Two-Stent Strategy for Bifurcation Lesions in Percutaneous Transluminal Coronary Angioplasty: Real-World Evidence

Background: Bifurcation lesions pose a high risk for adverse events after percutaneous coronary intervention (PCI). Evidence supporting the benefits of the two-stent strategy (2SS) for treating coronary bifurcation lesions in India is limited. This study aimed to evaluate the clinical outcomes of various 2SSs for percutaneous transluminal coronary angioplasty for bifurcation lesions in India. Materials and Methods: This retrospective, observational, multicentric, real-world study included 64 patients over 8 years. Data on demographics, medical history, PCI procedures, and outcomes were recorded. Descriptive statistics were computed using the SPSS software. Results: Patients (n = 64) had an average age of 65.3 ± 11.1 years, with 78.1% males. Acute coronary syndrome was reported in 18.8%, chronic stable angina in 40.6%, and unstable angina in 34.4% of participants. Two-vessel disease was observed in 98.4% of patients, and 99.4% had true bifurcation lesions. The commonly involved vessels were the left anterior descending artery (50%), left circumflex coronary artery (34.4%), and first diagonal artery (43.8%). Mean percent diameter stenosis was 87.2% ± 10.1%. The mean number of stents used was 2.00 ± 0.34. The 2SS techniques included the T and small protrusion (TAP) (39.1%), double kissing (DK) crush (18.8%), and the culotte techniques (14.1%). Procedural and angiographic success rate was 92.18%. Major adverse cardiovascular events at 1-year follow-up occurred in 7.8% of cases. Conclusion: The 2SS for bifurcation lesions showed favorable in-hospital and follow-up outcomes. Findings can serve as a resource for bifurcation angioplasty in India. Larger real-world studies with robust methodology are needed to validate these results.

Employing a random forest model to forecast the likelihood of coronary artery lesions in Kawasaki disease: a study centered on four biomarkers

Background:Kawasaki disease is an acute immune vasculitis,which is more common in children under 5 years old.Kawasaki disease mainly affects the cardiovascular system,especially the coronary arteries.Once coronary artery damage occurs,it can significantly impact the patient’s prognosis.Therefore,in some countries and regions,Kawasaki disease has become a common acquired heart disease.Methods:First,univariate analysis was conducted on each predictive factor.Then,Least Absolute Shrinkage and Selection Operator and random forest algorithms were used to screen all predictive factors,and the prediction model was evaluated using receiver operating characteristic curve,calibration curve,and Decision Curve Analysis.Results:This study,based on data from 228 Kawasaki disease patients,utilized a random forest model to identify four predictive factors:white blood cell count,creatine kinase isoenzyme MB,albumin,and neutrophil count.These factors were used to construct a prediction model,which achieved an area under the curve of 0.743.Conclusions:We developed a forest plot based on white blood cell count,creatine kinase isoenzyme MB,albumin,and neutrophil count to effectively predict the occurrence of coronary artery lesions in Kawasaki disease.

Homocysteine is associated with the progression of non-culprit coronary lesions in elderly acute coronary syndrome patients after percutaneous coronary intervention

Background The influence of homocysteine （Hcy） on the migration and proliferation of vascular smooth muscle cells has been well established. However, the impact of Hcy levels on the progression of non-culprit coronary lesions （NCCLs） is controversial. This study aims to evaluate whether the plasma level of Hcy is related to the progression of NCCLs after percutaneous coronary stent implantation in elderly patients with acute coronary syndrome （ACS）. Methods A total of 223 elderly patients （〉 65 years old） with ACS undergoing stent im- plantation and follow-up coronary angiography were enrolled. Laboratory determination comprised of blood sample evaluation for Hcy was carried out before baseline coronary intervention. The patients were classified into two groups according to the blood Hcy tertiles （〉 15 mmol/L or 〈 15 mmol/L）. Patients were followed up for 12.2 months. NCCL progression was assessed by three-dimensional quantitative coronary angiography. Results A significantly higher ratio of NCCL progression was observed in the group with baseline Hcy concentrations above 15 mmol/L compared to the group with concentrations below 15 mmol/L （41/127, 32.3% vs. 14/96, 14.6%, P = 0.002）. Multivariate Cox regression analysis showed that Hcy and diabetes mellitus were independent risk factors for NCCL progression. The crude haz- ard ratio （HR） of NCCL progression for Hcy level was 1.056 （95% CI： 1.01-1.104, P = 0.015）. The adjusted HR of NCCL progression for Hcy level was 1.024 （95% CI： 1.007-1.042, P = 0.007）. The adjusted HR of NCCL progression for diabetes mellitus was 1.992 （95% CI： 1.15-3.44, P = 0.013）. Conclusions Hcy is an independent risk factor for NCCL progression after 12 months of follow-up in elderly patients with ACS who has undergone percutaneous coronary stenting.

