Minimal Lumen Diameter Research Articles

Clinical Significance of Optical Coherence Tomography-Guided Percutaneous Coronary Intervention for In-Stent Restenosis Within Drug-Eluting Stents: Impact on Patient Outcomes.

The evidence for optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) in improving the prognosis of individuals with in-stent restenosis (ISR) is lacking. This retrospective study enrolled 588 consecutive individuals with drug-eluting stent ISR undergoing PCI from March 2010 to March 2022. Two hundred seven (35.2%) underwent OCT guidance, and 381 (64.8%) underwent angiography guidance. Clinical outcomes were analyzed using survival curves. The primary clinical endpoint was 2-year major adverse cardiovascular events (MACEs), a composite of all-cause death, myocardial infarction, and target-vessel revascularization. Compared with angiography guidance, OCT guidance demonstrated a higher frequency of drug-coated balloon use and adjunctive therapeutic modalities, including predilation, postdilation, nonslip element balloons, and noncompliant balloons (P<0.05). Following PCI, the OCT-guided group achieved a significantly larger minimum lumen diameter (2.36 versus 2.15 mm, P<0.001) and a lower percentage diameter stenosis (17% versus 20%, P<0.001) than the angiography-guided group. Survival analysis revealed significantly lower 2-year MACEs in the OCT-guided group compared with the angiography-guided group (7% versus 15%, P=0.007), validated in the propensity matching analysis (7% versus 15%, P=0.001). Multiple sensitivity analyses showed that OCT-guided PCI treatment was an independent protective factor for 2-year MACEs in individuals with drug-eluting stent ISR. Compared with angiography guidance, OCT guidance is associated with a lower 2-year MACE risk among individuals with drug-eluting stent ISR. Therefore, OCT should be actively considered for guiding PCI treatment in individuals with drug-eluting stent ISR. Url: clinicaltrials.gov. Identifier: NCT03809754.

Assessment of fractal ratio of vessel diameters in coronary bifurcation lesions by angiography and intravascular ultrasound.

Physiological coronary branching at the bifurcation has a constant fractal ratio (FR) of the diameter of the mother vessel to the sum of daughter vessels on quantitative coronary angiography (QCA). We sought to investigate the FR of diseased coronary bifurcations using QCA and intravascular ultrasound (IVUS) and its impact on late lumen loss after percutaneous coronary intervention (PCI). In multicentre prospective studies of the J-REVERSE and 3D OCT Bifurcation Registry, 402 and 109 bifurcations treated with stenting that completed QCAs and IVUS examinations, respectively were analysed. FR was investigated at the reference sites pre-PCI and the minimum lumen diameter (MLD) post-PCI. In the QCA analysis, constant FR was observed in the pre-PCI reference (0.62 ± 0.08) and in the post-PCI MLD site (0.74 ± 0.10), which was greater (p < 0.05). In the IVUS analysis, the constant FR in the post-PCI MLD site (0.67 ± 0.06) was similar to that in the pre-PCI reference (0.66 ± 0.06) and close to the physiological FR value (0.678). The fourth quintile of pre-PCI reference FR in the IVUS analysis showed numerically least late lumen loss in proximal main vessel (MV) (0.16 ± 0.22mm) and distal MV (0.13 ± 0.32mm) and significantly less in the side branch compared to higher FR quintile (-0.14 ± 0.27mm vs. 0.10 ± 0.19mm, p = 0.004), while no relationship was found in the QCA analysis. FR in the diseased coronary bifurcation was more accurately assessed on IVUS than on QCA, and the accomplishment of physiological FR might lead to less late lumen loss after bifurcation PCI.

