Small Vessel Lesions Research Articles

The Degree of Cognitive Impairment in Patients with Lacunar Stroke Depending on the Hemispheric Lateralization of the Lesion

The most susceptible to vascular dementia persons with lesions of small cerebral vessels. This variant of the pathology is characterized by subacute course and pathologic basis is diffuse changes in the white matter of the cerebral hemispheres and lacunar infarctions, in most cases - multiple. That is why the appearance of lacunar infarcts associated with step-progression of the disease. However, not in all cases, there is a significant cognitive defect even in a lacunary condition. The aim of the study was to identify cognitive impairment in patients with lacunar stroke, depending on hemispheric lateralization of the lesion. We observed and surveyed 70 patients (mean age 60.2 + 6.3) suffered the lacunar stroke with hemispheric lateralization of the lesion. In this work, we used the Mini-Mental State Examination (MMSE) and Montreal scale assessment of cognitive functions (MoCA), the Saint Louis University Mental Status Examination (SLUMS), which have been developed as a tool to identify and assess the severity of cognitive functions in general practice. Comparative analysis of cognitive impairment on the stage of the disease in the control group showed that in general, patients suffered lacunar stroke level of violations was significantly higher than the control group (p≤0.01). Cognitive function in right lacunar stroke corresponded moderate cognitive impairment and the restoration of the neurological defect in the dynamics were less expressed and are not complete. Cognitive impairment in the left hemisphere lacunar stroke had a mild degree of cognitive impairment and restoration of disturbed functions is progressing at a faster pace, about what speak reliable indicators of the late recovery period (p≤0.05). The differences in cognitive disorders at different focus lateralization underlie the clinical features and determine the nature and pace of the recovery of lost functions. Mild cognitive impairment in the left-hand lacunar stroke is a favorable prognostic factor in terms of the recovery of lost functions.

CLINICAL MANIFESTATIONS OF HEMORRHAGIC FEVER WITH RENAL SYNDROME IN RUSSIA

Hemorrhagic fever with renal syndrome (HFRS) is an acute viral disease with airborne pathogen transmission, characterized by systemic lesions of small vessels, hemorrhagic diathesis, hemodynamic disorders and kidney failure. In Russia, HFRS causative agents include 6 hantaviruses: Puumala, Kurkino and Sochi in the European part, Hantaan, Amur and Seoul in the Far East. Wild rodents are the natural hosts of hantaviruses and the source of HFRS infection for humans. HFRS clinical manifestations are acute onset, cyclic course, syndromes of fever and intoxication, hemorrhagic manifestations, pain in the lower back and abdomen, and acute renal failure which develops by day 4-5. Other typical features include leukocytosis with left shift, thrombocytopenia, elevated urea and creatinine, proteinuria, hematuria and decreased relative density of urine. In severe disease, the following complications develop: haemorrhage, toxic shock, pulmonary edema, rupture of renal capsule. Depending on the etiology, clinical forms of HFRS markedly vary by their severity and mortality.

Efficacy of everolimus-eluting stent implantation in patients with small coronary arteries (≤2.5 mm): outcomes of 3-year clinical follow-up

Previous studies have demonstrated that patients with small coronary artery lesions are at increased risk for late cardiac events after percutaneous coronary intervention. It remains uncertain whether second-generation drug-eluting stents have an advantage over first-generation drug-eluting stents in patients with small vessel lesions. Our aim was to compare in the 3-year clinical impact between second-generation everolimus-eluting stents (EES) and first-generation sirolimus-eluting stents (SES) in small vessel lesions. Four-hundred forty-four patients with small vessel lesions defined as reference diameter <2.5mm were treated with EES (237 patients, 265 lesions) or SES (207 patients, 220 lesions) and completed 3-year follow-up. We compared the major adverse clinical events (MACE) between the two groups. EES had no significant impact on the MACE rate compared with SES (4.6 vs. 7.2%, p=0.14). No significant differences were observed in the individual components of cardiac death (1.7 vs. 1.9%, p=0.78), myocardial infarction (1.3 vs. 3.4%, p=0.12), and ischemia-driven target lesion revascularization (2.3 vs. 4.6%, p=0.13) in EES and SES, respectively. Stent thrombosis, however, was significantly less in the EES group than in the SES group (0.7 vs. 3.4%, HR: 0.53, 95% CI 0.38-0.88, p<0.05). EES implantation did not significantly impact 3-year MACE rates compared to SES implantation in small vessel lesions. A significant reduction in the overall rate of stent thrombosis was observed in recipients of EES. While the SES group showed increasing rates of late and very late thrombosis, the EES group did not. EES offers a safe and effective treatment for small vessel lesions.

