Drug-eluting balloons versus new generation drug-eluting stents for the management of in-stent restenosis: an updated meta-analysis of randomized studies

Background New-generation drug-eluting stents (DES) was more effective in the treatment of in-stent restenosis (ISR) compared with the first-generation DES. Drug-eluting balloons (DEB) and new-generation DES had been available strategies in treatment of bare-metal stents/DES ISR (BMS/DES-ISR). Six new randomized trials have recently examined the angiographic outcomes and one-year clinical outcomes of DEB and new generation DES in BMS/DES-ISR. However, the optimal management for BMS/DES-ISR lesions remains controversial. Methods We searched the randomized clinical trials evaluating the angiographic outcomes and one-year clinical outcomes of DEB and new-generation DES in patients with BMS/DES-ISR. The primary endpoints were the angiographic outcomes, including the minimal luminal diameter (MLD), diameter stenosis %(DS%), late lumen loss (LLL), and binary restenosis (BR). Results A total of six randomized clinical trials with 1177 BMS/DES-ISR patients were included in our meta-analysis. For angiographic outcomes, there were significantly less MLD and more DS% with DEB compared to new-generation DES (MLD: MD =?0.18, 95% CI:?0.31– ?0.04, P < 0.001;DS%: MD = 5.68, 95% CI: 1.00–10.37, P < 0.001). Moreover, for one-year clinical outcomes, DEB was associated with a significant increase risk in target lesion revascularization (TLR)(RR = 2.93, 95% CI: 1.50–5.72, P = 0.002). However, DEB was associated with higher risks of major adverse cardiac event, target vessel revascularization, TLR, BR, and more DS% only in DES-ISR group. Conclusions DEB and new-generation DES have the similar clinical efficacy for the treatment of BMS-ISR. However, DES showed more MLD, less DS%, and a decreased risk of TLR for the treatment of DES-ISR.

Recent advances in cardiovascular stent for treatment of in-stent restenosis:Mechanisms and strategies

Treatments of atherogenesis,one of the most common cardiovascular diseases(CVD),are continuously being made thanks to innovation and an increasingly in-depth knowledge of percutaneous transluminal coronary angioplasty(PTCA),the most revolutionary medical procedure used for vascular restoration.Combined with an expanding balloon,vascular stents used at stricture sites enable the long-time restoration of vascular permeability.However,complication after stenting,in-stent restenosis(ISR),hinders the advancement of vascular stents and are associated with high medical costs for patients for decades years.Thus,the development of a high biocompatibility stent with improved safety and efficiency is urgently needed.This review provides an overview of current advances and potential technologies for the modification of stents for better treatment and prevention of ISR.In particular,the mechanisms of in-stent restenosis are investigated and summarized with the aim to comprehensively understanding the pathogenesis of stent complications.Then,according to different therapeutic functions,the current stent modification strategies are reviewed,including polymeric drug eluting stents,biological friendly stents,prohealing stents,and gene stents.Finally,the review provides an outlook of the challenges in the design of stents with optimal properties.Therefore,this review is a valuable and practical guideline for the development of cardiovascular stents.

Comparison of the efficacy of drug-eluting balloon for de novo lesions and in-stent restenosis lesions of the femoropopliteal arteries

Objective:To compare the efficacy of drug-eluting balloons for de novo and in-stent restenosis(ISR)for lesions of the femoropopliteal arteries during 12-month follow-up.Materials and methods:A retrospective analysis of 66 patients was performed.These patients had lower extremity atherosclerosis obliterans and were treated with drug-eluting balloons from June 2016 to June 2017.All the lesions were femoropopliteal,including 47 de novo lesions and 19 ISR lesions.Clinical results were followed up at 6 months and 12 months postoperatively.The primary patency rate,target lesion revascularization,Rutherford classification,ankle-brachial index,amputation rate and mortality were compared between the two groups.Results:All the 66 patients underwent the treatment of femoropopliteal artery lesions with unilateral limbs.The surgical success rates were 100%.No adverse events such as acute ischemia or amputation occurred in the hospital.There was no difference between the two groups'Rutherford classification and the ankle-brachial index at the 6-month follow-up(p>0.05).At the 12-month follow-up,the de novo group's Rutherford classification was lower than the ISR group(p=0.026),and the ankle-brachial index of the ISR group was lower(0.66±0.033 vs 0.52±0.056,p=0.036).There was no difference between the patency rate of the de novo group and the ISR group(93.6%vs 84.2%,p=0.229)at the 6-month follow-up.However,the ISR group patency rate was lower at the 12-month follow-up(63.2%vs 85.1%,p=0.048).As for revascularization there was no significant difference between the two groups at the 6-month follow-up(4.2%vs 10.5%,p=0.334),but a higher rate occurred in the ISR group at the 12-month follow-up(26.3%vs 6.4%,p=0.025).There were no significant differences in the mortality or amputation rate between the two groups(p>0.05).Conclusions:Drug-eluting balloons were effective in treating both de novo lesions and ISR lesions in the atherosclerotic femoropopliteal artery,but the 12-month follow-up results of ISR lesions were less favorable than the de novo lesions.

