Native Coronary Artery Stenosis Research Articles

Quantitative Coronary Angiography vs Intravascular Ultrasonography to Guide Drug-Eluting Stent Implantation

Although intravascular ultrasonography (IVUS) guidance promotes favorable outcomes after percutaneous coronary intervention (PCI), many catheterization laboratories worldwide lack access. To investigate whether systematic implementation of quantitative coronary angiography (QCA) to assist angiography-guided PCI could be an alternative strategy to IVUS guidance during stent implantation. This randomized, open-label, noninferiority clinical trial enrolled adults (aged ≥18 years) with chronic or acute coronary syndrome and angiographically confirmed native coronary artery stenosis requiring PCI. Patients were enrolled in 6 cardiac centers in Korea from February 23, 2017, to August 23, 2021, and follow-up occurred through August 25, 2022. All principal analyses were performed according to the intention-to-treat principle. After successful guidewire crossing of the first target lesion, patients were randomized in a 1:1 ratio to receive either QCA- or IVUS-guided PCI. The primary outcome was target lesion failure at 12 months, defined as a composite of cardiac death, target vessel myocardial infarction, or ischemia-driven target lesion revascularization. The trial was designed assuming an event rate of 8%, with the upper limit of the 1-sided 97.5% CI of the absolute difference in 12-month target lesion failure (QCA-guided PCI minus IVUS-guided PCI) to be less than 3.5 percentage points for noninferiority. The trial included 1528 patients who underwent PCI with QCA guidance (763; mean [SD] age, 64.1 [9.9] years; 574 males [75.2%]) or IVUS guidance (765; mean [SD] age, 64.6 [9.5] years; 622 males [81.3%]). The post-PCI mean (SD) minimum lumen diameter was similar between the QCA- and IVUS-guided PCI groups (2.57 [0.55] vs 2.60 [0.58] mm, P = .26). Target lesion failure at 12 months occurred in 29 of 763 patients (3.81%) in the QCA-guided PCI group and 29 of 765 patients (3.80%) in the IVUS-guided PCI group (absolute risk difference, 0.01 percentage points [95% CI, -1.91 to 1.93 percentage points]; hazard ratio, 1.00 [95% CI, 0.60-1.68]; P = .99). There was no difference in the rates of stent edge dissection (1.2% vs 0.7%, P = .25), coronary perforation (0.2% vs 0.4%, P = .41), or stent thrombosis (0.53% vs 0.66%, P = .74) between the QCA- and IVUS-guided PCI groups. The risk of the primary end point was consistent regardless of subgroup, with no significant interaction. Findings of this randomized clinical trial indicate that QCA and IVUS guidance during PCI showed similar rates of target lesion failure at 12 months. However, due to the lower-than-expected rates of target lesion failure in this trial, the findings should be interpreted with caution. ClinicalTrials.gov Identifier: NCT02978456.

Left internal thoracic artery bypass graft.

A 77-year-old man presented with chest discomfort on exertion for several weeks. Thirty-one years prior, he had performed on-pump coronary artery bypass grafting (CABG) using the pedicled left internal thoracic artery (LITA) to left anterior descending artery (LAD) and saphenous vein grafts (SVGs). The SVGs to the left circumflex artery had already occluded and to the right coronary artery (RCA) had previously required percutaneous coronary intervention (PCI). Although an electrocardiogram showed no remarkable change and echocardiography showed findings of known old posterior myocardial infarction, single-photon emission computed tomography demonstrated new inferior myocardial ischemia. Coronary angiography showed occlusion of all native coronary artery and severe stenosis of the residual SVG to RCA. On the other hand, the 31-year-old LITA graft revealed excellent patency (Panel and Supplementary material online, Video). Since the 1980s, the LITA for LAD grafting has been a cornerstone of CABG surgery.1 The European Society of Cardiology guideline recommends grafting with internal thoracic artery to the LAD as Class I.2 Furthermore, LITA graft had better patency than SVG for 20 years post-operatively.3 This case showed the over 30 years patency of LITA graft, although the use of a pump or the harvesting method might affect patency. This case indicated that it is precisely in patients less than 50 years of age scheduled for CABG that LITA to the LAD should be utilized.

