (P= 0.60), or syphon angle (P= 0.34), but relative malapposition increased by an estimated 13% (95% confidence interval: 4%-23%, P= 0.006) for each 1 mm increase in FD diameter. Inter-rater and intermethod agreements for apposition measurements were excellent and good, respectively. Three-dimensional fusion images provided clear visualization of structures of both the stent and parent artery with excellent diagnostic reliability. Careful deployment may be needed for FDs with larger diameters, as they tended to have larger relative malapposition.

A Novel Angiographic Risk Score for Femoropopliteal Interventions

Purpose To present a novel angiographic scoring system that stratifies the risk of restenosis after endovascular therapy (EVT) to inform the decision to use paclitaxel-eluting devices in the femoropopliteal segment. Materials and Methods A prospective, multicenter registry including 1799 limbs of 1578 patients (mean age 74±9 years; 1090 men) with symptomatic peripheral artery disease undergoing intravascular ultrasound–supported femoropopliteal EVT was used as the basis for developing the angiographic score. Multivariable analysis identified baseline patient and limb characteristics associated with restenosis at 12 months. These risk factors for 12-month restenosis were explored using a generalized linear mixed model with a logit-link function in which the inter-institutional and inter-subject variability were treated as random effects. The multiple imputation method was adopted to address missing data. Results of the regression analysis are presented as the odds ratio (OR) with 95% confidence interval (CI). Results Twelve-month primary patency was estimated to be 65.1% (95% CI 62.7% to 67.5%). After multivariable analysis, distal reference vessel diameter per 1 mm (OR 0.71, 95% CI 0.62 to 0.81, p<0.001), lesion length per 10 cm (OR 1.39, 95% CI 1.19 to 1.62, p<0.001), and chronic total occlusion (OR 1.56, 95% CI 1.15 to 2.10, p=0.004) were independently associated with the 12-month restenosis risk, whereas baseline patient risk factors were not. Compared to bare nitinol stent implantation, plain angioplasty (OR 2.31, 95% CI 1.67 to 3.18, p<0.001) was independently associated with a higher risk of 12-month restenosis, while drug-eluting stents (OR 0.65, 95% CI 0.43 to 0.99, p=0.045) and stent-grafts (OR 0.24, 95% CI 0.12 to 0.50, p<0.001) were independently associated with a lower risk of 12-month restenosis. The angiographic score, which was developed by using the 3 angiographic factors but not the TransAtlantic Society Consensus II (TASC) class, was significantly and independently associated with 12-month restenosis. Conclusion The current study demonstrated a novel angiographic score for 12-month restenosis after femoropopliteal EVT in a real-world clinical practice. The developed score was significantly and independently associated with the 12-month restenosis risk, but the TASC class was not.

One-Year Clinical Outcomes following Implantation of InnovaTM Self-Expanding Nitinol Stents in Patients with Peripheral Artery Diseases Presenting Femoropopliteal Artery Lesions.

Aim: Although the Innova™ self-expanding nitinol stent (Boston Scientific, Marlborough, MA) exhibits acceptable performance in long-term safety and efficacy when used for the treatment of femoropopliteal (FP) lesions, clinical outcomes following its implantation have not been systematically studied in real-world settings. We investigated the one-year clinical outcomes after implantation of Innova™ self-expanding nitinol stents for the treatment of FP lesions in real-world settings.Methods: In this multicenter study, 481 lesions in 453 consecutive patients with peripheral artery disease (PAD) (74 ± 9 years; male, 70%; diabetes mellitus, 61%; dialysis, 27%; critical limb ischemia, 37%) who underwent endovascular therapy with the implantation of Innova™ self-expanding nitinol stents for FP lesions were analyzed from February 2016 to April 2017. The primary endpoint was one-year restenosis, whereas the secondary endpoints included one-year major adverse limb events and predictors for one-year restenosis.Results: The mean lesion length was 18 ± 10 cm. One-year restenosis and major adverse limb event rates were 36% and 18%, respectively. Multivariate analysis revealed that the presence of diabetes mellitus (odds ratio [OR]: 1.83; 95% confidence interval [CI]: 1.07–3.13), distal reference vessel diameter (OR: 1.86; 95% CI: 1.09–3.16), spot stenting (OR: 2.27; 95% CI: 1.27–4.06), and lack of one-year cilostazol treatment (OR: 0.58; 95% CI: 0.33–1.00) were independent risk factors for one-year restenosis.Conclusion: The current study demonstrated one-year clinical outcomes after Innova™ self-expanding nitinol stent placement for the treatment of FP lesions, including challenging cases in real-world settings.