A Meta-analysis of the Biomarkers Associated with Coronary Artery Lesions Secondary to Kawasaki Disease in Chinese Children

The biomarkers associated with coronary artery lesions （CAL） secondary to Kawasaki disease （KD） in Chinese children were investigated by using Meta-analysis. We searched documents published from January 1997 to December 2009 from medical electronic databases. According to inclusion and exclusion criteria, eligible full-text papers were identified. We conducted a comprehensive quantitative analysis by using Stata10.0 statistical software package to assess the heterogeneity among the documents, calculated the summary effect and analyze publication bias and sensitivity. A total of 92 documents and 16 biomarkers were identified. All documents were case-control studies, and included 2398 patients in CAL group and 5932 patients in non-CAL （NCAL） group. The Meta-analysis showed that the levels of platelet count, platelet hematocrit （PCT）, neutrophils count, platelet distribution width （PDW）, mean platelet volume （MPV）, erythrocyte sedimentation rate （ESR）, cardiac troponin Ⅰ （cTnI）, and endothelin-1 （ET-1） in CAL group were significantly higher than those in NCAL group, and serum albumin （Alb） and hemoglobin （Hb） levels were significantly lower in CAL group （all P〈0.05）. White blood cell （WBC） count, serum sodium, matrix metalloproteinase 9 （MMP-9）, total cholesterol （TC）, hematocrit （HCT） and CD3＋T lymphocytes percentage had no statistically significant difference between the two groups. In conclusion, our results indicated that the 10 biomarkers including platelet count, neutrophils count, PCT, PDW, MPV, ESR, cTnI, ET-1, Alb and Hb were associated with CAL, and may be involved in the pathogenesis of CAL. The biomarkers of WBC count, serum sodium, MMP-9, TC, HCT, and CD3＋T lymphocytes percentage bore no relationship with the development of CAL among Chinese children with KD.

Cutting-balloon angioplasty before drug-eluting stent implantation for the treatment of severely calcified coronary lesions

Background Severely calcified coronary lesions respond poorly to balloon angioplasty, resulting in incomplete and asymmetrical stent expansion. Therefore, adequate plaque modification prior to drug-eluting stent （DES） implantation is the key for calcified lesion treat- ment. This study was to evaluate the safety and efficacy of cutting balloon angioplasty for severely calcified coronary lesions. Methods Ninety-two consecutive patients with severely calcified lesions （defined as calcium arc 〉 180% calcium length ratio 〉 0.5） treated with bal- loon dilatation before DES implantation were randomly divided into two groups based on the balloon type： 45 patients in the conventional balloon angioplasty （BA） group and 47 patients in the cutting balloon angioplasty （CB） group. Seven cases in BA group did not satisfactorily achieve dilatation and were transferred into the CB group. Intravascular ultrasound （IVUS） was performed before balloon dilatation and after stent implantation to obtain qualitative and quantitative lesion characteristics and evaluate the stent, including minimum lumen cross-sectional area （CSA）, calcified arc and length, minimum stent CSA, stent apposition, stent symmetry, stent expansion, vessel dissection, and branch vessel jail. In-hospital, 1-month, and 6-month major adverse cardiac events （MACE） were reported. Results There were no statistical differences in clinical characteristics between the two groups, including calcium arc （222.2° ± 22.2° vs. 235.0° ± 22.1 °, p=0.570）, calcium length ratio （0.67 ± 0.06 vs. 0.77± 0.05, P = 0.130）, and minimum lumen CSA before PCI （2.59 ±0.08 mm2 vs. 2.52 ± 0.08 mm2, P = 0.550）. After stent implantation, the final minimum stent CSA （6.26 ± 0.40 mm2 vs. 5.03 ± 0.33 mm2; P = 0.031） and acute lumen gain （3.74 ±0.38 mm2 w. 2.44 ± 0.29 mm2, P = 0.015） were significantly larger ila the CB group than that of the BA group. There were not statis tically differences in stent expansion, stent symmetry, incomplete stent apposition, vessel dissection and branch vessel jail between two groups. The 30-day and 6-month MACE rates were also not different. Conclusions Cutting balloon angioplasty before DES implantation in severely calcified lesions appears to be more efficacies including significantly larger final stent CSA and larger acute lumen gain, without increasing complications during operations and the MACE rate in 6-month.