Is coronary artery tortuosity apredisposing factor for drug-eluting stent restenosis?

Coronary artery tortuosity (CAT) is arelatively common finding on coronary angiography and may be associated with impaired left ventricular relaxation and coronary ischemia However, the significance of CAT remains unknown. This study aimed to investigate whether the severity of tortuosity in the targeted coronary segment is apredictor of stent restenosis. The study included atotal of 637 patients undergoing drug-eluting stent implantation due to stable or unstable angina and who had no native coronary artery stenosis on their last coronary angiogram. The patients were separated into two groups: 312 patients with in-stent restenosis and 325 patients without in-stent restenosis. All patients underwent computed tomography (CT) coronary angiography after invasive angiography and CAT was calculated using the computer software. Patients with in-stent restenosis had higher CAT than those without restenosis (1.25 ± 0.11 vs. 1.11 + 0.07, p < 0.001). Multivariate Cox regression analysis showed that the tortuosity index (hazard ratio [HR]: 1.246 95% confidence interval [CI]: 1.127-1.376 p < 0.001) and the circumflex lesion (HR: 1.437 95% CI: 1.062-1.942 p = 0.019) were independently associated with in-stent restenosis. With the threshold value of severe tortuosity set at 1.15, the prediction of could be made with 81% sensitivity and 80% specificity. The severity of tortuosity is proportional to coronary in-stent stenosis in patients with stable and unstable angina pectoris undergoing drug-eluting stent implantation for asevere single coronary artery.

Utility of fractional flow reserve in moderate in-stent re-stenosis and jailed side branches and comparison of fractional flow reserve with single-photon emission computed tomography-myocardial perfusion imaging in native coronary artery stenosis

Background: Functional flow reserve (FFR) is used to determine functional significance of coronary artery stenosis. FFR demonstrated discrepancy between angiographic and functional significance of jailed side branches (JSBs) as well as moderate in-stent restenosis (ISR), with only minority of such lesions having functional significance. An attempt was made to study the utility of FFR and comparison of FFR with single-photon emission computed tomography-myocardial perfusion imaging (SPECT-MPI) in native coronary artery stenoses. Methods: A total of 101 lesions in 79 patients with stable ischemic coronary artery disease were subjected to FFR and SPECT-MPI including native as well as ISR and JSB. Relation between FFR and perfusion imaging was analyzed quantitatively. Sensitivity, specificity, positive predictive value, and negative predictive value were used for diagnostic accuracy. Results: FFR was ≤≤ 0.75 in majority of the lesions having >70% stenosis. Most of the lesions having reversible perfusion defect had FFR ≤≤ 0.80. There was a significant negative correlation between summed difference score (SPECT-MPI) with FFR value. As FFR value decreased, summed difference score increased. Sensitivity and specificity did not differ much when FFR cutoff was taken as 0.75 or 0.80. Conclusion: There was a significant negative correlation between FFR and sum difference score (SPECT-MPI). Sensitivity and specificity of SPECT-MPI did not differ much when FFR value cutoff was taken as 0.75 or 0.80.