Intravascular lithotripsy in the management of underexpanded stents

Abstract Introduction Stent underexpansion significantly heightens the risk of major adverse cardiac events (MACE), and available treatment options for this condition remain limited. Intravascular Lithotripsy (IVL) technology disrupts superficial and deep calcium by using localized pulsative sonic pressure waves, emerges as a promising tool for underexpanded stents. Methods Following PRISMA guidelines, we systematically explored PubMed, SCOPUS, and Cochrane databases up to September 3, 2023, for studies evaluating IVL's safety and efficacy in treating underexpanded stents. We gathered angiographic (QCA) and intracoronary imaging (OCT or IVUS) data, examining the stent's minimal diameter stenosis (MDS), minimal lumen diameter (MLD), minimal stent area (MSA), and minimal lumen area (MLA) pre- and post-IVL application. Procedural success constituted the efficacy endpoint, while peri-procedural complications, in-hospital-30-days and long-term mortality, and MACE were safety endpoints Results This meta-analysis comprised 21 studies including 669 patients and 673 treated lesions in underexpanded stent. The mean age was 73.2 ± 2.1 years, with an overall IVL procedural success rate of 93% [(95% Confidence Interval (CI): 88%-96%, I2=29%), while the in-hospital-30-days and long-term mortality incidence were 1% (95% CI: 1%-3%, I2=0%) and 3% (95% CI: 2%-6%, I2=0), respectively. The 30-days target lesion revascularization (TLR) was approximately 6% (95% CI: 3%-12%, I2=50%). There was a significant increase in the MDS [Standardized Mean Difference (SMD): +50.52%, 95% CI: 39.4-61.6, I2=94%)] and in MSA (SMD: +3.52, 95% CI: 2.47 to -4.58, I2=83%) immediately after IVL application. It was observed a significant increase in MLD (SMD: +1.54, 95% CI: 1.09 to 1.98, I2=95%) and in the MLA (SMD: +3.64, 95% CI: 2.62-4.66, I2=5%). Major procedural and device related complications were 3% (95% CI: 1%-6%, I2=0%) and 1% (95% CI: 0%-2%, I2=85%) respectively. Notably low rates were observed for stent thrombosis (0%, 95% CI: 0%-2%, I2=0%), dissections (1%, 95% CI: 1%-4%, I2=0%), perforations (1%, 95% CI: 1%-3%, I2=0%) and no-reflow (0%, 95% CI: 0%-1%, I2=0%). Conclusions IVL demonstrates promise as a safe and effective strategy for underexpanded stent treatment, characterized by low rates of periprocedural complications. Future prospective studies are now warranted to compare IVL to other lesion preparation strategies.30day All-Cause Mortality after IVL use.Minimum Stent Diameter after IVL use.

Coronary stent edge segments as determinant of clinical outcomes: An OCTOBER Trial Substudy

Abstract Background Small lumen dimensions and high plaque burden in stent edge segments are known risk factors for subsequent clinical events after percutaneous coronary intervention (PCI). The evidence using intravascular optical coherence tomography is scarce. Purpose This study aimed to characterize edge segments after PCI and the relation to clinical outcomes in the randomized OCTOBER trial on bifurcation PCI optimized using optical coherence tomography. Methods This is a predefined substudy of the OCTOBER Trial. Edge segments were analysed in detail for degree of stenosis and plaque composition using a dedicated software. Data was planned to be analysed using multi-level cox regression analysis, but descriptive statistics was applied due to very low event rates after OCT-guided PCI. Main endpoints were OCT-detected edge residual stenosis, lipid plaque, calcification, and dissections. Post PCI coronary angiography was analysed for diameter stenosis, edge segment length and minimal lumen diameter. Patients with cardiac events were diagnosed with angiography duringt the two-year follow-up period. Results A total of 597 patients were treated with OCT-guided PCI. Analysable final OCT scans with no additional treatment was available for 505 patients in the main vessel and for the side branch in 289 cases. At deadline for abstract submission 242 scans with 474 edges were analysed and included in preliminary results.Lesions with ≥30% diameter stenosis was found in 20% of proximal edges, 24% of distal edges and 37% of side branch (SB) edges. A plaque burdenOCT ≥180° was found in 74% of proximal edges, 48% of distal edges, and 52% of SB edges. A lipid plaque wafound in 35%, 11% and 14%, dissections in 15%, 6% and 12%, and ≥180° calcium was found in 7%, 4% and 4% of edges respectively. Six patients (1%) of the total OCT-guided population had an edge-related event during the median two-year follow-up. Only two of these 6 patients had post-procedural OCT-scans of the event-related edge, thus 4 of the cases were effectively angiographic guided. Conclusion Only a small fraction of edge segments in the OCTOBER Trial were left with residual edge disease exceeding protocol thresholds. This resulted in historically very low rate of edge related events. No evaluation of a stent edge by OCT in otherwise OCT guided patients appeared to be the main predictor of edge related events. Final results are presented at ESC 2024.

Impact of ultra-high-resolution on cardiac CT assessment of coronary artery stenoses, plaque burden/composition, and pericoronary adipose tissue attenuation