Increased serum TREM-1 level is associated with in-stent restenosis,and activation of TREM-1 promotes inflammation,proliferation and migration in vascular smooth muscle cells

Background and Objective In-stent restenosis(ISR)remains a major limitation of percutaneous coronary intervention despite improvements in stent design and pharmacological agents,whereas the mechanism of ISR has not been fully clarified.In the present study,we sought to investigate the potential association of serum soluble TREM-1(sTREM-1)levels with the incidence of ISR.The role of TREM-1 was evaluated in cultured vascular smooth muscle cells(VSMCs).

Intracoronary brachytherapy for the treatment of recurrent drugeluting stent in-stent restenosis:A systematic review and metaanalysis

BACKGROUND We performed a meta-analysis on observational studies since randomized control trials are not available.We studied intracoronary brachytherapy(ICBT)and recurrent drug eluting stent in-stent restenosis(DES-ISR)to evaluate the procedural success,target lesion revascularization(TLR),incidence of myocardial infarction(MI)and all-cause mortality at 2 years follow-up.AIM To perform meta-analysis for patients undergoing ICBT for recurrent DES-ISR.METHODS We performed a systematic search of the PubMed/MEDLINE,Cochrane and DARE databases to identify relevant articles.Studies were excluded if intracoronary brachytherapy was used as a treatment modality for initial ISR and studies with bare metal stents.We used a random-effect model with DerSimonian&Laird method to calculate summary estimates.Heterogeneity was assessed using I2 statistics.RESULTS A total of 6 observational studies were included in the final analysis.Procedural angiographic success following intra-coronary brachytherapy was 99.8%.Incidence of MI at 1-year was 2%and 4.1%at 2-years,respectively.The incidence of TLR 14.1%at 1-year and 22.7%at 2-years,respectively.All-cause mortality at 1-and 2-year follow-up was 3%and 7.5%,respectively.CONCLUSION Given the observational nature of the studies included in the analysis,heterogeneity was significantly higher for outcomes.While there are no randomized controlled trials or definitive guidelines available for recurrent ISR associated with DES,this analysis suggests that brachytherapy might be the alternative approach for recurrent DES-ISR.Randomized controlled trials are required to confirm results from this study.

Finite Element Simulation of In-Stent Restenosis with Tissue Growth Model

In this study, a finite element simulation of in-stent restenosis (ISR) is conducted to simulate the deployment and expansion of a stent in an occluded artery with a contact model and a mechanics-based growth model. A tissue growth model based on the multiplicative decomposition of deformation is applied to investigate the growth of the plaque and artery wall upon the stent’s implantation. Due to the high stresses at the contact points between the stent struts and the tissue, further tissue injury or restenosis is observed. The simulation results show that after the stent deployment, the von Mises stress is significantly larger in the plaque compared to the artery wall, especially in the region that is in contact with the stent. However, the growth of the plaque and artery tends to even out the stress concentration over time. The tissue growth is found to be more significant near the inner wall than the outer layer. A 0.77 mm restenosis is predicted, which agrees with published clinical observations. The features of the artery growth are carefully analyzed, and the underlying mechanism is discussed. This study is the first attempt to apply finite element analysis to artery restenosis, which establishes a framework for predicting ISR’s occurrence and severity. The results also provide insights into understanding the underlying mechanism of in-stent restenosis.