RF95 VENOUS VS ARTERIAL COMPOSITE Y-GRAFT IN CABG: A COMPUTATIONAL FLUID-STRUCTURE STUDY

Background and Aim: Arterial or venous conduits used for Y-graft have different outcomes in terms of risk of restenosis and subsequent graft failure in coronary artery bypass grafting (CABG). The aim of the study was to investigate how the choice of the graft conduit predicts the risk of graft failure. Methods: We performed a computational fluid dynamics numerical simulation (FSI) analysis to describe the blood flow in the coronary arteries and grafts. Different Y-grafts with radial artery (RA) or saphenous vein (SV) were investigated by changing their mechanical properties (Young's modulus) and geometric characteristics. Coronary artery stenosis degree was also virtually varied, to assess the fluid behaviour in relation to the severity of the stenosis. Relative Residence Time (RRT) and Von Mises (VM) stresses were used as indicators of disturbed fluid-dynamic and for the analysis of the wall mechanics, respectively. Results: A more disturbed fluid-dynamic was observed for lower stenosis degree. Retrograde flow was present in the RA graft for the 50% and 70% stenosis degree. RRT values were higher in lower stenosis degree and both grafts. RRT and VM stresses were higher for the SV graft. Conclusions: Venous Y-graft is characterized by a more disturbed flow at the anastomosis site with a higher vessel's wall shear stress compared to the arterial one. Because of the potentially negative effects of competitive flow in low-grade native coronary artery stenosis, we confirm the better long-term patency in arterial CABG for critical coronary stenosis.

Outcomes of Fractional Flow Reserve-Based Deferral in Saphenous Vein Graft Narrowing

Fractional flow reserve (FFR) has been shown to improve clinical decision-making for revascularization in intermediate coronary stenosis in native coronary arteries of patients with stable coronary disease. However, its use for saphenous vein graft (SVG) lesions has not been well validated. We sought to determine the prognostic value of deferring intervention in lesions with FFR >0.8 in SVG lesions. Clinical, angiographic, and hemodynamic variables and long-term outcomes were recorded in consecutive patients in whom percutaneous coronary intervention was deferred based on an FFR >0.8 for intermediate native coronary artery or SVG stenosis. Thirty-three patients underwent FFR of SVG lesions and were compared with 532 patients who underwent native vessel FFR during the same period. There were no differences in age (66.6 [interquartile range, IQR 63 to 76] vs 65 years [IQR 61 to 70]; p = 0.12), diabetes (41% vs 50%; p = 0.35), or hypertension (94% vs 97%; p = 0.71). During a median follow-up of 3.2 years (IQR 1.7 to 4.6 years) major adverse cardiac event was significantly higher in SVG group (36% vs 21%; log rank p = 0.01). Similarly, the rate of target vessel failure was significantly higher in the SVG group (27% vs 14%; p = 0.01). Deferred SVG lesions had the worst survival free of target vessel failure compared with deferred native lesions in both patients with and without previous CABG. An SVG lesion was an independent predictor of major adverse cardiac events on Cox proportional hazards analysis (hazard ratio 2.26; confidence interval 1.19, 4.28; p = 0.01). In conclusion, nonischemic FFR carries a significantly worse prognosis in SVG compared with non-SVG lesions. Caution is warranted in utilizing FFR for clinical decision-making in SVG lesions.

OUTCOMES OF FRACTIONAL FLOW RESERVE BASED DEFERRAL IN SAPHENOUS VEIN GRAFT LESIONS

Background: Fractional flow reserve (FFR) has been shown to improve clinical decision-making for revascularization in intermediate coronary stenosis in native coronary arteries. Howerver, its use for saphenous vein graft (SVG) lesions has not been well validated. We sought to determine the

GW27-e0656 Zotarolimus eluting Resolute Integrity versus Everolimus eluting Xience Xpedition stents in the management of very long native coronary artery stenosis- A retrospective comparative real world study with propensity match analysis

GW27-e0656 Zotarolimus eluting Resolute Integrity versus Everolimus eluting Xience Xpedition stents in the management of very long native coronary artery stenosis- A retrospective comparative real world study with propensity match analysis

Bioresorbable vascular scaffold (BVS) for the treatment of native coronary artery stenosis: one year outcome

