Longer Lesions Research Articles

Atherectomy Followed by Drug-Coated Balloon Angioplasty Versus Surgery for Symptomatic Deep Femoral Artery Arteriosclerotic Disease.

Limited data are available regarding endovascular therapy of arteriosclerotic lesions of the deep femoral artery (DFA). In this study, we compare the outcomes of atherectomy combined with drug-coated balloon (DCB) angioplasty and open repair of DFA lesions. This is a multicenter retrospective registry of patients with peripheral artery occlusive disease Rutherford categories 2 to 5 treated by surgical profundaplasty (SP) or atherectomy followed by DCB for DFA lesions (symptomatic DFA). The primary endpoint was clinically driven target lesion revascularization (CD-TLR). Overall mortality, target limb reinterventions, major amputation, and major adverse limb events (MALEs) were additionally analyzed. A total of 373 patients treated for an arteriosclerotic lesion of the DFA between February 2015 and August 2021 were included, 301 treated by SP and 72 with atherectomy and DCB. The rates of chronic limb threatening ischemia (CLTI) were 42.2% and 22.2% (p<0.002) for the surgical and endovascular groups, respectively. A previous DFA intervention was more frequent in the endovascular group (30.6% vs 15.3%; p<0.003). Patients who had an open repair were more likely to have an occlusion of the profunda (34.9% vs 19.7%, p=0.014), severe calcified lesions (26.5% vs 5.6%, p=0.001), and lesions longer than 20 mm (95.7% vs 88.7%, p=0.024). After propensity score matching, no significant differences were found with regard to technical and hemodynamic success. At 24 months, no difference was found in terms of freedom from CD-TLR (95.7% vs 96.8%), freedom from all-cause mortality (94.2% vs 98.5%), freedom from MALE (90.4% vs 93.9%), and amputation-free survival (93.8% vs 97%). Following endovascular therapy, length of stay was significantly lower (p<0.001) and any reintervention on the index limb was more frequent (p=0.039). Patients with CLTI, occlusion of profunda, severe calcified lesions, and longer lesions are more frequently treated by open surgery, while reinterventions are more commonly treated by atherectomy and DCB. In patients with comparable clinical and lesion characteristics after matching, endovascular and surgical reconstruction of DFA lesions showed similar mid-term clinical outcomes. However, the risk of reintervention at the index limb is higher after endovascular treatment. Randomized studies are now warranted to compare both techniques in terms of medical and financial aspects. Atherectomy followed by DCB of symptomatic DFA is safe and effective. In patients with comparable clinical and lesion characteristics, outcomes are comparable with surgery. However, the risk of reintervention at the index limb is higher after endovascular treatment. Therefore, whenever possible an additional outflow vessel revascularization should be performed by the time of the primary intervention. Randomized studies are warranted to compare endovascular techniques and open surgery also under economic aspects.

Impact of prolonged drug-coated balloon inflation on residual stenosis and clinical outcomes in coronary artery disease patients: A propensity score matched analysis.

There is a paucity of data regarding the optimal duration of drug-coated balloon (DCB) inflation for coronary lesions. We sought to explore the effect of DCB angioplasty with versus without long inflation time on residual stenosis and clinical outcomes in patients with coronary artery disease. This study included 314 consecutive patients with 445 lesions undergoing paclitaxel DCB angioplasty using different inflation time, divided according to whether the total inflation time of the DCB was ≥180 s (prolonged group) or <180 s (standard group). The primary clinical endpoint, defined as a composite of all-cause death, myocardial infarction, stroke, or target lesion revascularization, was examined in 92 propensity score matched pairs. In the matched cohort, the median clinical follow-up period was 947 days. Postprocedural angiographic diameter stenosis was smaller in the prolonged group than in the standard group (30.0% [22.0-37.0] vs. 33.5% [25.5-40.5]; p = 0.042). Intravascular ultrasound measurements revealed that longer DCB inflation time resulted in smaller area stenosis (66.6 ± 7.8% vs. 69.4 ± 7.0%; p = 0.044) and a less mean increase in percent atheroma volume (-11.2 ± 7.1% vs. -7.4 ± 5.9%; p = 0.004) after angioplasty. The rate of the primary endpoint was lower in the prolonged group than in the standard group (log-rank p = 0.025). The efficacy of prolonged DCB inflation was prominent in patients with in-stent restenosis and longer lesions. Prolonged DCB inflation was associated with reduced residual stenosis and improved clinical outcomes in patients with coronary artery disease undergoing percutaneous coronary intervention. Prospective randomized trials are warranted to validate the benefits of DCB angioplasty with long inflation time.

Wide Distribution and Intraspecies Diversity in the Pathogenicity of Calonectria in Soil from Eucalyptus Plantations in Southern Guangxi of China.