Clinical study about the effect of Simiao Yong'an Decoction on preventing in-stent restenosis and regulating inflammation and oxidative stress after lower extremity stent angioplasty stenting

Objective:To study the effect of Simiao Yong'an Decoction on the prevention of in-stent restenosis and the regulation of inflammation and oxidative stress after lower extremity stent angioplasty.Methods:A prospective study was conducted on 60 ASO patients who underwent lower extremity stent angioplasty in our hospital between January 2014 and January 2018.The patients were randomly divided into observation group receiving postoperative Simiao Yong'an Decoction combined with antiplatelet drug treatment and control group receiving postoperative antiplatelet drug treatment.The conditions of in-stent restenosis were followed up,and the indicators of coagulation,inflammation and oxidative stress were detected.Results:The incidence of in-stent restenosis in observation group 1 year after operation was significantly lower than that in control group;6 months and 12 months after operation,the ankle brachial index(ABI)levels,minimal lumen diameter(MLD)levels at the stent and superoxide dismutase(SOD)contents of observation group were significantly higher than those of control group,whereas D-dimer(D-D)and fibrinogen degradation product(FDP)levels as well as P-selectin,C-reactive protein(CRP),tumor necrosis factor-α(TNF-α),malondialdehyde(MDA)and inducible nitric oxide synthase(iNOS)contents were significantly lower than those of control group.Conclusions:Simiao Yong'an Decoction can prevent the in-stent restenosis and inhibit the inflammation and oxidative stress after lower extremity stent angioplasty.

Restenosis of a drug eluting stent on the previous bioresorbable vascular scaffold successfully treated with a drug-coated balloon: A case report

BACKGROUND The in-stent restenosis(ISR)rates are reportedly inconsistent despite the increased use of second-generation drug eluting stent(DES).Although bioresorbable vascular scaffold(BVS)have substantial advantages with respect to vascular restoration,the rate of scaffold thrombosis is higher with BVS than with DES.Optimal treatment strategies have not been established for DES-ISR to date.CASE SUMMARY We report on a case of a 60-year-old man patient with acute coronary syndrome.He had a history of ST-segment elevation myocardial infarction associated with very late scaffold thrombosis and treated with a DES.Coronary angiography revealed significant stenosis,suggesting DES-ISR on the previous BVS.Optical coherence tomography(OCT)identified a plaque rupture and a disrupted scaffold strut in the neointimal proliferation of DES.To treat the DES-ISR on the previous BVS,we opted for a drug-coated balloon(DCB)after a balloon angioplasty using a semi-compliant and non-compliant balloon.The patient did not experience adverse cardiovascular events on using a DCB following the use of intensive dual antiplatelet therapy and statin for 24 mo.CONCLUSION This case highlights the importance of OCT as an imaging modality for characterizing the mechanism of target lesion failure.The use of a DCB following the administration of optimal pharmacologic therapy may be an optimal strategy for the treatment and prevention of recurrent BVS thrombosis and DES-ISR.

Clinico-Angiographic Profile and Prevalence of Restenosis in Patients Undergoing Percutaneous Transluminal Coronary Angioplasty to Left Main Coronary Artery: An Observational Cohort Study

Background: Patients who underwent percutaneous coronary intervention in left main coronary artery (LMCA) requires special concern, being high risk and increasing patient population. The aim of this study was to assess the clinical profile, angiographic status, and prevalence of restenosis in patients who underwent percutaneous transluminal coronary angioplasty (PTCA) in LMCA. Materials and Methods: This observational cohort study included 17 patients who underwent PTCA in LMCA during one-year study period at tertiary care centers in Government Medical College, Kozhikode, India. Data including various risk factors, clinical and angiographic details, stent used, procedural complications and outcomes including rate of restenosis were analyzed. Results: A total of 17 patients (mean age 53.88 ± 9.80 years) with 76.47% of males were included in the study. Smoking and hypertension were the most common risk factors presented in 52.94% and 47.06% of patients respectively. Single vessel disease (SVD) of LMCA was the most common pattern observed in 47.10%;the rate of restenosis was observed in 11.76% patients. Revascularization was performed in one patient (5.88%) with coronary artery bypass graft and in one patient (5.88%) with PTCA using drug eluting stent (DES). The overall procedural success was 88.24% in this study. Survival rate was 100% at one-year follow-up period. Conclusion: Our study involved patients who underwent PTCA in LMCA, showed smoking as a most prevalent risk factor for coronary artery disease and SVD as a most common pattern, comparatively low rate of restenosis and 100% of survival rate at one-year follow-up period.