Risk of coronary arterial lesions in immunoglobulin resistant Kawasaki disease

Objective: High-dose intravenous immunoglobulin (IVIG) decreases the risk for development of coronary arterial lesions (CAL) in Kawasaki disease (KD) while patients resistant to IVIG have higher risk. This study is aimed to investigate an additional therapy affects the risk for CAL in IVIG resistant KD. Design: The information from 11,510 children with KD was collected by the nationwide survey (2003-2004) in Japan. The secondary therapeutic strategies for IVIG resistant KD were an additional IVIG dose, steroids or both. The incidence of CAL was compared among 4 groups: G1, children responded to initial IVIG;G2, IVIG resistant patients receiving an additional IVIG dose;G3, IVIG resistant patients receiving additional steroids;G4, IVIG resistant patients receiving an additional IVIG dose plus steroids. CAL was assessed at 30th day of illness using ultrasound echocardiography. Results: 2229 patients (19.4%) were resistant to initial IVIG. Incidence of CAL was significantly lower in children responding to initial IVIG than in IVIG resistant patients (1.9% and 11.0%, respectively;odd’s ratio 6.3). The incidences of CAL in an each additional therapy group were as follows: G2: 6.7%, G3: 9.7%, G4: 22.2%. The risk for CAL was significantly higher in G4 as compared with G2 and G3. Giant aneurysmal formation (GA) was more frequently developed in G3 and G4 consisting of the patients receiving steroids (G1: 0.03%, G2: 0.63%, G3: 4.3%, G4: 3.7%). Conclusion: The incidence of CAL was considerably high in IVIG resistant KD and an additional therapy by steroids may increase the risk for GA.

Safety and efficacy of frequency-domain optical coherence tomography in evaluating and treating intermediate coronary lesions

AIM To establish whether frequency-domain optical coherence tomography(FD-OCT) is safe and effective in the evaluation and treatment of angiographicallyintermediate coronary lesions(ICL) METHODS Sixty-four patients with 2-dimensional quantitativecoronary angiography(2D-QCA) demonstrating ICL were included. OCT imaging was performed. According to predetermined OCT criteria, patients were assigned to either of 2 groups: OCT-guided percutaneous coronary intervention(PCI) or OCT-guided optimal medical therapy(OMT). The primary efficacy endpoint was to demonstrate the superiority and higher accuracy of FD-OCT compared to 2D-QCA in evaluating stenosis severity in patients with ICL. The primary safety endpoint was the incidence of 30-d major adverse cardiac events(MACE). Secondary endpoints included MACE at 12 mo and other clinical events.RESULTS Analysis of the primary efficacy endpoint demonstrates that 2D-QCA overestimates the stenosis severity of ICL in both the OCT-guided PCI and OMT groups, proving FD-OCT to be superior to and more precise than 2D-QCA in treating this subset of lesions. The primary safety endpoint was fully met with the incidence of 30-d MACE being nil in both the OCT-guided PCI and OCTguided OMT groups. Incidences of secondary endpoints were found to be low in both arms, the only exception being the relatively high incidence of recurrent episodes of angina which was, however, very similar in the 2 groups.CONCLUSION FD-OCT is safe and effective in the evaluation and treatment of ICL. Larger studies are needed to firmly establish the efficacy and safety of FD-OCT in treating ICL across all coronary artery disease population subgroups.