Abstract Background The newer generation of Bioresorbable Vascular Scaffold ABSORB (BVS 1.1) showed better outcome in regard to scaffold area reduction as a result of improved scaffold design and enhanced polymer processing. Objective To assess the safety and efficacy of treating significant native coronary artery stenosis using ABSORB BVS. Methods Ninety-nine patients with de novo native significant coronary artery stenosis were selected between September 2012 and September 2014 and were treated using ABSORB BVS. For each patient, the target and the peri-scaffold segments (5 mm proximal and distal to the scaffold edge) were analyzed by Quantitative Coronary Angiography (QCA) and Intravascular Ultrasound (IVUS) immediately after the procedure and at one year of follow-up. The major clinical endpoint was ischemia-driven major adverse cardiac events (ID-MACE) defined as a composite of cardiac death, myocardial infarction or ischemia-driven target lesion revascularization (ID-TLR). Results At one year, the overall scaffold area did not demonstrate any significant change. The angiographic insegment late lumen loss was estimated to be 0.11 ± 0.19 mm, while the IVUS assessment revealed a non-significant decrease in the minimal lumen area by 0.5% (p = 0.79), without significant change in the mean lumen area. There were no reported cardiac deaths. However, two cases of ID-TLR were recorded, one case with STEMI after two weeks due to thrombosis at the distal edge of the BVS and another case with restenosis after one year. Both were treated with metallic drug-eluting stents (Xience V). At one year the overall ID-MACE was found to be 2%. Conclusion The performance of ABSORB BVS in the treatment of significant de novo native coronary artery stenosis makes it an attractive option with favorable early and late outcome.

Evaluation of vascular healing of polymer-free sirolimus-eluting stents in native coronary artery stenosis: a serial follow-up at three and six months with optical coherence tomography imaging

Our aim was to assess vascular response after polymer-free sirolimus-eluting stent (SES) implantation by using an optical coherence tomography (OCT)-derived vascular healing score (HS), quantifying the deficiency of healing. In a prospective, multicentre, single-arm, open-label study, OCT examinations were performed at three months in 45 patients (47 lesions). Per protocol, 24 lesions which had not reached adequate vascular healing according to study criteria were scheduled for OCT examination at six months. The HS was calculated at two time points. Serial OCT imaging demonstrated that the proportion of covered stent struts increased from a median of 87.1% at three months to 98.6% at six months (p<0.001). The neointimal thickness increased from a median of 82.8 µm to 112.2 µm (p<0.001), whereas the median percentages of malapposed struts were 0.2% and 0.0% at the two respective time points. Neointimal volume obstruction increased from 6.3% to 12.8%, and the HS decreased from a median of 28.1 at three months to 2.4 at six months. In patients who had inadequate vascular healing three months after polymer-free SES implantation, serial OCT showed almost complete vascular healing at six months.

Late structural discontinuity and migration of a bioabsorbable scaffold in a saphenous vein graft

The use of bioresorbable vascular scaffolds (BVS) has many important and potentially useful features, on both pathophysiological and clinical grounds, for the treatment of native coronary artery stenosis. These advantages are less well established when BVS are employed in saphenous vein graft disease. We here describe a peculiar behavior of a previously (6 months) implanted BVS in a degenerated saphenous vein graft during treatment of an in-stent restenosis in a patient suffering from unstable angina. This BVS particular performance seems to suggest that different pathophysiological and anatomical conditions may play a relevant role in affecting the results of transluminal vascular therapy.

Hemodynamics of left internal mammary artery bypass graft: Effect of anastomotic geometry, coronary artery stenosis, and postoperative time