Construction and Analysis of an LncRNA-miRNA-mRNA Network Based on Competitive Endogenous RNA Reveal miRNAs Potentially Involved in In-stent Restenosis after Percutaneous Coronary Intervention

Objective:Percutaneous coronary intervention is one of the most common procedures used for the invasive treatment of patients with coronary heart disease;the incidence of in-stent restenosis(ISR)after percutaneous coronary intervention is 5%to 15%.In this study,a competitive endogenous RNA(ceRNA)network was constructed to investigate potential mechanisms involved in ISR.Methods:The expression data for differentially expressed microRNAs(DEmiRNAs)and messenger RNAs(mRNAs)between patients with and without ISR were obtained using limma package.Long noncoding RNAs(lncRNAs)were predicted based on the DEmiRNAs using the miRDB,miRTarBase,and TargetScan databases.An ISR-specific ceRNA network was subsequently constructed and investigated.To verify the key miRNAs of ceRNA,patients with and without ISR were enrolled from Guangdong Provincial Hospital of Chinese Medicine between January 2017 and December 2018(n=8,respectively);plasma was collected from all enrolled patients.Results:Based on the raw data obtained from the Gene Expression Omnibus database,472 DEmiRNAs and 304 differentilly expressed messenger RNAs between patients with and without ISR were identified.A ceRNA network was constructed by combining 270 IncRNAs,3 miRNAs(miR-125,miR-140,and miR-206),and 4 mRNAs(STRADB,TKT,PCTP,and BTG2).The hub genes of the ceRNA network of ISR included the following:miR-125,miR-206,miR-140,PCDHB9,CASC2,BAK1P1,CSPG4P3Y,CSPG4P4Y,STRCP1,and GRIP2.Verification of miRNAs of ceRNA also showed that the expression of miR-206 was upregulated in patients with ISR vs.those without ISR(P<0.05).In contrast,the expression of miR-140 and miR-125 was downregulated in patients with ISR vs.those without ISR(P<0.05).Conclusions:This study constructed noncoding RNA-related ceRNA networks for ISR.The results indicated that miR-206,miR-125,and miR-140 may be biomarkers of ISR.

Clinical characteristics of early and late drug-eluting stent in-stent restenosis and mid-term prognosis after repeated percutaneous coronary intervention

Background:The mechanism and characteristics of early and late drug-eluting stent in-stent restenosis(DES-ISR)have not been fully clarified.Whether there are different outcomes among those patients being irrespective of their repeated treatments remain a knowledge gap.Methods:A total of 250 patients who underwent initial stent implantation in our hospital,and then were readmitted to receive treatment for the reason of recurrent significant DES-ISR in 2016 were involved.The patients were categorized as early ISR(<12 months;E-ISR;n=32)and late ISR(≥12 months;L-ISR;n=218).Associations between patient characteristics and clinical performance,as well as clinical outcomes after a repeated percutaneous coronary intervention(PCI)were evaluated.Primary composite endpoint of major adverse cardiac events(MACEs)included cardiac death,non-fatal myocardial infarction(MI),or target lesion revascularization(TLR).Results:Most baseline characteristics are similar in both groups,except for the period of ISR,initial pre-procedure thrombolysis in myocardial infarction,and some serum biochemical indicators.The incidence of MACE(37.5%vs.5.5%;P<0.001)and TLR(37.5%vs.5.0%;P<0.001)is higher in the E-ISR group.After multivariate analysis,E-ISR(odds ratio[OR],13.267;[95%CI 4.984-35.311];P<0.001)and left ventricular systolic dysfunction(odds ratio[OR],6.317;[95%CI 1.145-34.843];P=0.034)are the independent predictors for MACE among DES-ISR patients in the mid-term follow-up of 12 months.Conclusions:Early ISR and left ventricular systolic dysfunction are associated with MACE during the mid-term follow-up period for DES-ISR patients.The results may benefit the risk stratification and secondary prevention for DES-ISR patients in clinical practice.