Vascular Contributions in Alzheimer's Disease-Related Neuropathological Changes: First Autopsy Evidence from a South Asian Aging Population.

Evidence from various consortia on vascular contributions has been inconsistent in determining the etiology of sporadic Alzheimer's disease (AD). To investigate vascular risk factors and cerebrovascular pathologies associated in manifestation of AD-related neuropathological changes of an elderly population. Postmortem brain samples from 76 elderly subjects (≥50 years) were used to study genetic polymorphisms, intracranial atherosclerosis of the circle of Willis (IASCW), and microscopic infarcts in deep white matters. From this cohort, 50 brains (≥60 years) were subjected to neuropathological diagnosis using immunohistopathological techniques. Besides the association with age, the apolipoprotein E ɛ4 allele was significantly and strongly associated with Thal amyloid-β phases ≥1 [odds ratio (OR) = 6.76, 95% confidence interval (CI) 1.37-33.45] and inversely with Braak neurofibrillary tangle (NFT) stages ≥III (0.02, 0.0-0.47). Illiterates showed a significant positive association for Braak NFT stages ≥IV (14.62, 1.21-176.73) and a significant negative association for microscopic infarcts (0.15, 0.03-0.71) in deep white matters. With respect to cerebrovascular pathologies, cerebral small vessel lesions (white matter hyperintensities and cerebral amyloid angiopathy) showed a higher degree of associations among them and with AD-related neuropathological changes (p < 0.05) compared to large vessel pathology (IASCW), which showed a significant association only with Braak NFT stages ≥I (p = 0.050). These findings suggest that besides age, education, and genetic factors, other vascular risk factors were not associated with AD-related neuropathological changes and urge prompt actions be taken against cerebral small vessel diseases since evidence for effective prevention is still lacking.

Visualization of mouse spinal cord intramedullary arteries using phase- and attenuation-contrast tomographic imaging.

Many spinal cord circulatory disorders present the substantial involvement of small vessel lesions. The central sulcus arteries supply nutrition to a large part of the spinal cord, and, if not detected early, lesions in the spinal cord will cause irreversible damage to the function of this organ. Thus, early detection of these small vessel lesions could potentially facilitate the effective diagnosis and treatment of these diseases. However, the detection of such small vessels is beyond the capability of current imaging techniques. In this study, an imaging method is proposed and the potential of phase-contrast imaging (PCI)- and attenuation-contrast imaging (ACI)-based synchrotron radiation for high-resolution tomography of intramedullary arteries in mouse spinal cord is validated. The three-dimensional vessel morphology, particularly that of the central sulcus arteries (CSA), detected with these two imaging models was quantitatively analyzed and compared. It was determined that both PCI- and ACI-based synchrotron radiation can be used to visualize the physiological arrangement of the entire intramedullary artery network in the mouse spinal cord in both two dimensions and three dimensions at a high-resolution scale. Additionally, the two-dimensional and three-dimensional vessel morphometric parameter measurements obtained with PCI are similar to the ACI data. Furthermore, PCI allows efficient and direct discrimination of the same branch level of the CSA without contrast agent injection and is expected to provide reliable biological information regarding the intramedullary artery. Compared with ACI, PCI might be a novel imaging method that offers a powerful imaging platform for evaluating pathological changes in small vessels and may also allow better clarification of their role in neurovascular disorders.