TCT-507 Increase of coronary lumen area with improved stent apposition after self-expandable stenting in total occlusions: results of the SPACIOUS pilot study

After successful percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO), distal vessel diameter can increase 12-18% over time, due to recuperation of endothelial and smooth muscle cell function. Increase of diameter might lead to a mismatch of stent size and malapposition.

A hybrid strategy with bioresorbable vascular scaffolds and drug eluting stents for treating complex coronary lesions.

Due to the inherent limitations of current generation BVSs, complex coronary artery disease often contains BVS unsuitable segments. Our aim was to assess the feasibility of a hybrid approach using bioresorbable vascular scaffolds (BVSs) and drug-eluting stents (DESs) for the treatment of complex coronary artery lesions not suitable for a scaffolding only approach. A retrospective multicenter cohort analysis was performed on patients with complex de novo or in-stent restenosis lesions treated with a hybrid BVS (Absorb BVS, Abbott Vascular, Santa Clara, CA) and DES strategy. The primary endpoint was target lesion failure (TLF) defined as a composite of cardiac death, target-vessel myocardial infarction (MI) and target lesion revascularization (TLR). A total of 98 patients (105 lesions) were treated with the hybrid strategy. Isolated long lesions in which either proximal or distal reference vessel diameters were not suitable for BVS were an indication in 36.2% (n=38) of cases. In contrast, 28% (n=29) of lesions treated with the hybrid strategy were bifurcations in which the side branch was predominantly treated with DES (n=28). DES bailout after BVS implantation was an indication in 21.9% (n=23 lesions). The rates of type B2/C and long lesions (>28mm) were 95.2% and 74.3% respectively. The mean total BVS and DES lengths implanted were 37.5±24.1mm and 25.0±14.7mm respectively. The rate of TLF in the overall cohort of patients (median follow-up 405days [interquartile range 189-658]) was 11.4% at 1-year. This was primarily driven by TLR (9.5%), with rates of cardiac death and target vessel MI of 2.1% and 1.4% respectively. No cases of definite or probable BVS/DES thrombosis occurred. In conclusion, the use of a hybrid BVS/DES strategy was feasible and associated with acceptable outcomes at 1-year, considering the length and complexity of lesions treated. Further, larger studies with longer follow-up are needed to confirm our findings.

A Novel Perforator Flap Training Model Using a Chicken Leg.

Living animal models are frequently used for perforator flap dissection training, but no ex vivo models have been described. The aim of this study is to present a novel nonliving model for perforator flap training based on a constant perforator in the chicken leg. A total of 15 chicken legs were used in this study. Anatomical dissection of the perforator was performed after its identification using ink injection, and in four of these specimens a perforator-based flap was raised. The anatomical dissection revealed a constant intramuscular perforator with a median length of 5.7 cm. Median proximal and distal vessel diameters were 0.93 and 0.4 mm, respectively. The median dissection time was 77.5 minutes. This study introduces a novel, affordable, and reproducible model for the intramuscular dissection of a perforator-based flap using an ex vivo animal model. Its consistent perforator and appropriate-sized vessels make it useful for training.

Technology limitations of BRS in bifurcations.

Recommended techniques for bifurcation stenting continue to be revised with specific attention to bioresorbable scaffolds (BRS). Optimal procedural success and long-term outcomes with BRS can perhaps be improved with careful attention to implantation techniques. Good vessel preparation is imperative for optimal expansion of the scaffold, and proper vessel sizing is necessary to ensure compliance with scaffold expansion limits and preservation of proper scaffold function. The European Bifurcation Club (EBC) recommends provisional stenting for the majority of bifurcation lesions: permanent metallic stents are sized according to the distal vessel diameter, with subsequent post-dilatation of the proximal vessel to ensure stent apposition in the proximal main vessel. Recent BRS-specific modifications to the EBC recommendation suggest that selecting the scaffold size based on the diameter of the proximal main vessel can mitigate the risk of overexpansion and potential strut fracture. Expansion of the BRS requires a thoughtful balance between the risk of malapposition associated with underdeployment and the risk of strut fracture due to overdeployment. Post-dilatation of scaffolds should be performed, always respecting the maximum expansion limit, to correct any potential scaffold malapposition and minimise flow disturbances. Finally, dual antiplatelet therapy plays an important role in BRS bifurcation treatment to avoid thromboembolic events.