Rapid progression of nonculprit coronary lesions six weeks after successful primary PCI in culprit artery:a case report

We report a case of a 49-year-old man who was admitted with a 3-hour history of sudden onset of substemal chest pain. Coronary angiography revealed that the left circumflex artery （LCX） was acutely and totally occluded at the mid-portion. In addition, the proximal and mid-portion of the right coronary artery （RCA） had a 60% occlusion. We inferred that the LCX was the culprit artery and primary PCI was successfully performed. Six weeks later, the patient had an eventful course with recurrence of chest pain. Coronary angiography showed no significant ste- nosis in the previous LCX lesion, while the proximal and middle potion of the RCA had a 90% occlusion. Our case demonstrates the systemic nature of acute coronary syndromes and highlights the inherent instability of coronary artery disease.

The first experience of multi-gripper robot assisted percutaneous coronary intervention in complex coronary lesions

With advances in the field of interventional cardiology,percutaneous coronary intervention(PCI)has become one of the main treatment methods for patients with coronary artery disease in clinical practice.^([1])Routine interventional therapy is performed under fluoroscopic guidance,and interventional cardiologists are therefore often exposed to radiation.As a result,the risks of cancer,cataract,hair loss and loss of skin pigmentation will be significantly incre-ased after long-term radiation exposure.

Evaluation of long stent implantation in diffuse coronary lesions for octogenarians

Objective To evaluate angiographic and clinical outcomes of ≥ 20mm long stents or overlapped stent implantation in diffuse coronary lesions for octogenarians, in comparison with patients under sixty. Methods Two groups (Group O: 47 lesions in 44 octogenarians, aged 81± 3 years; Group Y: 64 lesions in 58 patients under sixty, aged 54 ± 4 years) were compared with a 6-month follow-up. Results Success rate of the procedures was 100%. None had in-hospital major adverse cardiac events (MACE). There was no significant difference in angiographic restenosis between the groups at follow-up (Group O vs Group Y, 29.8 % vs 26.6 %, P = NS). The revascularization of target vessel and MACE was less in Group Y, but these showed no statistical significance (15.6% vs 23.4% and 20.7% vs 25.0%, respectively). Conclusions Long stent implantation for diffuse coronary lesions in octogenarians appears safe and feasible, with high procedural success and favorable long-term outcomes.

Effect of ramipril on progression of nonculprit lesions in patients with ST-elevation myocardial infarction after primary percutaneous coronary intervention

Objective To investigate the effect of ramipril on progression of nonculprit lesions in patients with ST-elevation myocardial infarction(STEMI) after primary percutaneous coronary intervention(PPCI). Methods A total of 200 patients(60.1 ± 11.3 years) with STEMI who underwent successful PPCI from January 2010 to December 2013 were enrolled in this study. All patients underwent PPCI as treatment for culprit lesions. Patients were divided into two groups according to the dosage of ramipril used at hospital discharge as follows: high dosage group(2.5–10 mg, q.d.) and low dosage group(1.25–2.5 mg, q.d.). Clinical and angiographic follow-up was performed for 12 months. The primary endpoint was clinically-driven percutaneous coronary intervention(PCI) for nonculprit lesions. The clinical and angiographic features were analyzed. Results Clinical and angiographic follow-up was performed with 87 patients in the high dosage group and 113 patients in the low dosage group. The numbers of patients who underwent additional PCI were six and 20 in the high and low dosage groups, respectively. The rate of having additional PCI performed was lower in the high dosage group than in the low dosage group(6.90% vs. 17.70%, P = 0.03). Conclusions A high dosage of ramipril may prevent progression of nonculprit lesions, which could be the major cause of recurrent PCI in patients with STEMI after PPCI.

Twelve-year outcomes after revascularization for ostial/shaft lesions in unprotected left main coronary artery

Objective To evaluate a very long-term clinical outcomes of patients treated with coronary artery bypass grafting(CABG) and percutaneous coronary intervention(PCI) with drug-eluting stents(DES) for ostial/shaft lesions in unprotected left main coronary artery(ULMCA). Methods & Results A total of 472 patients with isolated ostial/shaft lesions in ULMCA were enrolled, who received DES implantation or underwent CABG between January 2003 and July 2009 in Beijing Anzhen Hospital. The major endpoints of this study were death, repeat revascularization, non-procedural myocardial infarction(MI) and stroke. The median follow-up was twelve years(interquartile range: 9.4–14.0 years) in the overall patients. There were no significant differences of incidence of death(23.3% vs. 25.6%, P = 0.227), repeat revascularization(27.3% vs. 28.4%, P = 0.423), non-procedural MI(20.0% vs. 14.5%, P = 0.561), and stroke(6.1% vs. 9.3%, P = 0.255) between PCI and CABG groups before multivariate adjusting. After adjusting covariates with multivariate Cox hazard regression model, there were still no significant differences between PCI and CABG groups. Conclusions During the median follow-up of twelve years, we found that PCI with DES was as effective and safe as CABG in patients with left main ostial/shaft lesion in this observational study.

