Assessment of Coronary Stents by 64-slice Computed Tomography： In-stent Lumen Visibility and Patency

Objective To assess lumen visibility of coronary stents by 64-slice computed tomography （CT） coronary angiography, and determine the value of 64-slice CT in non-invasive detecting of in-stent restenosis after coronary artery stent implantation. Methods Totally, 60 patients （54 males, aged 57.0±12.7 years） and /05 stents were investigated by 64-slice CT at a mean interval of 20.0±16.6 months after coronary stents implantation. Axial multi-planar reconstruction images of the stents and curved-planar reconstruction images through the median of the stents were reconstructed for evaluating stent image quality on a 5-point scale （1=excellent, 5=nonassessable）, and stent lumen diameter was detected. Conventional coronary angiography was performed in 18 patients, and 32 stents were evaluated. Results Image quality was good to excellent on average （score 1.71±0.76）. Stent image quality score was correlated to heart rate （r=0. 281, P〈0.01） and stent diameter （r=-0.480, P〈0.001）. All the stents were assessable in lumen visibility with an average visible lumen diameter percentage of 60.7%±13.6%. Visible lumen diameter percentage was correlated to heart rate （r=-0.193, P〈0.05）, stent diameter （r=0.403, P〈0.001）, and stent image quality score （r=-0.500, P〈0.001）. Visible lumen diameter percentage also varied depending on the stent type. In comparison with the conventional coronary angiography, 4 of 6 in-stent stenoses were correctly detected. The sensitivity and specificity for the detection of in-stent stenosis were 66.7% and 84.6%, respectively. Conclusions Using a 64-slice CT, the stent lumen is partly visible in most of the stents. And 64-slice CT may be useful in the assessment of stent patency.     

Feasibility and Diagnostic Accuracy for Assessment of Coronary Artery Stenosis of Prospectively Electrocardiogram-gated High-pitch Spiral Acquisition Mode Dual-source CT Coronary Angiography in Patients with Relatively Higher Heart Rates:in Comparison wit

Objective To prospectively investigate the diagnostic accuracy for coronary artery stenosis of prospectively electrocardiogram-triggered spiral acquisition mode (high pitch mode) dual-source computed tomography coronary angiography (CTCA) in patients with relatively higher heart rates (HR) compared with catheter coronary angiography (CCA). Methods Forty-seven consecutive patients with relatively higher HR (>65 and <100 bpm) (20 male, 27 female; age 55±10 years) who both underwent dual-source CTCA and CCA were prospectively included in this study. All patients were performed CTCA using high pitch mode setting at 20%-30% of the R-R interval for the image acquisition. All coronary segments were evaluated by two blinded and independent observers with regard to image quality on a three-point scale (1: excellent to 3: non-diagnostic) and for the presence of significant coronary stenoses (defined as diameter narrowing exceeding 50%). Considered CCA as the standard of reference, the sensitivity, specificity, positive predictive value and negative predictive value were calculated. Radiation dose values were calculated using the dose-length product. Results Image quality was rated as being score 1 in 92.4% of segments, score 2 in 6.1% of segmentsand score 3 in 1.5% of segments. The average image quality score per segment was 1.064±0.306. The HR variability of patients with image score 1, 2 and 3 were 2.29±1.06 bpm, 5.17±1.37 bpm, 8.88±1.53 bpm, respectively. The average HR variability of patients with different image scores were significantly different (F=170.402, P=0.001). The sensitivity, specificity, positive and negative predictive values were 92.6%, 97.0%, 87.6%, 98.3%, respectively, per segment and 90.0%, 95.2%, 85.3%, 96.9%, respectively, per vessel and 100%, 63.6%, 90.0%, 100%, respectively, per patient. The effective radiation dose was on average 0.86±0.16 mSv. Conclusion In patients with HR more than 65 bpm and below 100 bpm without cardiac arrhythmia, the prospectively electrocardiogram-gated high-pitch spiral acquisition mode with image acquired timing set at 20%-30% of the R-R interval provides a high diagnostic accuracy for the assessment of coronary stenoses combined with a 1.5% of non-diagnostic coronary segments and a radiation dose below 1 mSv.     