Small-vessel treatment with contemporary newer-generation drug-eluting coronary stents in all-comers: Insights from 2-year DUTCH PEERS (TWENTE II) randomized trial

Treatment of lesions in small vessels was associated with worse clinical outcome, and various definitions of "small vessels" have been used. Data with novel drug-eluting stents are scarce. To compare the outcome of patients with vs without small-vessel treatment, we assessed 2-year follow-up data of the DUTCH PEERS randomized trial (ClinicalTrials.gov: NCT01331707), in which 1,811 all-comers were treated with contemporary zotarolimus-eluting (Resolute Integrity) or everolimus-eluting (Promus Element) stents. Primary end point was target lesion failure (TLF), a composite of cardiac death, target vessel myocardial infarction, and target lesion revascularization. The rates of TLF (9.5% vs 5.4%; P log rank = .001) and 2 individual components thereof-target vessel myocardial infarction (3.1% vs 1.3%; P log rank = .006) and target lesion revascularization (4.8% vs 2.8%; P log rank = .02)-were higher among 798 (44.1%) patients treated in at least one small vessel (<2.50 mm by quantitative coronary angiography). Multivariate analysis with propensity score adjustment demonstrated that treatment of small-vessel lesions independently predicted TLF at 2-year follow-up (hazard ratio 1.60, 95% CI 1.09-2.34). Patients with the smallest target vessel being <2.25 mm had TLF rates similar to patients with smallest target vessels of 2.25 to <2.50 mm; however, patients treated in vessels no smaller than 2.50 to <3.00 mm and patients treated in vessels ≥3.00 mm had lower TLF rates (9.3%, 9.8%, 5.0%, and 5.8%, respectively; P log rank = .009). Patients treated with novel drug-eluting stents in small-vessel lesions had higher adverse event rates than did patients who had no small-vessel treatment. Our data suggest that with current stents, a vessel diameter <2.50 mm is a suitable threshold to identify small target vessels.

Association of apolipoprotein E gene polymorphism with small-vessel lesions and stroke type in moyamoya disease: a preliminary study.

OBJECT The present study was conducted to investigate whether microbleeds or microinfarcts are associated with apolipoprotein E (APOE) gene polymorphisms in patients with moyamoya disease (MMD), and if so, whetherAPOE gene polymorphisms are also associated with stroke type in patients with MMD. METHODS This cross-sectional, multicenter study included 86 consecutive patients with MMD who underwent T2*-weighted gradient echo or susceptibility-weighted MR imaging and 83 healthy control volunteers. Baseline clinical and radiological characteristics were recorded at diagnosis, and inter- and intragroup differences in the APOE genotypes were assessed. Multivariate binary logistic regression models were used to determine the association factors for small-vessel lesions (SVLs) and hemorrhagic presentation in patients with MMD. RESULTS There was no difference in APOE gene polymorphism and the incidence of SVLs between patients with MMD and healthy controls (p > 0.05). In the MMD group, 7 (8.1%) patients had microbleeds and 32 (37.2%) patients had microinfarcts. Microbleeds were more frequently identified in patients with hemorrhagic-type than in nonhemorrhagictype MMD (p = 0.003). APOE genotypes differed according to the presence of microbleeds (p = 0.024). APOE ε2 or ε4 carriers also experienced microbleeds more frequently than APOE ε3/ε3 carriers (p = 0.013). In the multivariate regression analysis in patients with MMD, microbleeds were significantly related to APOE ε2 or ε4 carrier status (OR 7.86; 95% CI1.20-51.62; p = 0.032) and cerebral aneurysm (OR 17.31; 95% CI 2.09-143.57; p = 0.008). Microinfarcts were independently associated with hypertension (OR 3.01; 95% CI 1.05-7.86; p = 0.007). Hemorrhagic presentation was markedly associated with microbleeds (OR 10.63; 95% CI 1.11-102.0; p = 0.041). CONCLUSIONS These preliminary results did not show a difference in APOE gene polymorphisms between patients with MMD and healthy persons. However, they imply that APOE gene polymorphisms may play certain roles in the presence of microbleeds but not microinfarcts in patients with MMD. A further confirmatory study is necessary to elucidate the effect of APOE gene polymorphisms and SVLs on the future incidence of stroke in patients with MMD.