Although the left internal mammary artery (LIMA) bypass graft is the best choice for surgical revascularization, its hemodynamics are still complex and can result in long-term graft failure. Here, we performed a hemodynamic analysis of the LIMA-coronary artery with end-to-side/side-to-side anastomoses based on 15 patient-specific CTA images at various postoperative periods. We hypothesize that hemodynamic patterns are determined by the interplay of LIMA geometry, anastomotic configuration, and severity of native coronary artery stenosis, which are strongly affected by the postoperative time. A 3D finite volume method with the inlet pressure wave and outlet resistance boundary conditions was used to compute the distribution of pressure and flow, from which the time-averaged wall shear stress (TAWSS), oscillation shear index (OSI), time-averaged WSS gradient (TAWSSG), and transverse WSS (transWSS) were determined. To characterize the hemodynamic environment, we defined surface area ratios of low TAWSS (≤4dynes/cm2), high OSI (≥0.15), TAWSSG (≥500dynes/cm3), and transWSS (≥6dynes/cm2) in the LIMA graft and at the anastomosis between LIMA graft and coronary artery. These ratios were determined by the interplay of multiple morphometric parameters in the LIMA-coronary artery, but increased with postoperative time. These findings have significant implications for understanding LIMA graft patency.

Percutaneous coronary interventional strategies for treatment of in-stent restenosis: a network meta-analysis

Percutaneous coronary intervention (PCI) with drug-eluting stents is the standard of care for treatment of native coronary artery stenoses, but optimum treatment strategies for bare metal stent and drug-eluting stent in-stent restenosis (ISR) have not been established. We aimed to compare and rank percutaneous treatment strategies for ISR. We did a network meta-analysis to synthesise both direct and indirect evidence from relevant trials. We searched PubMed, the Cochrane Library Central Register of Controlled Trials, and Embase for randomised controlled trials published up to Oct 31, 2014, of different PCI strategies for treatment of any type of coronary ISR. The primary outcome was percent diameter stenosis at angiographic follow-up. This study is registered with PROSPERO, number CRD42014014191. We deemed 27 trials eligible, including 5923 patients, with follow-up ranging from 6 months to 60 months after the index intervention. Angiographic follow-up was available for 4975 (84%) of 5923 patients 6-12 months after the intervention. PCI with everolimus-eluting stents was the most effective treatment for percent diameter stenosis, with a difference of -9·0% (95% CI -15·8 to -2·2) versus drug-coated balloons (DCB), -9·4% (-17·4 to -1·4) versus sirolimus-eluting stents, -10·2% (-18·4 to -2·0) versus paclitaxel-eluting stents, -19·2% (-28·2 to -10·4) versus vascular brachytherapy, -23·4% (-36·2 to -10·8) versus bare metal stents, -24·2% (-32·2 to -16·4) versus balloon angioplasty, and -31·8% (-44·8 to -18·6) versus rotablation. DCB were ranked as the second most effective treatment, but without significant differences from sirolimus-eluting (-0·2% [95% CI -6·2 to 5·6]) or paclitaxel-eluting (-1·2% [-6·4 to 4·2]) stents. These findings suggest that two strategies should be considered for treatment of any type of coronary ISR: PCI with everolimus-eluting stents because of the best angiographic and clinical outcomes, and DCB because of its ability to provide favourable results without adding a new stent layer. None.

Abstract 711: In Hospital Complications After PCI After Insertion of DES versus BMS in the United States

Background: We evaluated the potential differences in patient complications and in-hospital mortality for patients who underwent primary percutaneous coronary intervention (PCI) with insertion of drug-eluting coronary artery stent (DES) versus those with insertion of bare metal stent (BMS) in the United States. Method: We used the Nationwide Inpatient Sample to examine differences in all-cause in-hospital mortality between DES versus BMS patients with a principal diagnosis of STEMI, NSTEMI and Coronary atherosclerosis ICD-9 codes. Bivariate and adjusted logistic regression analysis were used to identify any associations with DES versus BMS with increased subsequent complications and in-hospital mortality. Results: We identified 9140 admissions with PCI as a primary intervention, of which 85.03% native coronary artery stenosis, 5.9% presented with NSTEMI, 4.9% had STEMI, and 4.0% revascularized due to graft stenosis. Patients with graft stenosis and STEMI had the highest rates of BMS insertion (62% and 49% respectively). The odds of in-hospital mortality were higher for BMS insertion among all for different group. However, the association lost the statistical significance after adjusting for patient characteristics, except for patients with native coronary artery stenosis (OR =1.96 95% CI: 1.02-3.8). Major complications, including vascular, neurological, and mechanical complications were higher for BMS insertion for NSTEMI and graft coronary atherosclerosis patients. However, BMS insertion associated with less complication in STEMI patients and native coronary atherosclerosis. the later didn’t reach the statistical significance level. Interestingly, there was no in-hospital mortality in our sample among male with DES insertion. Conclusion: The clinical context of PCI and choice of DES versus BMS, with BMS a preferential choice in patients with evidence of thrombus (STEMI) is reflected in downstream complications and in-hospital mortality.