A comparative study of coronary angiography and optical coherence tomography findings in coronary artery disease patients with moderate stenosis

Objective To compare coronary angiography(CAG) and optical coherence tomography(OCT) findings in stenosis and culprit lesion morphology assessment in coronary artery disease patients with moderate stenosis(50%～70%).Methods 23 CAD patients with moderate stenosis(50%～70%) were enrolled in the study.These patients then underwent OCT analysis.CAG and OCT stenosis results were compared for conformity.OCT images of the culprit lesions were analyzed for more details about the morphological characteristics of the plaques in relation with the clinical diagnosis.Results Evaluation of stenosis of coronary lesions by Quantitative Coronary Angiography(QCA) corresponds approximately with OCT analysis estimation:CAG stenosis was 57.26% ±5.05,whereas the same OCT stenosis analysis reached a value of 61.17%±11.36,(P=0.032).From OCT image analysis,the vulnerable plaque was detected more in the culprit lesions of patients with a clinical diagnosis of unstable angina,than in stable angina pectoris patients(61.5%vs10%;P=0.012).     

Quantitative and qualitative assessment of non-obstructive left main coronary artery plaques using 64-multislice computed tomography compared with intravascular ultrasound

Background There are few reports of quantitative and qualitative measuring of left main coronary artery （LMCA） plaques by multislice computed tomography coronary angiography （MSCTA）, especially when compared with intravascular ultrasound （IVUS） as reference standard. The aim of this study was to evaluate the use of 64-MSCTA in the diagnosis of LMCA disease, and the accuracy of MSCTA in the quantitative and qualitative assessment of the LMCA lesion as compared with IVUS.Methods A total of 91 patients （53 men, 38 women, mean age （64.78±9.19） years） were examined by 64-MSCTA and IVUS. Compared with the IVUS, the sensitivity, specificity, positive and negative predictive values （PPV and NPV） of the MSCTA on the diagnosis of LMCA diseases were calculated. Also, kappa index （K） for the agreement between MSCTA and IVUS was calculated. Minimal lumen area （MLA）, external elastic membrane cross-sectional area （EEM-CSA） and plaque burden were measured by two blinded and independent operators on MSCTA cross-sectional reconstruction and compared with the parameters measured from IVUS by manually tracing. The CT value of soft, fibrous and calcific plaques was measured using IVUS classification of the plaques.Results The sensitivity, specificity, PPV and NPV of MSCTA for detecting LMCA plaques were 93.1%, 84.2%, 95.7%, 76.2%, respectively. Kappa index （K=0.744, P〈0.001） indicated excellent agreement between MSCTA and IVUS. The Pearson index between MLA on IVUS and MLA on MSCTA was 0.815 （P 〈0.01）. The Pearson index of plaque burden and EEM-CSA between IVUS and MSCTA was 0.736 and 0.740 respectively （both P 〈0.01）. The CT value of soft plaque, fibrous plaque and calcific plaque compared with IVUS were （52.52±15.71） HU, （108.32±43.44） HU and （604.16±377.67） HU （P〈0.001）. Receiver operating characteristic curve analysis of CT value of non-calcific plaques for predicting soft plaques showed the cutpoint was 54.35 HU, with a sensitivity of 83.3% and specificity of 94.4%. Conclusions Sixty-four section MSCTA is an effective diagnostic tool for the detection of LMCA plaques with higher sensitivity and specificity. The correlation of quantitative and qualitative analysis between MSCTA and IVUS was excellent. The CT value of plaques can help the diagnosis of plaque composition.     