Eucalyptus spp. are extensively cultivated in southern China because of their adaptability and versatile timber production. Calonectria leaf blight caused by Calonectria species is considered a major threat to Eucalyptus trees planted in China. The GuangXi Zhuang Autonomous Region is the provincial region with the largest distribution of Eucalyptus plantations in China. The present study aimed to expound the species diversity and pathogenicity of Calonectria isolates obtained from the soil of Eucalyptus plantations in GuangXi. A total of 188 Calonectria isolates were recovered from the soil located close to Eucalyptus trees, and the isolates were identified based on the DNA sequence comparisons of the four partial regions of the translation elongation factor 1-alpha (tef1), β-tubulin (tub2), calmodulin (cmdA), and histone H3 (his3) genes. The isolates were identified as Calonectria aconidialis (74.5%), C. hongkongensis (21.3%), C. pseudoreteaudii (2.1%), C. kyotensis (1.6%), and C. chinensis (0.5%). The inoculation results indicated that 40 isolates representing five Calonectria species were pathogenic to the three Eucalyptus genotypes. Two inoculated experiments consistently showed that the longest lesions were produced by the isolates of C. aconidialis. Some isolates of C. aconidialis, C. hongkongensis, and C. kyotensis produced significantly longer lesions than the positive controls, but not the isolates of C. pseudoreteaudii or C. chinensis. These results indicated that Calonectria isolated from the soil may pose a threat to Eucalyptus plantations. Some Calonectria isolates of the same species differed significantly in their virulence in the tested Eucalyptus genotypes. The resistance of different Eucalyptus genotypes to Calonectria isolates within the same species was inconsistent. The inoculation results in this study suggested that many Calonectria isolates in each species had different levels of pathogenicity, and many Eucalyptus genotypes need to be tested to select disease-resistant Eucalyptus genetic materials in the future. The results of the present study enhance our knowledge of species diversity and the potential damage caused by Calonectria in the soil of Eucalyptus plantations. Our results also provide new insights into the breeding of disease-resistant Eucalyptus genotypes for controlling Calonectria leaf blight in China in the future.

Linear epicardial cryoablation effects in a porcine model: Lesion characteristics and vascular risk.

Cryoablation in open-chest surgical interventions for ventricular arrhythmias has been reported with reasonable procedural outcomes. However, the characteristics of cryoablation lesions on the ventricular myocardium are not well defined. The purpose of the present study was to determine the tissue and vascular effects of a linear epicardial cryoablation probe in a porcine animal model. Five adult Yorkshire swine underwent median sternotomy and application of linear cryoablation lesions using a malleable aluminum linear cryoablation probe of varying duration (2, 3, 4, and 5 min), including one lesion placed intentionally over the left anterior descending coronary (LAD) artery. Histological analysis was performed. Maximum lesion depth was approximately 1.0 cm with 3 min freezes, with no significant increase in depth achieved with longer lesions. No transmural lesions were achieved. No large vessel epicardial coronary artery injuries were seen to the LAD; however, surprisingly, remote isolated interventricular septal injury was seen in all animals, suggestive of possible compromise of smaller coronary arterial vessels. Single application freezes with an aluminum linear cryoablation probe can create homogeneous ablative lesions over the ventricular myocardium with a maximum depth of approximately 1.0 cm. No large vessel injury occurred with direct lesion application of the LAD; however, small coronary vessels may be at risk.

The natural history of chronic limb-threatening ischemia after technical failure of endovascular intervention

ObjectivesThe treatment for chronic limb-threatening ischemia (CLTI) has changed dramatically in the last few decades with a shift toward an endovascular-first approach and aggressive revascularization to achieve limb salvage. As the size of the CLTI population and intervention rates increase, patients will continue to experience technical failure (TF). Here, we describe the natural history of patients after TF of endovascular intervention for CLTI. MethodsWe conducted a retrospective cohort study of patients with CLTI who attempted endovascular intervention or bypass at our multidisciplinary limb salvage center from 2013 to 2019. Patient characteristics were collected according to the Society for Vascular Surgery’s reporting standards. Primary outcomes included survival, limb salvage, wound healing, and revascularization patency. Product-limit Kaplan-Meier estimated survival functions for these outcomes, and between-group comparisons were made using Mantel-Cox log-rank nonparametric tests. ResultsWe identified 242 limbs from 220 unique patients who underwent primary bypass (n = 30) or attempted endovascular intervention (n = 212) at our limb salvage center. Endovascular intervention was a TF in 31 (14.6%) limbs. After TF, 13 limbs underwent secondary bypass and 18 limbs were managed medically. Patients who experienced TF tended to be older (P < .001), male (P = .003), current tobacco users (P = .014), have longer lesions (P = .001), and have chronic total occlusions of target arteries (P < .001) as compared with those who experienced technical success. Furthermore, the TF group had worse limb salvage (P = .047) and slower wound healing (P = .028), but their survival was not different. Survival, limb salvage, and wound healing were not different in patients who received secondary bypass or medical management after TF. The secondary bypass group was older (P = .012) and had a lower prevalence of tibial disease (P = .049) than the primary bypass group and trended toward decreased survival, limb salvage, and wound healing (P = .059, P = .083, and P = .051, respectively). ConclusionsIncreased age, male sex, current tobacco use, longer arterial lesions, and occluded target arteries are associated with TF of endovascular intervention. Limb salvage and wound healing are relatively poor after TF of endovascular intervention, but survival appears comparable with patients who experience technical success. Secondary bypass may not always rescue patients after TF, though our sample size limits statistical power. Interestingly, patients who received a secondary bypass after TF trended toward decreased survival, limb salvage, and wound healing compared with primary bypass.