Drug-coated balloons for treating de novo lesions in large coronary vessels:A case report

BACKGROUND Percutaneous transluminal coronary angioplasty,while an effective intervention,can frequently lead to acute occlusion with severe consequences.Although clinical trials have demonstrated the efficacy of drug-coated balloons(DCB)in treating acute coronary artery occlusion and in preventing restenosis,there has been limited exploration on the use of DCB in treating de novo lesions in large vessels.Currently,DCB are only recommended for patients with small vessel lesions and in-stent restenosis lesions,those at high risk of bleeding,and other special groups of patients.CASE SUMMARY This report presents a case of successful drug-coated balloon treatment of de novo lesions in large coronary vessels.Postoperatively,the patient demonstrated favorable recovery,with subsequent examination results revealing no significant differences from the previous examination.CONCLUSION The successful treatment of the patient in our case highlights the potential of DCB in the treatment of de novo lesions in large coronary vessels.

PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY FOR COMPLICATED CORONARY ARTERY LESIONS

Objective To research the effect of percutaneous transluminalcoronary angioplasty (PTCA) on treating complicated artery lesions.Methods Type B or type C of complicated coronary artery lesionswere confirmed by selective coronary angingraphy in 16 cases with coronaryheart disease.Gruentzig’s method was used in carring out PTCA.Results Fifteen of sixteen and thirty-two of thirty-five parts ofcoronary artery lesions were dilated successfully,the success rate was 93.7%and 88.5%,respectively.In failed four parts of PTCA,three parts werebecause of the guilding wire or the balloon failed to pass the narrow arterythrough,the other one was unable to be performed for the occurrencedsevere arrthymia during the procedure.Four stents were implantend foracute accident.Symptoms of the successful cases were improved ordisappeared after PTCA.Conclusion PTCA is also fit in treating complicated coronary arterylesions and has a better therapeutic effect,but it has more complications andrun more risks relatively.

Secondary coronary artery ostial lesions:Three case reports

BACKGROUND Atherosclerosis is one of the main causes of coronary artery ostial lesions seen clinically.Secondary coronary artery ostial lesions are rare,and cases reported previously were associated with syphilitic vasculitis and aortic dissection.Here,we report three rare cases of secondary coronary ostial lesions.Due to their rareness,these lesions can easily be neglected,which may lead to misdiagnosis and missed diagnosis.CASE SUMMARY We present three patients with acute myocardial infarction and unstable angina caused by secondary coronary artery ostial lesions.In Case 1,coronary angiography(CAG)revealed 90%stenosis of the left main coronary ostium.Chest contrast computed tomography(CT)suggested thymic carcinoma invading the left main coronary ostium.Coronary artery bypass grafting and tumor resection were performed.In Case 2,echocardiography revealed a sinus of Valsalva aneurysm(SVA)-like dilatation.CAG showed a right coronary sinus giant aneurysm and complete obstruction of the right coronary artery(RCA)ostium.Aortic contrast CT confirmed these findings.The Bentall procedure was performed.In Case 3,CT CAG identified an anomalous origin of the right coronary artery(AORCA)from the left sinus of Valsalva coursing between the aorta and pulmonary trunk,causing severe RCA ostium stenosis by compression.Surgical correction of the AORCA was performed.CONCLUSION The cases reported here suggest that we should consider other causes of coronary ostial lesions other than atherosclerosis.