Spontaneous white matter lesion in brain of stroke-prone renovascular hypertensive rats: a study from MRI, pathology and behavior.

Hypertension is considered one of the most important controllable risk factors for white matter lesion (WML). Our previous work found that stroke-prone renovascular hypertensive rats (RHRSP) displayed a high rate of WML. This study aimed to investigate the WML in RHRSP from MRI, pathology and behavior. RHRSP model was established by two-kidney, two-clipmethod and kept for 20 weeks. WML was decteted by magnetic resonance imaging (MRI) and loyez staining. Cognition was tested by morris water maze (MWM). Vascular changes were observed by HE staining on brain and carotid sections. Ultrastucture of blood brain barrier (BBB) were observed by transmission electron microscope. Immunofluorescence was used to detect albumin leakage and cell proliferation. T(2)-weighted MRI scans of RHRSP displayed diffuse, confluent white-matter hyperintensities. Pathological examination of the same rat showed marked vacuoles, disappearence of myelin and nerve fibers in white matter, supporting the neuroimaging findings. Spatial learning and memory impairment were observed in RHRSP. The small arteries in brain exhibited fibrinoid necrosis, hyalinosis and vascular remodeling. BBB disruption and plasma albumin leakage into vascular wall was observed in RHRSP. Increased cell proliferation in subventricular zone was seen in RHRSP. RHRSP demonstrated spontaneous WML and cognitive impairment. Hypertensive small vessel lesions and BBB disruption might paly causative factors for the onset and development of WML. The characteristic features of WML in RHRSP suggested it a valid animal model for WML.

Homocysteine: the common factor of heart and kidney injury

Homocysteine has been confirmed as the independent factor for cardiovascular disease.Hyperhomocysteinemia remains the prominent manifestation in the cases of chronic kidney disease, atypical hemolytic anemia, methylmalonic aciduria combined with kidney injuries.As the recognition of the kidney injuries caused by homocysteine remains obscure, this review tries to show the synthesis, metabolism of homocysteine and the possible mechanism of homocysteine-induced heart and kidney injuries.Besides, summarize the current treatment of lowering-hyperhomocysteinemia in order to arouse the pediatricians' attention of homocysteine which has endothelial cell toxicity and causes the wide lesions in great, middle and small vessels, and thus improve the outcomes of the patients. Key words: Homocysteine; Hyperhomocysteinemia; Cobalamin; Endothelial dysfunction; Child

Diagnosis and treatment of microangiopathic hemolytic anemia

"Microangiopathic hemolytic anemia (MAHA)" is now used to designate any hemolytic anemia related to RBC fragmentation, occurring in association with small vessel disease. In DIC, RBC fragmentation is thought to result from the deposition of fibrin or platelets within the microvasculature. The term "thrombotic microangiopathy (TMA)" is also used to describe syndromes characterized by MAHA, thrombocytopenia, and thrombotic lesions in small blood vessels. The most prominent diagnoses associated with TMA are thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). Many different disorders, including preeclampsia, infections, adverse drug reactions, hematopoietic stem cell transplantation, autoimmune diseases, and malignancies, can cause TMA (i.e., secondary TMA). Recently, because the pathogeneses of TTP and HUS have been elucidated, great progress has been made in diagnosis and treatments. However, the pathogenesis of secondary TMA remains unclear. Clinical problems awaiting solution in TMA management include determination of the positioning of rituximab in the treatment sequence of primary TTP, management of Shiga-toxin producing Escherichia coli-HUS complicated by encephalopathy, confirmation of the efficacy and long-term safety of eculizumab in the treatment of atypical HUS, and elucidating the pathogenesis of secondary TMA as well as improving the efficacy of treatment.