Stenting performs better than drug-coated balloon angioplasty in popliteal lesions

BackgroundPeripheral arterial disease (PAD) is a common and highly morbid disease. Although there have been recent advancements in the endovascular modalities to treat PAD, comparisons of these strategies, especially in the popliteal region, remain underinvestigated. The objective of this study was to compare midterm outcomes in patients with PAD undergoing treatment with both novel and SS compared with drug-coated balloon (DCB) angioplasty. MethodsAll patients at a multi-institution health system treated for PAD in the popliteal region from 2011 to 2019 were identified. Presenting features, operative details, and outcomes were included in the analysis. Patients who underwent popliteal revascularization with stents were compared with DCB. SS were compared separately with novel dedicated stents. Two-year primary patency was the primary outcome. ResultsWe included 408 patients (72.7 ± 11.8 years old; 57.1% men) in the analysis. There were 221 (54.7%) patients who underwent popliteal stenting and 187 (45.3%) who underwent popliteal DCB. There were high rates of tissue loss in both groups (57.9% vs 50.8%; P = .14). Stented patients had longer lesions (112.4 ± 3.2 vs 100.2 ± 5.8 mm; P = .03) and higher rates of concomitant superficial femoral artery treatment (88.2% vs 39.6%; P < .01). Chronic total occlusions accounted for the majority of lesions treated (stent 62.4%, DCB 64.2%). Perioperative complications were similar between groups. Primary patency for the stented group was higher at two years than the DCB group (61.0% vs 46.1%; P = .03). When evaluating stented patients only, SS had higher 2-year patency than novel stents in the popliteal segment (69.6% vs 51.4%; P = .04). On multivariable analysis, stenosis, as opposed to chronic total occlusion, was associated with improved patency (hazard ratio, 0.49; 95% confidence interval, 0.25-0.96; P = .04), whereas novel stents were associated with worse primary patency (hazard ratio, 2.01; 95% confidence interval, 1.09-3.73; P = .03). ConclusionsIn a population of patients with severe vascular disease, stents do not have inferior patency and limb salvage rates compared with DCB angioplasty when treating the popliteal region. For patients with advanced vascular disease, and especially tissue loss, stents and DCB are both beneficial when treating popliteal lesions.

Clinical Implications of the “Broken Line” Angiographic Pattern in Patients With Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized cause of acute myocardial infarction. Coronary angiography remains the best diagnostic tool; however, clinical suspicion and experience is required to interpret angiographic findings. This study sought to assess the clinical implications of the "broken line" (BKL) angiographic pattern in a large, nationwide, cohort of patients with SCAD. The Spanish SCAD registry (NCT03607981) prospectively enrolled consecutive patients with SCAD. All angiograms were centrally analyzed and the BKL pattern was systematically assessed. The BKL angiographic pattern was found in 64 of 389 patients (16%). Patients with the BKL appearance were more frequently female (97 vs 87%, p <0.05), presented more often as intramural hematoma (83 vs 58%, p <0.001), had longer lesions (47 ± 29 vs 36 ± 22 mm, p <0.01), and had severe tortuosity (25 vs 10%, p <0.01) but showed better initial coronary flow (thrombolysis in myocardial infarction flow 2.6 ± 0.8 vs 2.1 ± 1.2, p <0.01). Patients with BKL received more frequently conservative medical management (91 vs 76%, p <0.01). At late clinical follow-up (median 29 months, interquartile range 17 to 38) predefined adverse events (death, myocardial infarction, revascularization, recurrent SCAD, or stroke) occurred less frequently (3.5 vs 15%, p <0.05) in patients with the BKL appearance. The better clinical outcomes of patients in the BKL group persisted after adjusting for potential confounders (adjusted hazard ratio 0.2, 95% confidence interval 0.1 to 0.9, p <0.05). In conclusion, patients with SCAD presenting the BKL angiographic pattern are more frequently female and present more often as intramural hematoma with longer lesions and severe vessel tortuosity but have better coronary flow. Patients with the BKL morphology have a favorable prognosis (NCT03607981).

The Effect of Local Anesthetics and Contrast Agents on Radiofrequency Ablation Lesion Size.