Avoid overtreatment in the setting of chronic total occlusions: The role of blood flow restoration in positive vascular remodeling

A coronary chronic total occlusion (CTO) promotes negative remodeling in distal segments by negative vascular wall remodeling and plaque growth [ [1] Park J.J. Chae I.H. Cho Y.S. et al. The recanalization of chronic total occlusion leads to lumen area increase in distal reference segments in selected patients: an intravascular ultrasound study. JACC Cardiovasc. Interv. Aug 2012; 5: 827-836 Crossref PubMed Scopus (31) Google Scholar ]. As a result, epicardial coronary segments located distal to a CTO appear often as diffusely diseased arteries [ [2] Werner G.S. Schwarz G. Prochnau D. et al. Paclitaxel-eluting stents for the treatment of chronic total coronary occlusions: a strategy of extensive lesion coverage with drug-eluting stents. Catheter. Cardiovasc. Interv. 2006; 67: 1-9 Crossref PubMed Scopus (46) Google Scholar ]. It is unknown if these lesions are related to clinical events at follow-up and if they require percutaneous coronary intervention (PCI) with stenting, because blood flow restoration by recanalisation potentially leads to positive vascular remodeling in the distal reference segments [ [3] Gasparini G.L. Rossi M.L. Presbitero P. Follow-up improvement of distal vessel diameter after successful chronic total coronary occlusion recanalization. JACC Cardiovasc. Interv. Apr 2014; 7: e31-e33 Crossref PubMed Scopus (4) Google Scholar ]. Few data have been published to investigate the role of blood flow restoration in remodeling process after successful CTO PCI. A study of Park et al. [ [1] Park J.J. Chae I.H. Cho Y.S. et al. The recanalization of chronic total occlusion leads to lumen area increase in distal reference segments in selected patients: an intravascular ultrasound study. JACC Cardiovasc. Interv. Aug 2012; 5: 827-836 Crossref PubMed Scopus (31) Google Scholar ] showed that recanalization of a CTO led to lumen area increase in two-thirds of the patients. Independent predictors of lumen area increase were occlusion duration, a poor collateral flow and statin use. The degree of collateral flow might reflect the magnitude of hemodynamic stimuli deprivation, whereas the CTO duration correlates with the time in which vessels undergo a negative remodeling process. In a study of Galassi et al. [ [4] Galassi A.R. Tomasello S.D. Crea F. et al. Transient impairment of vasomotion function after successful chronic total occlusion recanalization. J. Am. Coll. Cardiol. Feb 21 2012; 59: 711-718 Crossref PubMed Scopus (70) Google Scholar ] authors have suggested that improvement of distal vessel diameter after CTO recanalization can be explained by an impaired endothelium-dependent and/or -independent vasomotion immediately after CTO recanalization, that improves at follow-up, or by a positive remodeling or by a combination of both. Gomez-Lara et al. [ [5] Gomez-Lara J. Teruel L. Homs S. et al. Lumen enlargement of the coronary segments located distal to chronic total occlusions successfully treated with drug-eluting stents at follow-up. EuroIntervention. Feb 2014; 9: 1181-1188 Crossref PubMed Scopus (32) Google Scholar ] have documented a notable late lumen enlargement between baseline and follow-up. These findings can be explained either by the absence of vasomotor response to non-endothelium-mediated stimuli immediately after the procedure and plaque regression. At follow-up, endothelium-independent response was restored in most patients, showing a remarkable luminal gain compared to the index procedure.

Follow-Up Improvement of Distal Vessel Diameter After Successful Chronic Total Coronary Occlusion Recanalization

Chronic total occlusion (CTO) of a coronary artery promotes negative remodeling in distal reference segments by negative vascular wall remodeling and plaque growth. Restoring blood flow by recanalization potentially leads to positive vascular remodeling. We present the case of a 53-year-old man, a

TCT-599 Enlargement of Distal Vessel Diameter after Percutaneous Coronary Intervention of Chronic Total Occlusion - Relationship with Collateral Flow and Intravascular Ultrasound Findings

Background: Although the vessel diameter distal to the recanalized CTO lesion is often smaller than expected immediately after recanalization, the vessel tends to increase their diameter after one year. Therefore, we assessed how the distal segment vessel diameter would increase at 1-year follow-up. Methods: Consecutive patients (n1⁄488) who received successfully recanalization of CTO lesions from July 2007 to September 2011 and had 1-year follow-up catheterization were analyzed. We classified them into two groups by the Rentrop collateral flow grade: Group A, grade 0 to 2 and Group B, grade 3. We evaluated by IVUS the plaque burden and minimum lumen diameter of the distal vessel segment immediately after recanalization. Vessel diameter distal to the recanalized CTO lesions (at 10mm from distal stent edge) was compared between follow-up and immediately after recanalization (baseline) by quantitative coronary angiography. Results: Vessel diameter increased significantly from baseline to follow-up (2.0 0.7mm vs. 2.4 0.7mm, P<0.05). Vessel diameter increased more in Group B than in Group A (76.9% vs. 94.3%mm P<0.05). There was no significant difference in IVUS findings between the patients with and without vessel diameter increase. Conclusions: Vessel diameter in the distal segment of CTO lesion increased at 1-year follow-up especially in the patients with good collateral flow.