Diagnostic accuracy of multidetector computed tomography coronary angiography in 325 consecutive patients referred for transcatheter aortic valve replacement

Multidetector computed tomography (MDCT) provides detailed assessment of valve annulus and iliofemoral vessels in transcatheter aortic valve replacement (TAVR) patients. However, data on diagnostic performance of MDCT coronary angiography (MDCT-CA) are scarce. The aim of the study is to assess diagnostic performance of MDCT for coronary artery evaluation before TAVR. A total of 325 consecutive patients (234 without previous myocardial revascularization, 49 with previous coronary stenting, and 42 with previous coronary artery bypass graft [CABG]) underwent invasive coronary angiography and MDCT before TAVR. MDCT-CA was performed using the same data set dedicated to standard MDCT aortic annulus evaluation. Multidetector computed tomography-CA evaluability and diagnostic accuracy in comparison with invasive coronary angiography as criterion standard were assessed. The MDCT-CA evaluability of native coronaries was 95.6%. The leading cause of unevaluability was beam-hardening artifact due to coronary calcifications. In a segment-based analysis, MDCT-CA showed sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for detecting ≥50% stenosis of 91%, 99.2%, 83.4%, 99.6% and 98.8%, respectively. The MDCT-CA evaluability of coronary stents was 82.1%. In a segment-based analysis, MDCT-CA showed sensitivity, specificity, PPV, NPV, and accuracy for detecting ≥50% in-stent restenosis of 94.1%, 86.7%, 66.7%, 98.1%, and 88.3%, respectively. All CABGs were correctly assessed by MDCT-CA. In a patient-based analysis, MDCT-CA showed sensitivity, specificity, PPV, NPV, and accuracy of 89.7%, 90.8%, 80.6%, 95.4%, and 90.5%, respectively. Multidetector computed tomography-CA allows to correctly rule out the presence of significant native coronary artery stenosis, significant in-stent restenosis, and CABG disease in patients referred for TAVR.

Assessment of Radial Artery Graft Patency in Symptomatic Patients

The purpose of this study is to evaluate the patency of radial artery (RA) grafts consistent with the target vessel characteristics. Between October 2001 and January 2012, 83 symptomatic patients or patients with positive ischemic test results underwent coronary angiography following coronary artery bypass grafting. Of these, 68 patients with 81 RA grafts at a mean 49.2 ± 31.9 months (range, 1-137 months) were evaluated. According to the location and degree of proximal stenosis, 5-year graft patency was determined by Kaplan-Meier analysis. The relationships between RA graft patency and degree of proximal stenosis, target vessel location, and inflow characteristics of grafts were assessed by means of Cox proportional hazard models. Mean age of the patients was 56.4 ± 10.2 years. The period between the operation and postoperative coronary angiography was 49.2 ± 31.9 months (range, 1-137 months; median, 48.8 months). There was no impact on RA patency with regard to preoperative characteristics of the patients. RA patency was higher for left coronary system compared with right system (p = 0.038; 85.5 vs. 65.4%). In addition, patency rate was statistically higher for the proximal stenosis ≥ 90% (odds ratio, 3.65; 95% confidence interval, 1.20-11.07; p = 0.018). Kaplan-Meier patency analysis showed a patency of RA as 79.2% at 5 years. RA graft patency differs with degree of preoperative native coronary artery stenosis and location of target vessel. RA grafts to not severely stenosed (< 90%) coronary system and to the right coronary territory carry a remarkably high risk of graft failure.