Radiofrequency ablation (RFA) is a validated treatment option for the treatment of chronic pain in patients with lumbar spondylosis. Lesion size has been suggested to correlate with good clinical outcomes. This has created an abundance of scientific interest in the development of products with larger lesion characteristics. Needle characteristics, energy transfer, and heat rate are known to modify lesion size. Here, we demonstrate that common intraoperative solutions, such as lidocaine, iodine, and gadolinium-based products, can also affect lesion shape. To determine whether lidocaine and contrast agents modify lesion characteristics during the performance of monopolar RFA. Controlled, ex vivo study using clinically relevant conditions and pre-injections. Academic institution in a procedural setting. RFA lesion size was compared among six cohorts: 1) lidocaine 1%, 2) lidocaine 2%, 3) iohexol 180, 4) iohexol 240, 5) gadodiamide, and 6) control (no fluid control). Radiofrequency (RF) current was applied for 90 seconds at 80°C via 20-gauge 100-mm standard RFA needles with 10-mm active tips in orgranic chicken breasts without preservative at room temperature (21°C). Twelve lesions were performed for each medication cohort. The length, width, and depth of each lesion were measured. The statistical significance between each medication group and the control group was evaluated by t test. The mean lesion surface area of monopolar RFA without any pre-injection used was 80.8 mm2. The mean surface area of the monopolar RF lesion with a pre-injection of 0.2 mL of 2% lidocaine was 114 mm2, and the mean surface area of the monopolar RF lesion with a pre-injection of 0.2 mL of iohexol240 was 130.6 mm2. The statistical analysis demonstrated that the control group had significantly smaller lesion sizes than did the groups in which lidocaine 2% and iohexol240 were used (P<0.01). There were no statistically significant differences among the groups in which lidocaine 1%, iohexol180, and gadodiamide were used. A notable difference was a 20% longer lesion with iohexol240 compared with the control group and a 20% wider lesion with lidocaine 2% compared with the control group. In vivo anatomy within a human was not used in this study, nor were the chicken breasts heated to physiological temperature. Randomization of pieces of chicken breast did not occur, and thus intrinsic differences among the chicken breast pieces could play a confounding role. Lidocaine 2% and iohexol240, when used as pre-injections in RFAs, were found to be associated with statistically significant increases in lesion surface area. However, RFAs with lidocaine 1%, iohexol180, or gadodiamide were not found to produce a statistically significant difference in lesion size compared with monopolar RFA without the use of injectate.

Atherosclerotic plaque characteristics on quantitative coronary computed tomography angiography associated with ischemia on positron emission tomography in diabetic patients

Patients with diabetes mellitus (DM) may show diffuse coronary artery atherosclerosis on coronary computed tomography angiography (CTA). The present study aimed at quantification of atherosclerotic plaque with CTA and its association with myocardial ischemia on positron emission tomography (PET) in DM patients. Of 922 symptomatic outpatients without previously known coronary artery disease who underwent CTA, 115 with DM (mean age 65 ± 8 years, 58% male) who had coronary atherosclerosis and underwent both quantified CTA (QCTA) and PET were included in the study. QCTA analysis was performed on a per-vessel basis and the most stenotic lesion of each vessel was considered. Myocardial ischemia on PET was based on absolute myocardial blood flow at stress ≤ 2.4 ml/g/min. Of the 345 vessels included in the analysis, 135 (39%) had flow-limiting stenosis and were characterized by having longer lesions, higher plaque volume, more extensive plaque burden and higher percentage of dense calcium (37 ± 22% vs 28 ± 22%, p = 0.001). On univariable analysis, QCTA parameters indicating the degree of stenosis, the plaque extent and composition were associated with presence of ischemia. The addition of the QCTA degree of stenosis parameters (x2 36.45 vs 88.18, p < 0.001) and the QCTA plaque extent parameters (x2 88.18 vs 97.44, p = 0.01) to a baseline model increased the association with ischemia. In DM patients, QCTA variables of vessel stenosis, plaque extent and composition are associated with ischemia on PET and characterize the hemodynamic significant atherosclerotic lesion.

Impact of Clinical and Morphological Factors on Long-Term Mortality in Patients with Myocardial Bridge.

Although myocardial bridging (MB) has been intensively investigated using different methods, the effect of bridge morphology on long-term outcome is still doubtful. We aimed at describing the anatomical differences in coronary angiography between symptomatic and non-symptomatic LAD myocardial bridges and to investigate the influence of clinical and morphological factors on long-term mortality. In our retrospective, long-term, single center study we found relevant MB on the left anterior descendent (LAD) coronary artery in 146 cases during a two-year period, when 11,385 patients underwent coronary angiography due to angina pectoris. Patients were divided into two groups: those with myocardial bridge only (LAD-MBneg, n = 78) and those with associated obstructive coronary artery disease (LAD-MBpos, n = 68). Clinical factors, morphology of bridge by quantitative coronary analysis and ten-year long mortality data were collected. The LAD-MBneg group was associated with younger age and decreased incidence of diabetes mellitus, as well as with increased minimal diameter to reference diameter ratio (LAD-MBneg 54.5 (13.1)% vs. LAD-MBpos 46.5 (16.4)%, p = 0.016), while there was a tendency towards longer lesions and higher vessel diameter values compared to the LAD-MBpos group. The LAD-MBpos group was associated with increased mortality compared to the LAD-MBneg group. The analysis of our data showed that morphological parameters of LAD bridge did not influence long-term mortality, either in the overall population or in the LAD-MBneg patients. Morphological parameters of LAD bridge did not influence long-term mortality outcomes; therefore, it suggests that anatomical differences might not predict long-term outcomes and should not influence therapy.