A comparison of location of acute symptomatic vs. 'silent' small vessel lesions.

BackgroundAcute lacunar ischaemic stroke, white matter hyperintensities, and lacunes are all features of cerebral small vessel disease. It is unclear why some small vessel disease lesions present with acute stroke symptoms, whereas others typically do not.AimTo test if lesion location could be one reason why some small vessel disease lesions present with acute stroke, whereas others accumulate covertly.MethodsWe identified prospectively patients who presented with acute lacunar stroke symptoms with a recent small subcortical infarct confirmed on magnetic resonance diffusion imaging. We compared the distribution of the acute infarcts with that of white matter hyperintensity and lacunes using computational image mapping methods.ResultsIn 188 patients, mean age 67 ± standard deviation 12 years, the lesions that presented with acute lacunar ischaemic stroke were located in or near the main motor and sensory tracts in (descending order): posterior limb of the internal capsule (probability density 0·2/mm3), centrum semiovale (probability density = 0·15/mm3), medial lentiform nucleus/lateral thalamus (probability density = 0·09/mm3), and pons (probability density = 0·02/mm3). Most lacunes were in the lentiform nucleus (probability density = 0·01–0·04/mm3) or external capsule (probability density = 0·05/mm3). Most white matter hyperintensities were in centrum semiovale (except for the area affected by the acute symptomatic infarcts), external capsules, basal ganglia, and brainstem, with little overlap with the acute symptomatic infarcts (analysis of variance, P < 0·01).ConclusionsLesions that present with acute lacunar ischaemic stroke symptoms may be more likely noticed by the patient through affecting the main motor and sensory tracts, whereas white matter hyperintensity and asymptomatic lacunes mainly affect other areas. Brain location could at least partly explain the symptomatic vs. covert development of small vessel disease.

Drug-coated balloons: a novel advance in the percutaneous treatment of coronary and peripheral artery disease

Since the introduction of plain old balloon angioplasty, there have been several improvements in the treatment of coronary artery disease, with the advent of bare metal stents and drug-eluting stents being two notable milestones. Although these stents confer better acute gains in coronary interventions, the risk of instent restenosis (ISR) remains, especially with bare metal stents. Hence, the idea of delivering antiproliferative drugs via a drug-coated balloon (DCB) has been explored to hopefully avoid the need to implant another stent within an ISR. This review aims to summarize available clinical evidence and current guidelines in the use of DCB in ISR. Additionally, the roles of DCB in de novo small vessel and bifurcation coronary lesions, in ST-elevation myocardial infarction and in peripheral arterial disease are also reviewed.

TCT-236 Four-Year Outcomes Following Implantation of the Promus Element® Platinum Chromium Everolimus-Eluting Stent in De Novo Coronary Artery Lesions in Small Vessels and Long Lesions: Results of the PLATINUM Small Vessel and Long Lesion Trials

TCT-236 Four-Year Outcomes Following Implantation of the Promus Element® Platinum Chromium Everolimus-Eluting Stent in De Novo Coronary Artery Lesions in Small Vessels and Long Lesions: Results of the PLATINUM Small Vessel and Long Lesion Trials

Clinical outcomes in real‐world patients with small vessel disease treated with XIENCE V® everolimus‐eluting stents: One year results from the XIENCE V® USA condition of approval post‐market study