Evaluation of coronary artery bypass grafts patency using CT angiography: a reports of multi-center study

Objective To investigate the diagnostic value of computed tomography angiography (CTA) for assessing patency of coronary artery bypass grafts (CABG) using conventional coronary artery angiography (CAG) as the reference standard.Methods This study was a multicenter study in China.A total of 83 participants had been enrolled,including 63 male patients (75.9％),age of (64 ± 9) years (44-84 years).The inclusion criteria were patients who had been performed both CAG and CTA within 3 months.Thirty of them had been scanned by 64 multidetector row spiral CT,and 53 of them had been scanned by dual source CT scanner.Two groups of radiologists evaluated CAG and CTA datasets blindly,and the results of CTA for assessing both stenosis (≥50％) and occlusion of CABGs were compared with the CAG results.Receiver operating characteristic (ROC) curves were used to evaluate the diagnostic efficacy of CTA.Results Among 83 cases,the median follow-up time after CABG surgery was 58.6 (1.0-227.1) months.A total of 240 CABG vessels were analyzed,including 80 arterial grafts and 160 venous grafts.The patent grafts to left anterior descending were 93 (78.8％,93/118),to left circumflex were 34 grafts (58.6％,34/58),and to the right coronary artery were 35 grafts (54.7％,35/64),derived a total patency of 67.5％ (162/240).In comparison to CAG results,the sensitivity and specificity of CTA for detecting CABG stenosis (≥50％) were 88.6％ (93/105) and 94.1％ (127/135),area under ROC curve was 0.917.For detecting CABG occlusion,the sensitivity and specificity were 97.4％ (76/78)and 96.9％ (157/162),area under ROC curve was 0.972.For the detection of native coronary artery stenosis and occlusion,the areas under ROC curves were 0.889 and 0.836,respectively.Conclusions CTA is a tool with high diagnostic sensitivity and specificity to evaluate stenosis and occlusion of CABG.The diagnostic efficacy is higher than the evaluation of native coronary arteries. Key words: Coronary artery disease; Coronary revascularization; Tomography,X-ray computed; Coronary angiography

Bioresorbable Vascular Scaffold (ABSORB BVS); first report in Egyptian patients with 6month angiographic/IVUS follow up

To evaluate the feasibility, efficacy, and safety of the ABSORB BVS (Bioresorbable Vascular Scaffold) for the treatment of de novo native coronary artery stenosis. Thirty patients with ischemic heart disease were selected between September 2012 and December 2012 and received ABSORB BVS for the treatment of de novo native significant coronary artery stenosis. Patients were followed up for six months after the procedure. In each patient, the treated segment and the periscaffold segments (5 mm proximal and distal to the scaffold edge) were analyzed by Quantitative coronary angiography (QCA) and phased-array intravascular ultrasound (IVUS) catheters in paired matched angiographic views after the procedure and at follow-up. The major clinical end point was ischemia-driven major adverse cardiac events (ID-MACE) defined as a composite of cardiac death, myocardial infarction or ischemia-driven target lesion revascularization. Overall the scaffold area remained unchanged. The angiographic late lumen loss amounted to 0.27 ± 0.32 mm with an IVUS relative decrease in minimal lumen area of 1.94% ( p = 0.12), without significant changes in the mean lumen area. After 2 weeks, 1 patient presented with STEMI, control coronary angiography revealed a patent stent with thrombus distal to it that was treated with a metallic drug-eluting stent (Xience V). There were no cardiac deaths or ischemia-driven target lesion revascularizations. At six months the hierarchical ID-MACE was 3.3%. ABSORB BVS seems an attractive option for the treatment of significant de novo native coronary artery stenosis with low risk of serious adverse events.