Drug-coated Balloon Angioplasty Versus Drug-eluting Stenting for Femoropopliteal Arterial Disease: A Review of the Current Status

Endovascular procedures are frequently performed for symptomatic femoropopliteal disease. Drug-eluting stents (DES) and drug-coated balloons (DCB) were introduced to improve long-term outcomes and demonstrated superior outcomes to percutaneous transluminal angioplasty in randomised clinical trials. Femoropopliteal disease, however, can be challenging to treat using an endovascular approach as this segment suffers increased biomechanical stress during extremity movements, which may lead to chronic vascular injury or even stent fracture. The advantages of DCB include the direct and homogeneous delivery of an antiproliferative agent to the arterial wall, and the ability to reach tortuous and longer lesions without a vascular implant; however, the lack of scaffold makes the intervention prone to significant recoil. Even though the use of DCB, a leave-nothing-behind strategy, may appear desirable, the need for bailout stenting will increase as lesions become more complex. This review summarises and compares the currently available evidence regarding the use of DCB and DES in the treatment of femoropopliteal disease.

Mid-term mortality after stenting of distal left main stenosis with regular, third generation drug eluting stent or dedicated bifurcation stent or surgery-registry based,all-comers data

Abstract Background Distal left main (LM) bifurcation lesions remain a challenge for interventional cardiologists and they are associated with significant morbidity and mortality. The aim of the current study was to identify predictors of cardiac mortality at mid-term follow up after PCI (DES vs. dedicated bifurcation stent) or CABG. Methods All patients with distal LM stenosis ≥50% were included in prospective registry starting from 01.2015. The exclusion criteria for registry are cardiogenic shock, a priory life expectancy duration &amp;lt;1 year, lack of inform consent. All patients were prospectively followed about the alive status through the national security number data base. All deaths were deemed cardiac if proof otherwise (the data patient families or family's physicians were contacted through phone call about the reason of death) Results For three year follow up period (median 35 months, IQR 18–50) 303 patients were included. 220 patients were stented with 3rd generation DES, 43 with dedicated bifurcation stent BiOSS (Balton, Poland), and rest were sent for CABG. The mean age was 67±10 years, 72% were males, 37% diabetics, all with hypertension, 97% dyslipidemia, 15% PAD, 9% COPD, 16% carotid artery disease, previous MI 28%, previous PCI 50% - without significant difference between three groups. The frequency of acute coronary syndrome during admission was 11% - without difference in frequency between groups. The patient referred to CABG had significantly lower left ventricular EDV and ESV, more severe mitral regurgitation and kinetic disturbances, higher SYNTAX score and longer lesion length. On univariate COX regression analysis, the following factors were associated with mortality: age, NYHA class, GFR, baseline troponin, hemoglobin, LV EF, mitral regurgitation, kinetics disturbances, treatment with beta blockers, ACE inhibitors, statin, atrial fibrillation, SYNTAX score, lesion length. The type of treatment was not associated with differences in mortality (figure). On COX multiple regression survival analysis independent predictors of survival were: age (HR=1.036, CI 1.005–1.068, p=0.023); COPD (HR=2.313, CI 1.170–4.572, p=0.016); GFR (HR=0.988, CI 0.978–1.000, p=0.048); hemoglobin (HR=0.970, CI 0.955–0.986, p=0.000); left ventricular EF (HR=0.958, CI 0.832–0.985, p=0.003). Conclusions The type of treatment was not associated with mid-term mortality. Our data demonstrate that dedicated bifurcation stent could be used safely for distal LM stenosis treatment with similar safety as 3rd generation DES. Funding Acknowledgement Type of funding sources: None.

Risk factors and frequency of postprocedural hemodynamic instability after carotid artery stent placement