The purpose of this study was to evaluate the 1-year clinical outcomes of more complex XIENCE V USA real-world patients with small versus nonsmall vessel lesions. Patients with small vessel lesions undergoing coronary stent placement are at higher risk of major adverse cardiac events. Improved safety and efficacy of XIENCE V everolimus eluting stents (EES) have been previously demonstrated in selected low-risk small vessel populations in randomized clinical trials. The XIENCE V USA study was a condition of approval, single-arm study in unselected real-world patients. Baseline and 1-year clinical outcomes were compared between XIENCE V USA patients who received a single 2.5 mm stent (small vessel group, N = 838) and patients implanted with a single >2.5 mm stent (non-small vessel group, N = 2,015). Mean reference vessel diameter was 2.55 ± 0.36 and 3.25 ± 0.46 mm in the small and non-small vessel groups, respectively (P < 0.001). Small vessel group had more females, presented with a higher rate of diabetes, and had more complex lesion characteristics. The definite or probable ST rates analyzed using Kaplan-Meier method were low and not significantly different between the groups at 0.37 and 0.40% for the small and nonsmall vessel group (P = 0.88), respectively. The composite rate of cardiac death or MI was comparable at 4.5% for the small and 5.1% for the non-small vessel 1 groups (P = 0.57). The 1-year target lesion revascularization rate was also comparable in the small vessel group (3.8% vs. 3.0%, P = 0.35). Despite gender difference, higher prevalence of diabetes and more complex lesions in the small vessel groups, the 1-year clinical outcomes were similar in both small and nonsmall vessel groups. These results demonstrate the therapeutic benefit of XIENCE V EES in a real-world all inclusive patient population with small vessel disease.

Drug eluting baloons — the new method of treating coronary artery disease

Cardiologia CROATICA Coronary artery disease (CAD) is one of the most common causes of death. Various technological advancements in interventional cardiology have significantly improved the treatment of CAD and significantly reduced the mortality of cardiovascular diseases. One recent development, the drug eluting balloon (DEB), decreases the incidence of restenosis and acute coronary events. DEB uses Paccocath technology in which the intima of the blood vessel is filled with carrier applied drug, paclitaxel, which penetrates into the lesion, preventing proliferation of vascular media and stabilizing atherosclerotic plaque. By applying that procedure the risk of restenosis is significantly reduced and most importantly the new acute coronary event. While the most common indication for DEB is stent restenosis, studies have also shown good results with bifurcation lesions, lesions in small vessels, certain lesions in native coronary arteries, and in patients who require a month of dual anti-aggregative therapy prior to noncardiac surgery. In our experience with twenty patients, the indication for DEB was restenosis in sixteen patients, lesion at a bifurcation in three patients, and a new lesion in one patient. Clinical observation was not an indication for recoronarography in any of our patients. Our early success with DEB reaffirms the method for treating CAD, with an emphasis on shortening the length of dual anti-aggregative therapy.

Skin rash and arthritis a simplified appraisal of less common associations

Skin and joint manifestations are part of the clinical spectrum of many disorders. Well-known associations include psoriatic arthritis and arthritis associated with autoimmune connective tissue diseases. This review focuses on less common associations where skin lesions can provide easily accessible and valuable diagnostic clues, and directly lead to the specific diagnosis or limit the list of possibilities. This may also affect health care resources as diagnostic tests are often low-specific, highly expensive and poorly available. This group of diseases can be divided into two subsets, based on the presence/absence of fever, and then further classified according to elementary skin lesions (macular, urticarial, maculo-papular, vesico-bullous, pustular, petechial and nodular). In most instances joint involvement occurs as peripheral migrating polyarthritis. Erythematosus macular or urticarial rashes occur in most febrile disorders such as monogenic autoinflammatory syndromes, Schnitzler's syndrome, Still's disease and rheumatic fever and afebrile diseases as urticarial vasculitis. Pustular rash may be observed in chronic recurrent multifocal osteomyelitis (CRMO) and pyogenic arthritis with pyoderma gangrenosum and acne (PAPA) syndrome (both febrile) as well as in Behcet's disease and Synovitis, acne, pustulosis, hyperostosis and osteitis syndrome (both non-febrile). Papular lesions are typical of secondary syphilis, sarcoidosis, interstitial granulomatous dermatitis, papular petechial of cutaneous small-vessel vasculitis and nodular lesions of polyarteritis nodosa and multicentric reticulohistiocytosis all of which are afebrile. Differential diagnosis includes infections and drug reactions which may mimic several of these conditions. To biopsy the right skin lesion at the right time it is essential to obtain relevant histological information.