Abstract Background Conventional coronary computed tomography angiography (CCTA) overestimates stenoses within stents and calcified arteries due to "blooming" artifacts. Ultra-high-resolution coronary CT (UHR-CT) may overcome this limitation because of higher spatial resolution. Purpose To investigate differences in coronary arterial lumen volume, stenosis severity, and plaque composition, between CCTA and UHRCT in patients with stents and/or high coronary calcium scores. Methods As part of a prospective pilot study, 14 patients referred for invasive coronary angiography for evaluation of obstructive CAD underwent UHRCT (Canon Precision, 160 x 0.25mm slices) prior to catheterization. Images of identical cardiac phases were reconstructed in two badges for comparison: 1) Ultra-high resolution using a 1,024 x 1,024 matrix, 0.25 mm, and 2) conventional resolution with a 524 x 524 matrix, 0.5 mm. All images were reconstructed using iterative reconstruction algorithm (AIDR 3D) and a sharp kernel (FC05). For the left main and three coronary arteries, an automated contour analysis using a dedicated software (QAngioCT RE 3.2, Medis, Netherlands) was performed to compare conventional CCTA vs. UHR-CT resolution images across common vascular and plaque metrics, including lumen and vessel volume, plaque burden/volume, plaque composition based upon predefined fixed intensity cut-off values of CT attenuation, minimal and maximal plaque thickness, pericoronary adipose tissue attenuation (PCAT), minimal lumen area and diameter, and diameter stenosis. All lumen and vessel contours were generated by the software, without manual editing. The segment model proposed by the SCCT was used as reference and the lesions classified as greater than 25% stenosis by visual assessment were recorded. The quality of the images was subjectively assessed using a 5-point Likert scale. Vessel segments with scores 1 (severe artifacts) and 2 (pronounced artifacts) were not included in the analysis. Results The mean patient age was 68.5 years (±6.8), 2 were female (14.3%), 6 patients had stents (11 stented segments) and the mean Agatston score was 947.6 (±449) among the 8 non-stented patients. A total of 56 vessels, 133 segments, and 57 lesions were analyzed. Eight segments (6%) were excluded from the analysis due to poor quality. Results on a per segment and per lesion basis were summarized in the table. The mean PCAT value was significantly lower for the UHRCT images compared to NR reconstruction in both segment (p&amp;lt;0.001) and lesion based (p=0.002) analyses. Plaque differentiation varied by UHRCT resulted in a lower fibrous plaque volumes but higher necrotic (low attenuation) plaque volumes. Conclusions Ultra-high-resolution CT image analysis results in significantly different coronary artery plaque volume and PCAT assessment vs. conventional resolution CCTA. These findings have implications for evaluating high-risk plaque features and perivascular inflammation in patients.Table 1

Comparison of different calcium modification strategies for coronary calcified nodules: insights from optical coherence tomography

Abstract Background The optimal treatment strategy for coronary calcified nodules (CN) remains uncertain. Purpose We sought to compare the safety and efficacy of different calcium modification strategies for managing CN using optical coherence tomography (OCT). Methods In this single-center retrospective cohort study, consecutive patients undergoing OCT-guided percutaneous coronary intervention (PCI) for severely calcified lesions using rotational atherectomy (RA), orbital atherectomy (OA), or intravascular lithotripsy (IVL) between January 2017 and December 2022 were included. OCT analysis was performed through our institutional core-laboratory to identify CN, assess plaque characteristics, and evaluate post-stent optimization. Primary outcomes were minimum stent area (MSA) and MSA at CN site post-PCI. One-year target vessel failure (TVF), defined as a composite of cardiac death, target-vessel myocardial infarction, or ischemia-driven target vessel revascularization, was also recorded. Results Among a total of 154 patients with 158 lesions, CN was identified in 54 lesions (34.2%) and managed with RA (39%, n=21), OA (33%, n=18), or IVL (28%, n=15). The IVL group exhibited a larger minimal lumen diameter, maximum calcium arc, and maximum calcium thickness at baseline. Post-PCI OCT demonstrated comparable MSA (RA: 5.91 ± 0.33mm², OA: 5.94 ± 0.38mm², IVL: 6.46 ± 0.45mm²; p=0.61) and MSA at CN site (6.77 ± 0.49mm², 6.71 ± 0.51mm², 7.13 ± 0.59mm², respectively; p=0.87) after adjusting for procedural and morphologic factors among the groups. The incidence of TVF at one year was similar among the groups. Conclusions In patients undergoing PCI for severely calcified lesions with CN, comparable procedural and clinical outcomes can be achieved using RA, OA, or IVL. The equivalence across these techniques underscores a role for individualized decision-making integrating patient- and lesion-specific characteristics, as well as center expertise when selecting a treatment strategy for CN.OCT findings and clinical outcomes

Very short-term effects of single dose of proprotein convertase subtilisin kexin 9 inhibitor therapy before percutaneous coronary intervention

Abstract Introduction Several pioneering studies have reported that continuous administration of proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitor reduces cardiovascular events and plaque volume on intravascular ultrasound and increase the thickness of the fibrous-cap on optical coherence tomography after 52-76 weeks.[1,2] However, the effect of PCSK9 inhibitors in very short period of time has not adequately been evaluated. Purpose This study aimed to investigate the effect of the single dose of PCSK9 inhibitor in regard to serial change of plaque composition in very short period with near-infrared spectroscopy with intravascular ultrasound (NIRS-IVUS). Methods This prospective, single arm, single-center, interventional study included 27 consecutive coronary artery disease patients (silent myocardial ischemia and stable angina) who performed NIRS-IVUS at the time of coronary angiography for diagnosis between June 2021 and August 2023. Maximal lipid-core burden index over any 4-mm segment (max-LCBI4mm) and total lipid-core burden index (T-LCBI) at the target lesions were assessed with NIRS-IVUS and they were administered evolocumab 420mg. After 2 to 6 weeks, percutaneous coronary intervention (PCI) was performed on a standby basis and repeat NIRS-IVUS were performed at PCI. Results The median max-LCBI4mm showed a significant decrease from 387 to 315 (IQR: 268 to 572 and IQR: 221 to 488, respectively; p = 0.02) in a lesion-wise analysis. The median T-LCBI also showed a significant decrease from 160 to 117 (IQR: 105 to 263 and IQR: 65 to 226, respectively; p = 0.02). Minimum lumen area and minimum lumen diameter showed no significant changes. Conclusions Single dose of PCSK9 inhibitor therapy before PCI resulted in significant degression of lipid core plaques identified by NIRS at the target lesion in very short period of time.Changes of max-LCBI4mmChanges of T-LCBI

Rotational, orbital atherectomy and intravascular lithotripsy for coronary calcified nodules: insights from optical coherence tomography.