The frequency, risk factors and long term consequences of reflexive postprocedural hypotension (PH) following carotid artery stenting (CAS) are not well known. Prospective analysis of 30 patients with 6-month follow-up undergoing CAS with an emboli-protection device was performed. A validated 24-hour ABPM was taken 24 hours before and after CAS. PH was defined as systolic blood pressure (SBP) &lt;90 mm Hg, or decrease in mean arterial BP (MAP) of ≥20% or systolic BP (SBP) of ≥30 mm Hg of baseline BP reading. Neurological assessments were performed 24 hours after CAS and at 6 month follow-up visit. Median age was 69 years, 70% were male, 86% of patients had symptomatic carotid stenosis. Twenty patients (67%) experienced PH, 43% had transient bradycardia, 30% had both PH and bradycardia. The cumulated postprocedural mean SBP and DBP decreased from baseline 128/67 mm Hg to 108/54 mm Hg (p &lt;0.01), mean day (69/min) and night HR (58/min) decreased to respectively 58/min and 49/min (p &lt;0.01). We found no association of PH with age, ischemic heart disease, bifurcation involvement, balloon size, inflation pressure, longer lesion length. Patients with PH significantly (p &lt;0.05) less often were treated with Ca-antagonist (25% vs 70%), more often had ipsilateral ulcerated plaque (85% vs 50%) and had hemodynamically significant stenosis of contralateral ICA (60% vs 30%). During 6 month follow-up only 1 case of neurological deterioration was noticed. PH was a common phenomenon after CAS, however it did not result in neurological complications. Patients at risk can be possibly identified through clinical and angiographic variables.

Imaging Features of Symptomatic MCA Stenosis in Patients of Different Ages: A Vessel Wall MR Imaging Study.

The prevalence of intracranial artery stenosis is high in Asian people. This study aimed to investigate whether there are differences in the imaging features of symptomatic MCA stenosis in patients of different ages using vessel wall MR imaging. We retrospectively reviewed the data of consecutive patients with unilateral MCA stenosis based on a prospectively established vessel wall MR imaging data base between January 2017 and December 2018. According to age, the patients were divided into the young group (18-45 years of age) and the middle-aged and elderly group (older than 45 years of age). Overall, 131 patients with unilateral MCA stenosis were included (45.8% in the young group and 54.2% in the middle-aged and elderly group). Middle-aged and elderly patients had a higher prevalence of hypertension (P = .01) and diabetes (P = .05). The lesion length (P < .0001), proportion of circular involvement (P = .006), and proportion of circular enhancement (P = .03) were higher in the young group than in the middle-aged and elderly group. The analysis of the atherosclerotic subgroup showed that compared with middle-aged and elderly patients, young patients had longer lesions (P = .002). The atherosclerotic-versus-nonatherosclerotic subgroup analysis showed that the maximal wall thickness in the patients with atherosclerosis was larger than that of patients without it (P = .002). Compared with the middle-aged and elderly group, young patients with MCA stenosis tended to have longer lesions and more circular wall involvement and circular enhancement, which may indicate the differences in underlying vascular pathophysiologic and developmental mechanisms in symptomatic MCA stenosis.

Predictors of Carotid Artery Stenting-Induced Hemodynamic Instability.

To address the predictors of hemodynamic instability (HI) related to carotid artery stenting (CAS) and evaluate the association between HI and periprocedural adverse outcomes. This study comprised all consecutive patients who underwent CAS for atherosclerotic carotid artery stenosis from March 2014 to May 2018. A standardized dose of atropine (0.4 mg) was given prior to stent deployment. Changes in heart rate, blood pressure, and neurological status were monitored and recorded. Potential predictors of HI were tested in multivariate analysis using binary logistic regression model. A total of 728 patients were enrolled. Two hundred twenty seven patients (31.2%) developed periprocedural HI. The presence of hypertension (OR, 2.037; 95% CI, 1.292-3.211; P = 0.0022), symptomatic carotid lesions (OR, 1.704; 95% CI, 1.057-2.747; P = 0.0287), right sided lesions (OR, 3.090; 95% CI, 1.934-4.935; P ≤ 0.0001), hyperechoic/calcified plaques (OR, 2.195; 95% CI, 1.458-3.304; p P = 0.0002), and longer lesions (OR, 1.043; 95% CI, 1.012-1.076; P = 0.0072) were significant predictable factors for the occurrence of HI. On the other hand, smoking was significantly associated with a 48.1% decrease in risk of development of HI (OR, 0.519; 95% CI, 0.358-0.754; P = 0.0006). There were no statistically significant differences in periprocedural morbidity or mortality between patients with and without HI. HI occurs in a considerable percentage of patients undergoing CAS. Hypertension, right sided, symptomatic carotid lesions, calcified plaques, and longer lesions were shown to be independent risk factors for the development of periprocedural HI. Conversely, smoking demonstrated a protective effect. HI did not appear to predispose to periprocedural adverse events.