Paclitaxel-eluting balloons or paclitaxel-eluting stents for the treatment of small-vessel coronary artery disease?

Obstructive lesions in small coronary vessels are frequent, but the percutaneous coronary intervention (PCI) of these lesions remains a challenge in contemporary practice. Failure of revascularization after PCI is principally related to restenosis of the treated vessel [1]. After PCI, vessel caliber is inversely proportional to the antirestenotic efficacy of the treatment [2,3]. Consequently, the drawbacks intrinsic to PCI, such as mechanical vessel recoil and constrictive remodeling (after plain old balloon angioplasty), as well as neointimal hyperplasia (after stent implantation), become deleterious in this setting, principally due to the vessel’s reduced ability to accommodate a given degree of late lumen loss necessitating repeat revascularization procedures. The introduction of bare-metal stents (BMS) has represented a monumental leap in interventional cardiology; however, their use in small vessels did not provide the benefits demonstrated in other types of lesions. A noteworthy trial, ISAR-SMART, comparing balloon angioplasty with BMS in vessels with a caliber between 2.0 and 2.8 mm, showed no significant differences between the two groups in angiographic or clinical restenosis at follow-up [4]. The limitations of BMS for preventing restenosis are explained by the fact that the absolute magnitude of extra acute gain achievable by stenting over balloon angioplasty in small-vessel disease is relatively small and does not compensate for the reduced capacity of these small-caliber vessels to accommodate for increased neointimal hyperplasia seen after stent implantation. The pathophysiological mechanisms underlying BMS failure in this setting have led to the search for pharmaceutical methods and biological modalities to prevent restenosis. Therefore, by targeting the biological mechanisms that underlie neointimal hyperplasia and by providing an effective delivery system that results in adequate local tissue–drug

Intravascular ultrasound analysis of small vessel lesions treated with the sparrow coronary stent system: Results of the CARE II trial

The aim of this study was to evaluate the Sparrow sirolimus-eluting stent (Sparrow-SES) against the Sparrow bare-metal stent (Sparrow-BMS) and conventional balloon-expandable bare-metal stent (BMS: Driver/Micro-Driver stent, Medtronic Vascular, Santa Rosa, CA). The Sparrow stent (Biosensors International, Singapore) consists of a guide wire-based, self-expandable, ultra-thin nitinol stent. The performance of this device with sirolimus in a fully biodegradable polymer has not been determined. A total of 74 patients were included in this intravascular ultrasound (IVUS) sub-study of the CARE II trial, which was a prospective, randomized, multicenter trial in the treatment of single de novo native coronary artery lesions in vessels ranging from 2.0 mm to 2.75 mm in diameter (Sparrow-SES: n = 31, Sparrow-BMS: n = 22, BMS: n = 21). Stent volume index (VI) was significantly increased 8-month later in Sparrow-SES and Sparrow-BMS, but not in BMS (4.0 ± 1.0 to 4.6 ± 1.0 mm(3) /mm, p<0.0001, 4.0 ± 0.6 to 4.4 ± 0.8 mm(3) /mm, p<0.05, and 5.2 ± 1.0 to 5.1 ± 0.9 mm(3) /mm, p=0.421, respectively). % neointimal obstruction in Sparrow-SES was significantly smaller than those in Sparrow-BMS and BMS at follow-up (17.6 ± 9.4 vs. 36.2 ± 13.8 and 39.9 ± 11.1%, p<0.001). Sparrow-SES showed a mean 15% stent expansion and good suppression of neointimal proliferation, resulting in a significantly lower percentage of change in lumen VI during follow-up period (Sparrow-SES: -6.2 ± 16.2%, Sparrow-BMS: -30.4 ± 11.6%, BMS: -40.4 ± 10.0%, p<0.001). The self-expanding Sparrow-SES demonstrated chronic stent expansion, good suppression of neointimal proliferation and resulted in a more preserved lumen in stented small vessels compared with the Sparrow-BMS and conventional balloon expandable BMS.