The optimal treatment strategy for coronary calcified nodules (CN) remains uncertain. We aimed to evaluate the efficacy and safety of different calcium modification strategies, including rotational atherectomy (RA), orbital atherectomy (OA), and intravascular lithotripsy (IVL) for managing CN with optical coherence tomography (OCT) guidance. Consecutive patients undergoing OCT-guided percutaneous coronary intervention (PCI) for severely calcified lesions using RA, OA, or IVL between January 2017 and December 2022 were included. Primary endpoint was minimum stent area (MSA) post-PCI. Secondary endpoints included MSA at CN site and 1-year target vessel failure (TVF), defined as a composite of cardiac death, target-vessel myocardial infarction, or target vessel revascularization. Among 154 patients and 158 lesions, CN was identified in 54 lesions (34.2%) and managed with RA (39%, n = 21), OA (33%, n = 18), or IVL (28%, n = 15). The IVL group exhibited a larger minimal lumen diameter, maximum calcium arc, and maximum calcium thickness. Post-PCI OCT demonstrated comparable MSA (RA: 6.23 ± 0.34 mm², OA: 5.75 ± 0.39 mm², IVL: 6.24 ± 0.46 mm²; p = 0.62) and MSA at CN site (7.17 ± 0.43 mm², 6.46 ± 0.49 mm², 7.86 ± 0.56 mm², respectively; p = 0.55) after adjusting for morphologic factors. The incidence of TVF at 1 year was similar among the group (RA: 19.0%, OA: 22.2%, IVL: 13.3%, p = 0.81). In patients undergoing PCI for CN, similar procedural and clinical outcomes can be achieved using RA, OA, or IVL. These findings warrant further investigation in larger, prospective trials.

Usefulness of percutaneous transluminal coronary balloon angioplasty for coronary artery stenosis after surgery for CHD.

Coronary artery involvements occur rarely both during cardiac repair and in the late period after surgery, and it may result in myocardial ischaemia and infarction. We present six cases who underwent percutaneous transluminal coronary balloon angioplasty for coronary artery stenosis in the late period after surgery. The patients included four boys and two girls. Post-operative states involving anomalous origin of the left coronary artery from the pulmonary artery and d-transposition of the great arteries were observed in two patients each. Two patients with univentricular heart had coronary artery injuries during surgery. The age at the angioplasty ranged from 1 month to 14 years, with a median of 3 years. The interval from the operation to angioplasty ranged from 37 days to 14 years (median 8 months). The interval from the angioplasty to follow-up coronary angiography ranged from 2 months to 14 years (median 11 months). The follow-up period ranged from 2 months to 20 years (median 8 years). One patient underwent a stent implantation because of post-procedure recoil. Coronary artery stenosis improved immediately after procedure in the six patients without complication, and restenosis occurred post-procedure in one patient. Five patients had no cardiac events. Although the angioplasty's initial effect may not be dramatic, it can improve late after the procedure. It was considered that the optimal balloon-reference vessel ratio to obtain a minimal effective lumen diameter was about 1.0. Angioplasty post-surgery for CHD in children was feasible and without complications.

Impact of Severity and Extent of Iliofemoral Atherosclerosis on Clinical Outcomes in Patients Undergoing TAVR

BackgroundVascular complications remain a major concern in transfemoral transcatheter aortic valve replacement (TAVR). The Hostile score has been proposed to stratify risk in TAVR patients with peripheral artery disease. ObjectivesThe authors aimed to assess the validity of the Hostile score in predicting iliofemoral vascular complications after TAVR. MethodsIn a prospective TAVR registry, we validated the Hostile score for the prediction of puncture and non–puncture site vascular complications. This scoring system integrates the extent (number of lesions, lesion length, and minimum lumen diameter) and complexity (tortuosity, calcification, and the presence of obstruction) of iliofemoral atherosclerosis. ResultsOf 2,023 patients who underwent transfemoral TAVR with contemporary devices between March 2014 and June 2022, 106 (5.2%) patients experienced puncture site vascular complications and 28 (1.4%) patients experienced non–puncture site vascular complications. The Hostile score was higher in patients with vascular complications than those without complications (1.00 [Q1-Q3: 0-5.00] vs 1.00 [Q1-Q3: 0-4.00]; P < .001). A higher body mass index (OR: 1.23; 95% CI: 1.04-1.50) and the use of Prostar (OR: 6.03; 95% CI: 2.23-16.30) or MANTA (OR: 6.18; 95% CI: 2.67-14.27) compared with ProGlide were independent predictors of puncture site vascular complications, whereas a higher Hostile score (OR: 1.91; 95% CI: 1.55-2.35) and female sex (OR: 2.69; 95% CI: 1.12-6.42) were independent predictors of non–puncture site vascular complications. The area under the receiver-operating characteristic curves for the prediction of puncture site and non–puncture site vascular complications were 0.554 and 0.829, respectively. ConclusionsThe Hostile score proved useful in predicting non–puncture site vascular complications after TAVR. (SwissTAVI Registry; NCT01368250).