A138 ENDOSCOPIC SUBMUCOSAL DISSECTION FOR BARRETT’S NEOPLASIA IN A NORTH AMERICAN ACADEMIC CENTRE

Abstract Background Endoscopic submucosal dissection (ESD) is carving out an increasing role in the treatment of Barrett’s associated neoplastic lesions. Though endoscopic therapy is classically performed with endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA), ESD provides the advantage of en-bloc resections, and greater R0 resection rates, which are defined as negative deep and lateral margins on histology. Aims Our aim is to present procedural outcomes and subgroup analysis from one of the largest single centre cohorts of esophageal ESD in North America, and the first from Canada. Methods All patients undergoing esophageal ESD for Barrett’s neoplasia between Oct 2016 and June 2020 at a single tertiary care centre in Canada were included in the cohort. Demographic, procedural data and lesion characteristics are presented. Subgroup analysis was performed on patients who underwent extensive resection (≥75% of esophageal circumference) and patients who developed strictures. Statistical analysis included chi square testing on categorical variables and unpaired t-test for continuous variables. Binomial univariable logistic regression was performed to investigate factors associated with stricture formation. Results Thirty-four patients underwent esophageal ESD for Barrett’s associated neoplasia during the study period. The median lesion diameter was 5.7 cm (IQR 4.2 -7.5) and median procedure time 129 min (IQR 66–200). The en-bloc resection rate was 97%, and the R0 resection rate was 91%. Curative resection was achieved in 82% of patients. Upstaging from the pre-resection biopsy to post-ESD histology occurred in 59% of cases. Two adverse events occurred (1 delayed bleed, 1 aspiration event). There were no perforations. Procedural outcomes were similar between patients with extensive resections, but patients with ≥75% circumferential resection developed more strictures (65% vs 13%, p=0.001). Stricture formation was associated with extensive resection (OR 15.4, 95%CI[2.50 - 95.01]) and longer lesion diameter (OR 1.73, 95%CI [1.11 - 2.70]). Conclusions Our experience with ESD for Barrett’s related neoplasia shows excellent en-bloc and R0 resection rate, and provides more accurate histological specimens. Curative resection is possible in the vast majority of cases, including those with extensive resections. Further investigation into stricture prophylaxis will be useful as larger resections are attempted. Funding Agencies None

Laboratory Assays Used to Rank Potato Cultivar Tolerance to Blackleg Showed That Tuber Vacuum Infiltration Results Correlate With Field Observations.

Seed potato certification data collected in Colorado from 2012 to 2016 was used to rank potato cultivar tolerance to blackleg. Five cultivars with different tolerance levels to blackleg ('Chipeta' ≈ 'Alegria' ≈ 'Lamoka' < 'Classic Russet' < 'Yukon Gem') were tested to determine whether we could validate field data with laboratory assays. A strain isolated from Colorado, Pectobacterium atrosepticum CW1-4, and the P. atrosepticum type strain, 33260, were used to inoculate plants through vacuum infiltration of tubers or stem inoculation. Disease was assessed with time-lapse video and by measuring lesion length and disease incidence. After vacuum infiltration of tubers with P. atrosepticum CW1-4 and 33260, cultivars varied in tolerance to soft rot ('Lamoka' < 'Classic Russet' < 'Alegria' ≈ 'Yukon Gem' < 'Chipeta'). Blackleg tolerance of the five cultivars also varied after vacuum infiltration ('Lamoka' < 'Alegria' ≈ 'Chipeta' < 'Classic Russet' ≈ 'Yukon Gem'). All cultivars were susceptible after stem inoculation with either strain. In this assay, 'Chipeta' had the longest lesions, and 'Lamoka' had the smallest lesions. Time-lapse video was used to assess 'Classic Russet' and 'Yukon Gem.' 'Yukon Gem' developed disease symptoms faster than 'Classic Russet,' but the difference was not significant. These results indicate that relative susceptibility of the five cultivars to P. atrosepticum depends on the assay used and that laboratory and greenhouse results differed from field observations.

Abstract 15409: The Need for Lesion-specific Stent Optimization Criteria in Intravascular Ultrasound-guided Intervention for Diffuse Long Coronary Lesions: An Individual Patient-level Pooled Analysis of Four Randomized Controlled Trials

Introduction: Achieving stent optimization on intravascular ultrasound (IVUS) is associated with favorable clinical outcomes in new-generation drug-eluting stents (DESs) implantation. Little is known about the stent optimization criteria in lesion subsets assorted according to vessel size and lesion length. Hypothesis: We hypothesized lesion-specific IVUS criteria could provide a better prediction for the outcomes after DES implantation for diffuse coronary lesions. Methods: From four randomized trials comparing IVUS and angiography guidance in long coronary lesions, a total of 1,194 patients who underwent IVUS-guided intervention with DESs ≥26 mm in length were included. Primary endpoint was a major adverse cardiac event (MACE), defined as a composite of cardiovascular death, myocardial infarction, target vessel revascularization, or stent thrombosis at 1 year following intervention. Results: MACE occurred in 41 (3.4%) patients. Among possible combinations of absolute and relative expansion criteria, the combination best predicting MACE was minimal stent area (MSA) ≥5.4 mm 2 or 80% of mean lumen area (MLA) (Youden index=0.250) in overall patients. In 2x2 factorial subgroup analyses, the MSA cutoff was 4.9 mm 2 or 85% of MLA for shorter (&lt;30 mm) lesions with a smaller vessel diameter (reference vessel diameter [RVD] &lt;3.0 mm) (Index=0.616) and 5.6 mm 2 or 85% for shorter lesions with a larger vessel diameter (RVD ≥3.0 mm) (Index=0.211). In longer lesions (≥30 mm), the MSA cutoff was 5.5 mm 2 or 70% of MLA for smaller vessels (RVD &lt;3.0 mm) (Index=0.469), and 6.2 mm 2 or 70% for larger vessels (RVD ≥3.0 mm) (Index=0.578). Conclusions: When IVUS is used to optimize DES implantations for long coronary stenoses, applying different criteria according to angiographic parameters might improve the outcomes. In relatively longer lesions with a larger vessel diameter, pursuing to achieve a higher absolute MSA value rather than relative expansion might be more important.