Comparison of Long-Term Outcomes Between Everolimus-Eluting and Sirolimus-Eluting Stents in Small Vessels

Although second-generation everolimus-eluting stents (EESs) have demonstrated superiority over first-generation paclitaxel-eluting stents for a broad subset of patients and lesions, it is unclear whether the same applies to sirolimus-eluting stents (SESs). The present study compared the long-term clinical outcomes between EESs and SESs in patients with small coronary artery disease. A cohort of 643 patients treated with EESs (220 patients with 245 lesions) or SESs (423 patients with 523 lesions) in small vessel lesions (defined as those receiving stents ≤2.5 mm) were retrospectively analyzed. The end points included target lesion revascularization, target vessel revascularization, major adverse cardiovascular events (all-cause death, myocardial infarction, or target lesion revascularization), and definite stent thrombosis at 1 year of follow-up. The baseline characteristics were generally similar between the 2 groups, except that more systemic hypertension was seen in the EES group and more patients had a family history of coronary artery disease in the SES group. The 1-year target lesion revascularization (5.6% vs 4.8%, p = 0.68) and target vessel revascularization (5.6% vs 7.6%, p = 0.33) rates showed no significant differences between the EES and SES groups. Overall major adverse cardiovascular events occurred in 9.1% of the EES- and 8.6% of SES-treated patients (p = 0.83). This similar major adverse cardiovascular events rate remained after adjustment. The rate of stent thrombosis was 0% in the EES group and 1.2% in the SES group (p = 0.17). In conclusion, EESs demonstrated comparable clinical outcomes to those of SESs in small vessel interventions. The absence of stent thrombosis among patients treated with EESs suggests a good safety profile for this second-generation drug-eluting stent, which should be carefully studied in a larger series of patients with small vessel disease.

Commentary: Drug-Eluting Balloons for Carotid In-Stent Restenosis: Can This Technology Deliver the Goods?

Percutaneous transluminal treatment of coronary and peripheral artery diseases has revolutionized the field of interventional medicine. Over the years, progressive technological and pharmacological advances have improved clinical outcome and offered an effective alternative to surgical treatment of atherosclerotic disease in both coronary and peripheral districts. Relatively new to this field are drug-eluting balloons (DEBs), which represent an attractive and novel treatment modality that offers numerous theoretical advantages over standard angioplasty and stent technologies. Among these benefits are homogenous distribution of an antiproliferative drug to the vessel wall (not just to segments of the wall in direct contact with stent struts); immediate drug release without the use of a polymer that could trigger late thrombosis; no prolonged, direct drug contact with the arterial wall, allowing better reendothelization of the vessel if a bare metal stent (BMS) is used in conjunction; no foreign object left in the body, which is especially important in peripheral applications where stents may be used for suboptimal results; maintenance of original vessel anatomy and flexibility, important during superficial femoral artery revascularization especially; and finally, lower restenosis rates in some indications. Recently, data from randomized clinical trials (RCT) showed that this technology is a viable alternative for the treatment of coronary in-stent restenosis (ISR) and of de novo and restenotic lesions in the peripheral arteries. Furthermore, treatment of bifurcation lesions, de novo lesions in small vessels, long lesions, and cerebrovascular interventions have been proposed. In the setting of ISR, the first major impact of DEBs in the management of ISR was shown by the results of the Paccocath ISR I trial (Treatment of In-Stent Restenosis by Paclitaxel Coated PTCA Balloons) comparing the efficacy of the Paccocath drug-eluting balloon vs. an uncoated balloon. The 6-month angiographic results showed binary restenosis and major adverse cardiovascular event (MACE) rates of 5% and 4%, respectively, in the DEB group compared with 43% and 31%, respectively, in the uncoated balloon group (p1⁄40.002 and 0.02). During a follow-up of 5.461.2 years, the clinical event rate was significantly reduced in patients treated with the DEB (59.3% vs. 27.8% MACE, p1⁄40.009), which was mainly driven by the reduction in target lesion revascularization (TLR) from 38.9% to 9.3% (p1⁄40.004).