Comparision of high sensitivity C-reactive protein and matrix metalloproteinase 9 in patients with unstable angina between with and without significant coronary artery plaques

Background Inflammation within vulnerable coronary plaques may cause unstable angina by promoting rupture and erosion. C-reactive protein (CRP) is the most reliable and accessible test method for clinical use for identifying coronary artery disease event. Matrix metalloproteinase 9 (MMP-9) is highly over-expressed in the vulnerable regions of a plaque.Our aim was to evaluate the plasma levels of MMP-9 and hsCRP in subjects with both unstable angina and coronary plaques, as well as in those with unstable angina without coronary plaques.Methods Patients with newly diagnosed unstable angina pectoris from clinical presentation and ECG, who were undergoing coronary angiography from April 2007 to April 2009, were included in this study. A total of 170 subjects were enrolled in the study. Before angiography, the baseline clinical data (mainly including conventional risk factors) was collected.These patients were divided into two groups, a non-plaque group (G1) which included 55 patients with no significant stenosis or less than 20% stenosis in at least one of the major coronary artery branches, and a plaque group (G2) which included 115 patients with at least one of the major coronary artery branches unstable angina pectoris with at least 50% stenosis of one major coronary artery. The patients presenting with calcified nodules of a major coronary artery were excluded from this study.We examined the serum levels of MMP-9 for all cases by multi-effect enzyme-linked immunosorbent assay.Results There was a significant difference in the serum levels of MMP-9 between the two groups (P＜0.001). The percentage of patients with hypertension, diabetes and current smokers were significantly different between the two groups (P=0.034, P=0.031, and P=0.044 respectively). The univariate Logistic regression analyses of risk factors showed that smoking was the main risk factor for angina in the non-plaque group with the OR being 1.95 (95% Cl 1.02-3.75).Hypertension, diabetes mellitus were negatively related with the occurrence of angina in the non-plaque group with the ORs being 0.50, and 0.36, respectively (95% Cl 0.26-0.96 and 0.14-0.94). The MMP-9 level was negatively related to the occurrence of angina in the non-plaque group with an OR of 0.59 (95% Cl 0.47-0.81).Conclusions There is a significantly difference in MMP-9 levels between the plaque and non-plaque groups. Current smoking has a significant influence on unstable angina patients without documented plaques. The serum MMP-9 level may be a significant biomarker which can help differentiate patients with unstable angina with plaques from those with unstable angina but without plaques.     

Assessment of coronary artery disease with second harmonic myocardial perfusion contrast echocardiography

Objectives To assess the relationship between myocardial regional perfusion using second harmonic myocardial contrast echocardiography (MCE) by venous injection of Levovist and coronary artery stenosis detected by coronary angiography to determine whether MCE can be used to detect coronary artery disease (CAD) and its sensitivity and specificity for detecting CAD.Methods Thirty-six patients who underwent coronary artery angiography and MCE formed the study groups.Ten myocardial segments (5 each in the apical two- and four-chamber views) from the images were scored for detecting myocardial perfusion as follows: 1, normal perfusion; 2, decreased perfusion; and 3, perfusion defect.The arteries were classified as normal or diseased.The diseased arteries were classified into three groups according to the perfusion scores.Results There were significant differences in coronary diameter stenosis among the different perfusion score groups (P&lt;0.001).There were 10 total occluded arteries, and the myocardial perfusion scores were different because of different collateral circulation.In the normal perfusion group (Group A), the coronary diameter stenosis was 65%±12%, and the myocardial perfusion score index was 1±0.00.In the decreased perfusion group (Group B), the average coronary diameter stenosis was 82%±8%, and the myocardial perfusion score was 1.93±0.16.The diameter stenosis was less than 85% in 63 % of the coronary arteries (including diameter stenosis ≤75% in 12% of the vessels).The diameter stenosis was 85%-90% in 22% of the coronary arteries and &gt;90% in 15% of the arteries.In the perfusion defect group (Group C), the average diameter stenosis was 90%±6%, and the myocardial perfusion score index was 2.89±0.24.The diameter stenosis was　≥85% in 94% of the coronary arteries, and the diameter stenosis was &lt;85% and &gt;75% only in 6% of the coronary arteries.The overall sensitivity and specificity of MCE in identifying angiographic coronary diameter stenosis was 67% and 100%, respectively.The false negative rate was 32.6% for the 108 coronary arteries.Further subdivided analysis showed the sensitivities in Groups A, B and C were 0, 100%, and 100%, respectively.The sensitivity increased with increased lumen diameter stenosis of coronary arteries.Conclusions There is a close relationship between coronary artery stenosis and MCE perfusion scores.MCE with venous injection of new generation contrast can define the presence of CAD and lesion graded classifications.Some disagreements between perfusion score and coronary diameter of stenosis may indicate other factors such as different collateral circulation, which should be further investigated.As artery stenosis increases, the sensitivity of MCE is increased.     