A Novel guide extension assisted stenting technique for coronary bifurcation lesions

A challenging technical scenario frequently encountered in a percutaneous coronary intervention of a coronary bifurcation lesion(CBL)is stent implantation of only the stenosed segment without compromising the other two normal segments in non-true bifurcation lesions.Another is precise stent implantation covering the side branch ostium without leaving excessive stent metal at the other two segments of a bifurcation lesion in complex true bifurcation lesions.The aim of this study was to describe a novel stenting technique for both non-true and true CBLs by using a guide extension catheter(GuideLiner).With the assistance of a guide extension catheter mounted on both the main and the side-branch guidewires and with its intubation down to the bifurcation carina,a stent can be implanted in the side branch segment or distal main segment of the bifurcation lesion appropriately without compromising the other two segments of the coronary bifurcation.Stent implantation is described in three bifurcation lesions in three cases and shown in detail with illustrative figures.The technique facilitates side-branch only stenting in side-branch mono-ostial(medina 0,0,1)CBL or only the distal main segment in distal mono-ostial(medina 0,1,0)CBL without compromising the other two remaining segments when using the onestent technique in non-true CBLs without leaving unnecessary excessive stent metal at the bifurcation site and when using a two-stent technique in complex true bifurcation lesions(tri-ostial or medina 1,1,1).Consequently,through optimizing stent deployment,the technique may have the potential to reduce the risk of subacute stent thrombosis and future in-stent restenosis.The most appropriate lesions suitable for the technique,and some other practical tips are also described.

Echocardiography in Diagnosis and Prevention of the Coronary Artery Lesions in Kawasaki Disease

Kawasaki disease (muco-cutaneous lymph node syndrome, MCLS) was first reported by Kawasaki in 1967. It was characteried by nonvascular polymorphous rash, fever, ulcer in oral mucosa, edema of hands of feet, cervix lymphadenopathy and desquamations in peripheral extremities. Because of unknown pathogens, no lab examination was available as a single easily recognized diagnostic marker; the diagnosis is

Clinical applications of fractional flow reserve in bifurcation lesions

Pereutaneous coronary intervention （PCI） for coronary bifurcation lesions has been associated with lower procedural success rates and worse clinical outcomes compared with PCI for simple coronary lesions. Angiographic evaluation alone is sometimes inaccurate and does not reflect the fimctional significance of bifurcation lesions. The fractional flow reserve （FFR） is an easily obtainable, reliable, and reproducible physiologic parameter. This parameter is epicardial lesion specific and reflects both degree of stenosis and the myocardial territory supplied by the specific artery. Recent studies have shown that FFR-guided provisional side branch intervention strategy for bifurcation lesions is feasible and effective and can reduce unnecessary complex interventions and related complications. However, an adequate understanding of coronary physiology and the pitfalls of FFR is essential to properly use FFR for PCI of complex bifurcation lesions.

Excimer laser coronary atherectomy for a severe calcified coronary ostium lesion:A case report

BACKGROUND Percutaneous coronary intervention can be challenging for ostial coronary artery lesions due to calcium burden and elastic fiber content.Excimer laser coronary atherectomy(ELCA)is a less common treatment for severe calcified coronary ostium lesions.CASE SUMMARY An 81-year-old male presented to the Cardiology Department of Qingdao Municipal Hospital with a 1-year history of chest pain.Coronary angiography showed severe calcific stenosis(approximately 90%)in the right coronary artery ostium.The right coronary artery ostium was unable to be advanced using a 2.5 mm×12.0 mm balloon(NC Sprinter,Medtronic,United States)or dilated using a 2.0 mm×12.0 mm balloon(Sprinter,Medtronic,United States).The patient underwent successful ELCA and balloon dilation of the calcified coronary ostium lesion.CONCLUSION ELCA appears to be a safe and effective treatment for the management of severe calcified coronary ostium lesions.

Percutaneous coronary Intervention for ostial occlusion lesion of an anomalous right coronary artery

Ostial lesions present many challenges for percutaneous coronary intervention （PCI）. Coronary anomaly will further increase difficulties in performing PCI for the patient. We present such a case as ostial occlusion of an right coronary artery with high takeoff. A 77-year-old male was referred to our institution with a diagnosis of non-ST elevated acute myocardial infarction. Selective coronary angiography and nonselective ascending aortography could not identify the origin of the right coronary artery. Multi-slices computed tomography showed RCA ostial totally occluded. A successful PCI was performed and a perfect final result was achieved utilized with many tips and tricks, including buddy wtre technique and focused-force angloplasty（J Genatr Cardio12009, 6：189-192）.