Drug-eluting stent and drug-coated balloon for in-stent restenosis: A meta-analysis

&lt;p&gt;The optimal strategy for patients with in-stent restenosis (ISR) is controversial. We aimed to compare the effects of a drug-coating balloon (DCB) and drug-eluting stent (DES) in ISR treatment.&lt;strong&gt; &lt;/strong&gt;Clinical trials were extensively collected, and retrieved items were screened for inclusion. Both clinical (major adverse cardiac event (MACE); myocardial infarction (MI); and target lesion revascularization (TLR) and angiographic (minimal lumen diameter (MLD), and stenosis relative to reference lumen diameter (SRLD) endpoints were extracted and compared. MACE and MI were not significantly different between the groups. Pooled results of TLR showed a marginal effect that DES was superior to DCB (13.50% for DCB vs&lt;em&gt;.&lt;/em&gt; 11.17% for DES, RR = 1.256, 95% CI: 0.997 to 1.583, &lt;em&gt;P&lt;/em&gt; = 0.053), with heterogeneity across studies (&lt;em&gt;I&lt;/em&gt;&lt;sup&gt;2&lt;/sup&gt; = 42.0%, Cochrane &lt;em&gt;Q&lt;/em&gt;-test = 0.069). Meta-regression identified bare metal stent (BMS) or drug eluting stents (DES) implanted in the previous intervention and proportions of diabetes in the DCB group as sources of heterogeneity. DES implantation also significantly improved angiographic outcomes (WMD for MLD: −0.318, 95% CI: −0.424 to −0.213, &lt;em&gt;P&lt;/em&gt;&lt;em&gt; &lt;/em&gt;&amp;lt; 0.001; WMD for SRLD: 6.164%, 95% CI: 4.915% to 7.412%, &lt;em&gt;P&lt;/em&gt;&lt;em&gt; &lt;/em&gt;&amp;lt; 0.001). All DES, including everolimus-eluting ones, did not benefit BMS-ISR patients compared with DCB treatment.&lt;strong&gt; &lt;/strong&gt;DES implantation, which is superior to DCB angioplasty only in DES-ISR patients, should be preferred in the DES-ISR population to reduce TLR. DCB may be preferred in BMS-ISR to avoid increasing stent layers.&lt;/p&gt;

Very short-term effects of a single dose of a proprotein convertase subtilisin/kexin 9 inhibitor before percutaneous coronary intervention: A single-arm study

Background and aimsThe short-term (within 6 weeks) effects of proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors on lipid plaques have not been adequately evaluated. We aimed to investigate whether a single dose of a PCSK9 inhibitor before percutaneous coronary intervention (PCI) could reduce the abundance of lipid-core plaques identified via near-infrared spectroscopy intravascular ultrasound (NIRS-IVUS) at target lesions within a very short period. MethodsThis prospective, single-arm, single-center interventional study enrolled 27 consecutive patients with coronary artery disease. These patients underwent NIRS-IVUS during coronary angiography and repeat NIRS-IVUS during PCI performed between 2 and 6 weeks after the single-dose administration of 420 mg evolocumab. Changes in lesion lipid-core burden index (LCBI) and maximal LCBI over any 4-mm segment (max-LCBI4mm) were assessed using NIRS at the target lesions, along with lipid profile. ResultsThe max-LCBI4mm significantly decreased from 387 before PCSK9 inhibitor administration to 315 after its administration (interquartile range [IQR]: 268–572 and 221–488, respectively; p = 0.02) within a very short period. The lesion LCBI also decreased from 161 to 117 (IQR: 105–263 and 65–226, respectively; p = 0.02). No significant changes were observed in the minimum lumen area and diameter. After PCSK9 inhibitor administration, low-density lipoprotein (LDL) cholesterol (p < 0.001), lipoprotein(a) (p = 0.001), and malondialdehyde-modified LDL (p < 0.001) levels decreased compared with those before its administration. ConclusionsA single dose of the PCSK9 inhibitor administered before PCI reduced the abundance of lipid-core plaques identified via NIRS-IVUS at target lesions within a very short period of 2–6 weeks.