Relationship between coronary artery remodeling and cumulative incidence of coronary angiographic lesions with vulnerable characteristics in patients with stable angina pectoris

ackground Development of vulnerable lesions is not limited to the target lesions, but a pan-coronary process. Such lesions are identified by positive remodeling （intravascular ultrasound （IVUS） and complex lesions （angiography））. The prevalence of lesions with vulnerable characteristics in patients with stable angina was not well known. The purpose of the present study was to evaluate the relationship between coronary artery remodeling and incidence of angiographic complex lesions and its calcification in stable angina patients.Methods One hundred and sixty-one stable angina patients （95 males, aged （68±11） years） with 161 de novo target lesions were studied using pre-interventional IVUS. Remodeling index was defined as the lesion divided by reference vessel area; positive remodeling was defined as remodeling index 〉1.05. Besides the 161 target lesions, there were 613 angiographic lesions with 〉30% diameter stenoses, classified as complex or smooth. Multiple complexes were defined as more than one complex lesion in one patient. Stenoses of at least 70% were described as tight. Calcium arc area was used as a new method to quantify coronary calcification.Results Fifty-six patients had positive remodeling target lesion, while 105 did not. The overall number of lesions with a diameter stenoses 〉30% was similar in patients with or without positive remodeling, and the frequency of angiographically complex lesions was higher in positive remodeling patients, especially at non-target site. Calcium arc area was smaller in patients with positive remodeling.Conclusions Positive remodeling on intravascular ultrasound was associated with more complex lesions angiographic findings, especially at non target site. Positive remodeling was found less calcified in patients with stable angina.     

4排螺旋CT对冠状动脉粥样硬化性心脏病的临床价值

目的 探讨4排螺旋CT冠状造影在诊断冠状动脉粥样硬化性心脏病(简称冠心病)中的价值.方法 收集临床上初步拟诊为冠心病的35例患者的93支血管并进行螺旋CT冠状造影和常规冠状动脉造影检查,对比分析螺旋CT冠状造影的准确性.结果 螺旋CT冠状造影发现47支冠状动脉狭窄,常规冠状动脉造影检查发现51支冠状动脉狭窄.螺旋CT冠状造影发现的44支血管狭窄与冠状动脉造影结果一致,敏感性为86.3%,特异性为100%.螺旋CT冠状造影和常规冠状动脉造影检查结果大体一致.结论 4排螺旋CT冠状造影可作为诊断冠心病的一种无创筛选检查方法,提高了冠状动脉造影诊断冠心病的符合率. Abstract： Objective To explore the diagnosticclinical value of 4 -detector row spiral CT with coronary artery disease. Methods Spiral CT coronary angiography (CTCA) and conventionalcoronary angiography(CAG) were used in 93 arteries of 35 coronary artery disease patients. To analysis the precise level of CTCA through contrasting. Results CTCA showed the angiostegnosis with 47coronary arteries,CAG showed theangiostegnosis with 51coronary arteries. The angiostegnosis results of 44 coronary arteries were same with CTCA and CAG. The total sensitivity of CTCA was 86.3% , and specificity was 100%.The results of CTCA and CCA were coincidentalin general. Conclusions 4 - detector row spiral CT can be used as a noninvasive screening method for the patients with suspected coronary artery disease, and the coincidence ratewasincreased ofcoronary angiography with coronary artery disease.     