Elutax paclitaxel-eluting balloon followed by bare-metal stent compared with Xience V drug-eluting stent in the treatment of de novo coronary stenosis: A randomized trial

Paclitaxel-eluting balloons (PEBs) are a promising alternative to drug-eluting stent (DES) in the treatment of coronary stenoses. The aim of our study was to compare the 9-month restenosis rates of a strategy of predilatation with PEB followed by bare-metal CoCr stent (PEB + BMS group) versus implantation of everolimus DES (DES group). This randomized, single-center study planned to enroll 366 patients with stable angina (183 patients per arm) undergoing percutaneous coronary intervention of a de novo, native coronary artery stenosis ≤ 15 mm in length. Primary end point, in a noninferiority study design, was 9-month binary angiographic restenosis. A frequency-domain optical coherence tomography substudy investigated the percentage of uncovered stent struts per lesion, the percentage of malapposed/uncovered struts per lesion, and the percentage of net volume obstruction at 9-month follow-up among the first consecutive 30 patients enrolled in the PEB + BMS group. The study was prematurely halted after enrollment of 125 patients, 59 in the PEB + BMS group and 66 in the DES group, because of excess of ischemia-driven target lesion revascularization in the PEB + BMS group. When all the enrolled patients completed their follow-up, IDLTR rates were 14% in the PEB + BMS versus 2% in DES group (P = .001). Binary restenosis, either in-stent or in-segment, was significantly higher in the PEB + BMS compared with DES group (17% vs 3% [P = .01] and 25% vs 4% [P = .009] respectively). Frequency-domain optical coherence tomography demonstrated important neointimal regrowth in the PEB + BMS group, similar to historical BMS data. In the treatment of de novo coronary stenosis, a strategy of predilatation with PEB before BMS implantation was significantly inferior to implantation of an everolimus DES stent in terms of 9-month target lesion revascularization. Frequency-domain optical coherence tomography data confirm the lack of efficacy of this strategy.

Long-term clinical outcome after fractional flow reserve– versus angio-guided percutaneous coronary intervention in patients with intermediate stenosis of coronary artery bypass grafts

Fractional flow reserve (FFR)-guided percutaneous revascularization (percutaneous coronary intervention [PCI]) of intermediate stenosis in native coronary artery is safe and associated with better clinical outcomes as compared with an angiography-guided PCI. It is unknown whether this applies to coronary artery bypass grafts (CABGs). We included 223 patients with CABG and with stable or unstable angina and an intermediate stenosis involving an arterial or a venous graft. Patients were divided into 2 groups: FFR guided (n = 65, PCI performed in case of FFR ≤0.80) and angio guided (n = 158, PCI performed based on angiographic evaluation). Primary end point was major adverse cardiac and cerebrovascular event, defined as death, myocardial infarction, target vessel failure, and cerebrovascular accident (CVA). The 2 groups were similar in terms of demographic and clinical characteristics. Percutaneous coronary intervention was performed in 23 patients (35%) of the FFR-guided group and 90 patients (57%) of the angio-guided group (P < .01). In the FFR-guided group, PCI was more often performed in arterial grafts as compared with the angio-guided group (16 [70%] vs 12 [13%], respectively; P < .01). Follow-up was obtained in 96% of patients at a median of 3.8 years (1.6-4.0 years). At multivariate analysis, major adverse cardiac and cerebrovascular event rate was significantly lower in the FFR-guided group as compared with the angio-guided group (18 [28%] vs 77 [51%], hazard ratio 0.33 [0.11-0.96], P = .043]. Procedure costs were overall reduced in the FFR-guided group (€2240 ± €652 vs €2416 ± €522, P = .03). An FFR-guided PCI of intermediate stenosis in bypass grafts is safe and results in better clinical outcomes as compared with an angio-guided PCI. This clinical benefit is achieved with a significant overall reduction in procedural costs.