Abstract 16507: Complex Percutaneous Coronary Intervention Features Worsen Prognosis in Diabetic Patients: Insights From a Large Single-center Registry

Introduction: Despite the increasing number of complex percutaneous coronary interventions (CPCI), data regarding outcomes following CPCI in patients with diabetes mellitus (DM) are scarce. Hypothesis: Compared to the general population, diabetic patients undergoing CPCI have worse prognosis. Methods: We analyzed data of patients who underwent PCI in a tertiary-care center between 2009 and 2017. Patients were divided into 2 groups (CPCI and non-CPCI) stratified by presence of DM. CPCI was defined as having ≥1 of the following: stent length &gt;60 mm, ≥3 stents implanted, ≥3 lesions, ≥3 target vessels, bifurcation with ≥2 stents, or chronic total occlusion. The main outcome was major adverse cardiac events (MACE), a composite of death, myocardial infarction (MI) and target vessel revascularization (TVR) at 1 year. Results: Out of 20,412 patients included, 5,038 (24.7%) underwent CPCI. Patients with DM constituted 46.5% (n=9,494) of the overall cohort and 44.5% (n=2,240) of CPCI group. Among patients undergoing CPCI, diabetics were younger, more likely to be female, and had more cardiovascular risk factors (kidney disease, dyslipidemia, and hypertension) than non-diabetics. In addition, diabetic patients had more advanced coronary disease (multivessel disease, high syntax score, and longer lesion length). At 1 year, diabetic patients had higher risk of MACE than non-diabetic, regardless of PCI complexity ( Figure 1 ). Nonetheless, there was a significant interaction between CPCI and diabetes in terms of mortality at 1 year (p-interaction=0.009). In contrast, compared to non-diabetics, a higher risk of TVR ( adj HR 1.49, 95% CI [1.24 - 1.78], p &lt;0.001) and bleeding ( adj HR 1.45, 95% CI [1.05 - 1.98], p=0.02) was observed in diabetics undergoing non-CPCI but not CPCI. Conclusion: Diabetic patients are at higher risk of MACE than the general population regardless of PCI complexity. Yet, 1-year mortality is substantially higher in diabetics undergoing CPCI than non-CPCI.

Higher level of high sensitivity C-reactive protein is associated with more fibrocalcific plaque and longer lesion in patients with acute coronary syndrome

Abstract Background The association between the level of high sensitivity C-reactive protein (hsCRP) and coronary plaque characteristics in patients with acute coronary syndrome (ACS) remains to be elucidated. Purpose To clarify the morphological characteristics of culprit lesion in patients with ACS according to the hsCRP levels using optical coherence tomography (OCT). Methods A total of 215 consecutive patients with ACS, who underwent OCT imaging of culprit lesions were included. The patients were classified into either the higher hsCRP group (hsCRP ≥0.14 mg/dL, n=108) or the lower hsCRP group (hsCRP &amp;lt;0.14 mg/dL, n=107) according to the median preprocedural hsCRP level. The morphological characteristics of culprit lesion assessed by OCT were compared between the two groups. Results The higher hsCRP group had higher prevalence of insulin therapy (14 vs. 6%, p=0.037) and current smoker than the lower hsCRP group (37 vs. 18%, p=0.002). The prevalence of long lesion (≥25 mm, 67 vs. 53%, p=0.041) and fibrocalcific plaque (53 vs. 33%, p=0.003) was significantly higher in the higher hsCRP group than in the lower hsCRP group (Figure). On the other hand, the prevalence of plaque rupture (36 vs. 46%, p=0.174) and lipid-rich plaque (47 vs. 64%, p=0.011) was rather lower in the higher hsCRP group than in the lower hsCRP group (Figure). In a multivariate analysis, fibrocalcific plaque (odds ratio [OR]: 2.098, 95% confidence interval [CI]: 1.125–3.913, p=0.019), lesion length (mm, OR: 1.036, 95% CI: 1.010–1.061, p=0.004) and current smoker (OR: 2.757, 95% CI: 1.388–5.476, p=0.003) was independently associated with higher hsCRP level. Conclusions ACS patients with high hsCRP levels had more fibrocalcific plaque and longer lesion than those with low hsCRP levels. The association between high hsCRP levels and vulnerable characteristics of culprit plaque was not demonstrated. Funding Acknowledgement Type of funding source: None