Sex differences in plaque characteristics of fractional flow reserve-negative non-culprit lesions after myocardial infarction

Background and aimsRecurrent events after myocardial infarction (MI) are common and often originate from native non-culprit (NC) lesions that are non-flow limiting. These lesions consequently pose as targets to improve long-term outcome. It is, however, largely unknown whether these lesions differ between sexes. The aim of this study was to assess such potential differences. MethodsFrom the PECTUS-obs study, we assessed sex-related differences in plaque characteristics of fractional flow reserve (FFR)-negative intermediate NC lesions in 420 MI-patients. ResultsAmong the included patients, 80 (19.1 %) were female and 340 (80.9 %) male. Women were older and more frequently had hypertension and diabetes. In total, 494 NC lesions were analyzed. After adjustment for clinical characteristics and accounting for within-patients clustering, lesion length was longer in female patients (20.8 ± 10.0 vs 18.3 ± 8.5 mm, p = 0.048) and minimum lumen area (2.30 ± 1.42 vs 2.78 ± 1.54 mm2, p < 0.001) and minimum lumen diameter (1.39 ± 0.45 vs 1.54 ± 0.44 mm, p < 0.001) were smaller. The minimum fibrous cap thickness was smaller among females (96 ± 53 vs 112 ± 72 μm, p = 0.025), with more lesions harboring a thin cap fibroatheroma (39.3 % vs 24.9 %, p < 0.001). Major adverse cardiovascular events at two years occurred in 6.3 % of female patients and 11.8 % of male patients (p = 0.15). ConclusionsFFR-negative NC lesions after MI harbored more high-risk plaque features in female patients. Although this did not translate into an excess of recurrent events in female patients in this modestly sized cohort, it remains to be investigated whether this difference affects clinical outcome.

Intravascular ultrasound-guided drug-coated balloon angioplasty for femoropopliteal artery disease: a clinical trial.

Drug-coated balloons (DCBs) have demonstrated favourable outcomes following endovascular therapy for femoropopliteal artery (FPA) disease. However, uncertainty remains whether the use of intravascular ultrasound (IVUS) can improve the outcomes of DCBs. This prospective, multicentre, randomized trial, conducted at seven centres in South Korea, compared the outcomes of IVUS-guided vs. angiography-guided angioplasty for treating FPA disease with DCBs. Patients were assigned to receive IVUS-guided (n = 119) or angiography-guided (n = 118) angioplasty using DCBs. The primary endpoint was 12-month primary patency. Between May 2016 and August 2022, 237 patients were enrolled and 204 (86.0%) completed the trial (median follow-up; 363 days). The IVUS guidance group showed significantly higher primary patency [83.8% vs. 70.1%; cumulative difference 19.6% (95% confidence interval 6.8 to 32.3); P = .01] and increased freedom from clinically driven target lesion revascularization [92.4% vs. 83.0%; difference 11.6% (95% confidence interval 3.1 to 20.1); P = .02], sustained clinical improvement (89.1% vs. 76.3%, P = .01), and haemodynamic improvement (82.4% vs. 66.9%, P = .01) at 12 months compared with the angiography guidance group. The IVUS group utilized larger balloon diameters and pressures for pre-dilation, more frequent post-dilation, and higher pressures for post-dilation, resulting in a greater post-procedural minimum lumen diameter (3.90 ± 0.59 vs. 3.71 ± 0.73 mm, P = .03). Intravascular ultrasound guidance significantly improved the outcomes of DCBs for FPA disease in terms of primary patency, freedom from clinically driven target lesion revascularization, and sustained clinical and haemodynamic improvement at 12 months. These benefits may be attributed to IVUS-guided optimization of the lesion before and after DCB treatment.

Paclitaxel-coated versus sirolimus-coated balloon angioplasty for coronary artery disease: A systematic review and meta-analysis.

Although use of sirolimus-based analogs has shown superiority over paclitaxel in drug-eluting stents, the relative efficacy of these two agents released from drug-coated balloons (DCB) is unclear. The present meta-analysis is aimed to compare outcomes after percutaneous coronary intervention (PCI) with paclitaxel-coated balloons (PCB) versus sirolimus-coated balloons (SCB) for either in-stent restenosis or native de novo lesions. The study outcomes were 1) target lesion failure (TLF), a composite of cardiac death, target vessel myocardial infarction, or target lesion revascularization, and 2) follow-up angiographic parameters including late lumen loss (LLL), diameter stenosis, and minimal lumen diameter (MLD). Pooled odds ratios (OR) and weighted mean differences (WMD) with 95% confidence intervals (CI) were calculated by using random-effects models. A search of PubMed, EMBASE, and Cochrane Library from their inception to January 2024 identified five randomized clinical trials and three observational studies with a total of 1861 patients (889 in PCB and 972 in SCB groups). During 9-12 months of follow-up, there was no significant difference in TLF (OR 1.01, 95% CI 0.75-1.35) between the two groups. On follow-up angiography at 6-9 months, MLD (WMD 0.10, 95% CI 0.02-0.17) was larger in PCB but there was no statistically significant difference in LLL (WMD -0.11, 95% CI -0.23-0.02) and diameter stenosis (WMD -3.33, 95% CI -8.11-1.45). Among patients undergoing DCB-only PCI, the risk of TLF was similar during 9-12 months of follow-up after PCB and SCB treatment. However, the MLD was larger favoring PCB over SCB on follow-up angiography.