斑块旋切术联合药物涂层球囊治疗下肢动脉硬化闭塞症的效果分析

目的探究斑块旋切术(DA)联合药物涂层球囊(DCB)治疗下肢动脉硬化闭塞症(ASO)对患者再狭窄率和晚期管腔丢失(LLL)、最小管腔直径(MLD)的影响及安全性。方法选取2018年9月至2019年12月本院收治的94例ASO患者作为研究对象,根据手术方案不同分为对照组(n=52)和实验组(n=42)。对照组采用DCB扩张,实验组在对照组基础上采用DA,比较两组手术前后Rutherford分级、踝肱指数(ABI)及术后再狭窄率、LLL、MLD、并发症发生情况。结果两组Rutherford分级与ABI组间、时间、交互比较差异有统计学意义(P<0.05)。组内比较:术后6、12个月,两组Rutherford分级均低于术前,ABI均高于术前,且术后12个月的Rutherford分级低于术后6个月,但术后12个月的ABI均低于术后6个月(P<0.05)。组间比较:术前,两组Rutherford分级、ABI比较差异无统计学意义;术后6、12个月,实验组Rutherford分级均低于对照组,ABI均高于对照组,差异有统计学意义(P<0.05)。术后6个月,实验组再狭窄率低于对照组,LLL小于对照组,MLD大于对照组,差异有统计学意义(P<0.05);术后12个月,实验组再狭窄率与术后6个月比较差异无统计学意义,对照组再狭窄率高于术后6个月,两组LLL均大于术后6个月,MLD均小于术后6个月,但实验组再狭窄率低于对照组,LLL小于对照组,MLD大于对照组,差异有统计学意义(P<0.05)。结论DA联合DCB能有效改善ASO患者的临床症状,同时,可减少患者术后LLL的发生,扩张管腔直径,降低术后再狭窄率,且安全性高,值得临床推广应用。

Role of plasma C-reactive protein in predicting in-stent restenosis in patients with stable angina after coronary stenting

Background The role of plasma high sensitivity C-reactive protein （hs-CRP） in in-stent restenosis （ISR） remains controversial. We investigated plasma hs-CRP level at both admission and follow-up in patients with stable angina （SA）after successful coronary stenting in order to clarify the predictive value of hs-CRP for ISR.Methods We summarized 303 consecutive chronic SA patients with coronary drug-eluting stent （DES） implantation.The ISR was analyzed by quantitative coronary analysis （QCA） at a mean follow-up of 8 months, and the patients were divided into two groups according to the detected ISR as ISR group （n=48） and non-ISR group （n=255）. Plasma hs-CRP was examined at both admission and 8-month follow-up in all patients, standard medication continued throughout the investigation period.Results QCA presented that 48 patients （15.8%） suffered from ISR at follow-up. The basic clinical characteristics were similar between the two groups, while plasma hs-CRP was higher in ISR group than that in non-ISR group at both admission and follow-up, P 〈0.001 respectively. Multivariate regression analysis indicated that plasma hs-CRP level at either admission or follow-up could independently predict ISR occurrence （OR=5.581, 95% Cl 2.532-12.302, P〈0.001and OR=6.299, 95% CI 2.722-14.577, P 〈0.001, respectively）.Conclusions Our data indicate that plasma hs-CRP level may independently predict ISR at both admission and follow-up in SA patients with coronary DES implantation, which implies that a chronic, sustained systemic inflammatory response might be involved in ISR pathogenesis.

Inflammation inhibitory effects of sirolimus and paclitaxel-eluting stents on interleukin-1β-induced coronary artery in-stent restenosis in pigs

Background Coronary artery in-stent restenosis （ISR） and late stent thrombosis remain as important complications of stenting. The inflammation reactions to sirolimus and paclitaxel-eluting stents were investigated in a swine stenosis model induced by interleukin （IL）-1β.Methods Mini pigs （n=12; 2-3 months old and weighing 25-30 kg） were subjected to thoracotomy. Segments （10 mm）of the mid left anterior descending coronary artery and left circumflex coronary artery were exposed and aseptically wrapped with a cotton mesh soaked with IL-1β （5 μg）. After 2 weeks, the animals were anesthetized and quantitative coronary arteriography （QCA） was performed. The stenosis sites were randomized into three groups for stent insertion： a sirolimus-eluting stent （SES） group （FirebirdTM, n=7）, a paclitaxel-eluting stent （PES） group （TAXUSTM, n=9）, and a bare-metal stent （BMS） group （YINYITM, Dalian Yinyi Biomaterials Development Co., Ltd, China, n=8）. The three different stents were randomly implanted into stenosis segments. Expression of monocyte chemoattractant protein-1 （MCP-1）, tumor necrosis factor-alpha （TNF-α）, P-selectin and vascular cell adhesion molecule-1 （VCAM-1） was determined by reverse transcription-coupled polymerase chain reaction （RT-PCR）.Results QCA showed severe stenosis in IL-1β treated segments. The SES and PES groups showed lower 1-month angiographic late lumen loss （LLL） within the stent and the lesion compared with BMS （P 〈0.05） by follow-up QCA. The SES showed lower LLL than that of PES in reducing 1-month inflammation lesions in pigs by follow-up QCA （（0.15±0.06）mm vs. （0.33±0.01） mm, P 〈0.0001）. The neointimal hyperplasia areas in SES and PES showed lower than those of BMS （SES （11.6±1.7） mm2, PES （27.2±1.6） mm2 vs. BMS （76.2±1.3） mm2, P 〈0.0001）. The mRNA expression of MCP-1 by RT-PCR in SES and PES showed lower than that of BMS at 30 days after stenting （SES 0.20±0.03, PES 0.48±0.49 vs.BMS 0.58±0.07, P 〈0.05）. Levels of VCAM-1 in SES were significantly lower than those of PES and BMS （SES 0.35±0.08 vs. PES 0.65±0.13, BMS 0.70±0.06, P 〈0.05）. Histochemical immunostaining of vessel walls showed lower inflammatory chemokine MCP-1 expression in the SES and PES groups compared with BMS.Conclusion SESs were superior in reducing 1-month angiographic LLL in inflammation lesions in pigs, strongly suggesting that SESs can suppress inflammatory reactions in ISR at multiple points.

A novel mechanism of inhibiting in-stent restenosis with arsenic trioxide drug-eluting stent: Enhancing contractile phenotype of vascular smooth muscle cells via YAP pathway

Objective:Arsenic trioxide(ATO or As2O3)has beneficial effects on suppressing neointimal hyperplasia and restenosis,but the mechanism is still unclear.The goal of this study is to further understand the mechanism of ATO's inhibitory effect on vascular smooth muscle cells(VSMCs).Methods and results:Through in vitro cell culture and in vivo stent implanting into the carotid arteries of rabbit,a synthetic-to-contractile phenotypic transition was induced and the proliferation of VSMCs was inhibited by ATO.F-actin filaments were clustered and the elasticity modulus was increased within the phenotypic modulation of VSMCs induced by ATO in vitro.Meanwhile,Yes-associated protein(YAP)nuclear translocation was inhibited by ATO both in vivo and in vitro.It was found that ROCK inhibitor or YAP inactivator could partially mask the phenotype modulation of ATO on VSMCs.Conclusions:The interaction of YAP with the ROCK pathway through ATO seems to mediate the contractile phenotype of VSMCs.This provides an indication of the clinical therapeutic mechanism for the beneficial bioactive effect of ATO-drug eluting stent(AES)on in-stent restenosis(ISR).

Clinical outcome after management of unprotected left main in-stent restenosis after bare metal or drug-eluting stents

Background Implantation of either bare metal stent （BMS） or drug-eluting stent （DES） has been used in every day practice for patients with unprotected left main stenosis （UPLMS）. There are still a lack of data regading the subsequent results of UPLMS in-stent restenosis （ISR）. The present study aimed at determing the clinical outcome of UPLMS ISR patients after implantation of either BMS or DES.Methods Patients with UPLMS ISR after stenting were included. The primary endpoint was the cumulative major adverse cardiac events （MACE）, including cardiac death, myocardial infarction （Ml）, and target vessel revascularization （TVR）.Results UPLMS ISR rate was 14.8% （n=73, 15.7% after BMS, 14.5% for DES） after average of （3.89±2.01） years （range from 1 to 10.5 years） follow-up. Angiographic follow-up between 6-8 months was available in 85.3%. Of these,repeat percutaneous coronary intervention （PCI） was used in 62 （84.9%） patients, with medicine only in 9 （12.4%） and coronary artery bypass graft （CABG） in 2 （2.7%）. Most repeat PCI patients were with unstable angina （87.0%）, and had decreased left ventricular ejection fraction （（42.58±5.12）%）, fewer focal/ostial left circumflex branch （LCX） lesions, in relative to medicine only group. After （31.9±23.3） months, the MACE, Ml, TVR and cardiac death were 31.5%, 1.4%, 24.1% and 8.2%, respectively. Definite and possible stent thrombosis occurred in 1 （1.4%） patient.Conclusions Medical therapy for asymptomatic isolated ostial LCX was safe. Repeat PCI for UPLMS ISR was associated with acceptable early and short-term clinical outcome. Further study was needed to elucidate the role of CABG in treating UPLMS ISR.