Intravascular lithotripsy-assisted transfemoral transcatheter aortic valve implantation after failed balloon angioplasty in patients with severe calcified peripheral artery disease.

Calcific peripheral artery disease (PAD) is a common finding in patients scheduled for transcatheter aortic valve implantation (TAVI) and often requires iliofemoral axis preparation. However, evidence about the use of intravascular lithotripsy (IVL) in this setting is scarce. The aim of this study was to describe in-hospital and mid-term outcomes of IVL-assisted transfemoral (TF)-TAVI in patients with severe calcific PAD. The study included 13 patients with severe calcified PAD who were initially scheduled for balloon angioplasty (PTA)-assisted TF-TAVI but were eventually treated with peripheral IVL between October 2020 and February 2024. Accurate analysis of preoperative computed tomography scans revealed difficult TF access routes (severe calcified PAD with minimal lumen diameter ≤ 4.5 mm, circumferential calcification along iliofemoral axis, and marked vessels tortuosity). In all cases, IVL was performed after PTA failure and allowed successful valve delivery. One patient had procedural bleeding (BARC-3a). The valve was successfully delivered without complications in 12 patients (92.3%), and no major adverse events were reported at the longest follow-up (median 18.5 months). IVL-assisted TF-TAVI may represent a feasible and safe option for patients presenting with severe aortic stenosis and severe calcified PAD. However, standardization of the access site severity as well as indications for a planned up-front IVL-assisted strategy are missing and require dedicated studies.

Computed tomography coronary angiography assessment of left main coronary artery stenosis severity

BackgroundAngiographic assessment of left main coronary artery (LMCA) stenosis severity can be unreliable. In cases of ambiguity, intravascular ultrasound (IVUS) can be utilised with a minimal lumen area (MLA) of ≥6 ​mm2 an accepted threshold for safe deferral of revascularization. We sought to assess whether quantitative computer tomography coronary angiography (CTCA) measures could assist clinicians making LMCA revascularization decisions when compared with IVUS as gold standard. MethodsConsecutive patients undergoing IVUS assessment of angiographically intermediate LMCA stenosis were included. All patients had undergone 320-slice CTCA <90 days prior to IVUS imaging. Offline quantitative assessment of IVUS- and CT-derived measures were undertaken with the cohort divided into those with significant (s-LMCA) versus non-significant (ns-LMCA) disease using the accepted IVUS threshold. ResultsFifty-eight patients were included, with no difference in mean age (61.5 ​± ​12.2 vs. 59.7 ​± ​11.9 years, p ​= ​0.57), diabetic status (24.2% vs 16.0%, p ​= ​0.44) or other baseline demographics between groups. Patients with ns-LMCA had larger CT luminal area (8.64 ​± ​3.91 vs. 5.41 ​± ​1.54 ​mm2, p ​< ​0.001), larger minimal lumen diameter (MLD) (3.25 ​± ​0.74 vs. 2.56 ​± ​0.38 ​mm, p ​< ​0.001) and lower area stenosis (45.74 ​± ​18.10 vs. 60.93 ​± ​14.68%, p ​= ​0.001). There was a significant positive correlation between CTCA and IVUS MLA (r ​= ​0.68, p ​< ​0.001) and MLD (r ​= ​0.67, p ​< ​0.001). ROC analysis demonstrated CTCA MLA cut-off <8.29 ​mm2 provides the greatest negative predictive value and sensitivity in predicting the presence of significant LMCA disease. ConclusionCTCA derived MLA and MLD have a strong correlation with IVUS. A CTCA derived MLA cut-off <8.29 ​mm2 showed greatest clinical utility for predicting the need for further assessment, based on IVUS gold standard.

Long-term outcomes of IVUS-guided and angiography-guided drug-eluting stent implantation for left main coronary artery disease: a retrospective consort study

BackgroundIn patients with unprotected left main coronary artery disease (ULMCAD), this study compared the long-term prognosis of drug-eluting stent insertion guided by intravascular ultrasonography (IVUS) vs. angiography.Patients and methodsThis retrospective consort investigation was performed in December 2021. This analysis included 199 patients who underwent IVUS-guided (IVUS group, n = 81) or angiography-guided (angiography group, n = 118) drug-eluting stent implantation at the Affiliated Hospital of Inner Mongolia Medical University between September 2013 and September 2018. Major adverse cardiac events (MACE) were defined as cardiovascular death, sudden cardiac death, myocardial infarction.ResultsThe IVUS group had considerably lower proportions of MACE within 1 year postoperatively (P = 0.002) and cardiac mortality within 3 years postoperatively (P = 0.018) compared to the angiography group. However, after adjusting for confounding variables, the hazard ratio for 3-year cardiac mortality was similar between the two groups (P = 0.28). In the IVUS group, there was considerably greater minimum lumen diameter (MLD) (P = 0.046), and reduced frequencies of target vessel restenosis (P < 0.050) and myocardial infarction (MI) (P = 0.024) compared to the angiography group. Cox regression analysis for 3-year cardiac mortality found that MSD was independently associated with low cardiac mortality (HR = 0.1, 95% CI: 0.01–14.92, P = 0.030).ConclusionIVUS-guided drug-eluting stent implantation may lead to better long-term prognosis in patients with ULMCAD, and MSD may be a predictor for lower cardiac mortality.

Predictors and prognostic value of coronary computed tomography angiography for unrecognized myocardial infarction in patients with chronic coronary syndrome

ObjectiveUnrecognized myocardial infarction (UMI) on delayed-enhancement cardiac magnetic resonance imaging (DE-CMR) and coronary computed tomography angiography (CCTA) derived high-risk features provide prognostic information in patients with chronic coronary syndrome (CCS). The study aimed to assess the prognostic value of UMI and predictors of UMI using CCTA in patients with CCS who underwent elective percutaneous coronary intervention (PCI). MethodsThis study enrolled 181 patients with CCS who underwent DE-CMR and CCTA before elective PCI. The CCTA-derived predictors of UMI and the association of baseline clinical characteristics, CCTA findings, and CMR-derived factors, including UMI, with MACEs, defined as death, nonfatal myocardial infarction, unplanned late revascularization, hospitalization for congestive heart failure, and stroke, were investigated. ResultsUMI was detected in 57 (31.5%) patients. ROC analysis revealed that the optimal cut-off values of Agatston score and mean peri-coronary fat attenuation index (FAI) for predicting the presence of UMI were 397 and −69.8, respectively. The multivariable logistic regression analysis revealed that left ventricular mass, Agatston score >397, mean FAI >−69.8, positive remodeling of the target lesion, and CCTA-derived stenosis severity were independent predictors of UMI. Kaplan–Meier analysis revealed that patients with UMI were associated with increased risk of MACEs. The Cox proportional hazards analysis showed post-PCI minimum lumen diameter and the presence of UMI were independent predictors of MACEs. The risk of MACEs significantly increased according to the number of four preprocedural CCTA-relevant features of UMI. ConclusionPreprocedural comprehensive CCTA analysis may help predict the presence of UMI and provide prognostic information in patients with CCS who underwent PCI.

The association of cholesterol crystals and non-culprit plaque characteristics in AMI patients: an OCT study

Objective: To analyze plaque characteristics of non-culprit coronary lesions with cholesterol crystals in patients with acute myocardial infarction(AMI) by using optical coherence tomography(OCT). We also investigated the potential association between cholesterol crystals with plaque rupture and healed plaque at non-culprit segment. Methods: This study was a retrospective cohort study. Between January 2017 and December 2017, patients with AMI who underwent 3-vessel OCT imaging were included in this study. Patients were divided into two groups according to the presence or absence of cholesterol crystals at the non-culprit lesions. All patients underwent coronary angiography and OCT examination, and non-culprit plaque characteristics were compared between the two groups. The generalized estimating equation log-binomial multirariate regression model was used to assess the relationship between non-culprit lesions with cholesterol crystals and plaque rupture and plaque healing. The follow-up data collection ended in October 2023. Kaplan-Meier survival curves were plotted, and log-rank tests were used to compare the cumulative incidence of major adverse cardiovascular events between the two groups. Results: A total of 173 AMI patients were included (aged (56.8±11.6) years; 124 men (71.7%)). Among 710 non-culprit lesions identified by OCT, there were 102 (14.4%) in cholesterol crystals group and 608 (85.6%) in non-cholesterol crystals group. Compared with non-culprit lesions without cholesterol crystals, those with cholesterol crystals had smaller minimum lumen diameter, severer diameter stenosis, and longer lesion length (all P<0.01). The prevalence of plaque rupture (17.6% (18/102) vs. 4.9% (30/608), P=0.001) and thin-cap fibroatheroma (31.4% (32/102) vs. 11.5% (70/608), P<0.01) was higher in the cholesterol crystals groups than in the non-cholesterol crystals group. In addition, vulnerable plaque characteristics such as (44.1% (45/102) vs. 25.8% (157/608), P<0.01), macrophages were more frequently observed in non-culprit lesions with cholesterol crystals. The generalized estimating equation log-binomial multivariate regression analyses showed that non-culprit cholesterol crystals were positively correlated with healed plaque (OR=1.583, 95%CI: 1.004-2.495, P=0.048). Conversely, cholesterol crystals were not associated with plaque rupture (OR=1.632, 95%CI: 0.745-3.576, P=0.221). The follow-up time was 2 142 (1 880, 2 198) days. Non-culprit cholesterol crystals were not related to the major adverse cardiovascular events in patients with AMI (log-rank P=0.558). Conclusions: Among AMI patients, non-culprit lesions with cholesterol crystals presented with severer luminal stenosis and increased plaque vulnerability. The presence of non-culprit cholesterol crystals was associated with rather than plaque rupture.