Simulation of vessel tissue remodeling with residual stress:an application to in-stent restenosis

We present a numerical procedure to model the artery wall remodeling stimulated by stenting considering varying degree of residual stresses.This framework sets up biological remodeling with the existence of residual stress.Previous studies suggest that the residual stress originates from the growth and remodeling of the premature tissue.Meanwhile,it is known that tissue remodeling can happen under mechanical loading.However,none of the existing research studies the impact of residual stress on the mechanical-driven growth of biomaterials.To fill this gap,we build a numerical framework that couples the residual stress with a growth model,and examine its impact on tissue remodeling.The proposed approach is applied to in-stent restenosis,where the tissue remodeling process is modeled with finite element method,and the residual stress is generated geometrically using open angle method.The result shows that residual stress reverses the radial distribution of stress concentration,which is ameliorated by tissue remodeling.The thickening of vessel wall tends to increase with residual stress,which links to more severe in-stent restenosis.The results demonstrate the important interplay between residual stress and tissue remodeling.The findings suggest that residual stress should be considered in the future simulation of tissue remodeling.

The value of serum levels of aldosterone in predicting in-stent restenosis after coronary stent implantation

In recent years,Percutaneous coronary intervention(PCI) as an effective treatment for coronary heart disease has been widely carried out in China.However,people is still confronted with the problem that the incidence of in-stent restenosis (ISR) after PCI.Some risk factors of coronary heart disease have been obviously known,but the in-dependent predictor factors for the ISR has not been clear.Clarifying risk factors for ISR to establish interfering meas-ures may be a new direction for PCI treatment in the future.At present,it has been reported that aldosterone (ALD) may be involved in ISR.In order to further investigate the relationship between the serum ALD levels and ISR,our re-search was to determine the ALD and other serum markers to explore the impact factors of ISR.Methods We meas-ured serum ALD,high sensitivity C-reactive protein (hs-CRP) ,adiponectin (ADP) and other indicators in 258 pa-tients with coronary stenting,and made routine follow-up for 6-9 months to perform coronary angiography.According to the results of coronary angiography,all patients were divided into restenosis group and non-restenosis group.We an-alyzed the relationship between ALD,other indicators and ISR to explore whether serum ALD was an independent risk factor ISR.Results Serum ALD levels were significantly higher in restenosis group than non-restenosis group.Logis-tic regression analysis showed that diabetes,ALD,hs-CRP and complex lesions were also independent risk factors for ISR (P < 0.05) ,while the ADP was as a protective factor for ISR (P < 0.05) .Conclusions ALD is one of inde-pendent risk factors for ISR after undergoing coronary stent implantation in patients.It has the possibility of becoming one new method in this medical field.

残余心血管风险与冠状动脉支架失败关系的研究进展

动脉粥样硬化性心血管疾病(ASCVD)是全球人类致死致残的首位病因。目前诸多研究已对高血脂、高血压以及不良生活方式等传统心血管危险因素展开了深入的研究并取得跨越式进展,尽管传统危险因素已被全面普及且有效防治,但可能导致患者再发不良心血管事件的残余心血管风险尚有待充分研究。经皮冠状动脉介入治疗是ASCVD治疗的一大基石,但与之相关的一系列并发症不可小觑,可导致患者远期生存率下降。如何使ASCVD患者在治疗后获得更好的预后一直是心血管领域研究的热点、重点和难点。现系统总结残余心血管风险与冠状动脉支架失败的联系,旨在为支架植入患者远期预后及再发事件的防治提供新思路。

Stenting for Aorto-Ostial In-Stent Restenosis via Side Strut of an Excessively Protruding Stent Guided by Intracoronary Imaging

To the Editor:A 54-year-old man was admitted for progressive chest pain.Four years ago,the patient had surgical aortic valve replacement (SAVR),and preoperative multislice computed tomography (MSCT)showed no coronary stenosis.A year after SAVR,he presented with chest pain,and coronary angiogram revealed an isolated ostial left main coronary artery (LMCA) stenosis [Figure 1a].A 4.0mm × 18.0mm stent (Medtronic Vascular, Santa Rosa,CA,USA)was implanted without a high-pressure postdilation [Figure 1b].The patient was discharged on aspirin, ticagrelor (replaced with clopidogrel after 3months),and statins. Unfortunately,the stent was found to protrude into the aorta by approximately 10mm by MSCT at 4-month follow-up [Figure 1c].