Assessment of culprit lesions by intravascular ultrasound in patients with acute myocardial infarction

Background Intravascular ultrasound has become the standard invasive method for diagnosing coronary artery disease. The aim of the present study was to evaluate the ability of intravascular ultrasound for assessment of culprit lesion morphology during primary percutaneous coronary intervention （PCI） in patients with acute myocardial infarction （AMI）.
Methods We performed 18 intravascular ultrasound assessments preintervention during the primary PCi for AMI. intravascular ultrasound analysis included qualitative and quantitative measurements of reference and lesion external elastic membrane （EEM）, lumen, and plaque plus media （P＆M） area. Positive remodeling was defined as lesion/mean reference EEM 〉1.0. Culprit lesions were identified by a combination of electrocardiogram （ECG） and coronary angiography.
Results There was an average of- 1.44 infarct-related artery （IRA） plaques per patient. The incidences of thrombus and plaque ruptures were 28% （5） and 33% （6）, respectively. Hypoechoic plaque was observed in 72% （13） of AMI patients. Calcified lesions could be found in 33% （6） of culprit lesions. Sixty percent of the culprit lesion sites presented with positive remodeling.
Conclusions Intravascular ultrasound is a safe and feasible imaging modality in patients with AMI and can help identify plaque rupture, intracoronary thrombus or calcification. The culprit lesion site in AMI cases often presents with positive remodeling.     

Sixty-four-multi-detector computed tomography diagnosis of coronary artery anomalies in 66 patients

Background The abnormalities of coronary arteries, though rare and sometimes benign, may first present clinically as myocardial infarction or sudden death. Multi-detector computed tomography （MDCT） is a non-invasive test that is highly suitable for detecting these anomalies. The study aimed to review the 64-MDCT appearance of the coronary artery anomalies in 66 patients and to discuss the clinical importance of these anomalies.Methods In 6014 consecutive patients examined over 12 months by 64-MDCT for the study of coronary artery disease, 66 were diagnosed for coronary artery anomalies. All patients were symptomatic for one or more of the following diseases： chest pain, dyspnoea, palpitations, arrhythmia and myocardial infarction. Nine patients had undergone a coronary angiography. All the CT images were evaluated by two radiologists and one cardiologist. The right coronary artery （RCA） and the conus branch arising separately, myocardial bridging and duplication of arteries were not analysed in our study.Results The incidence of coronary artery anomalies found in our study group was 1.097%. In the selected patients, seven different types of coronary anomalies were found by 64-MDCT examination. The high takeoff, origin of the coronary artery from the opposite or noncoronary sinus with an anomalous course, and coronary artery fistula were the three common forms of anomalies （n=16, 18 and 16, respectively）. Compared with the results of the coronary angiography, the number of the drainage sites of two coronary artery fistula was less in MDCT images （3 small sites in total）. In all cases, coronary artery computed tomography angiography （CTA） technique was able to recognize the origin of the coronary artery, its three-dimensional course and its spatial relationship with the adjacent structures. Conventional coronary angiography in two cases, however, was unable to provide sufficient information for correct and complete diagnosis.Conclusions In conclusion, the study showed that 64-MDCT, especially the volume rendering technique （VRT）, may be useful for the assessment of complex variations, even if the conventional angiography may not be sufficient. It may be considered as the first-choice imaging modality when an anomalous coronary artery is suspected.     

Diagnostic value of dual-source CT in Kawasaki disease

Background Doppler color echocardiography is a common method for detecting coronary artery lesions in patients with Kawasaki disease（KD）.However,the diagnostic accuracy for the whole coronary artery lesions is limited.The purpose of this study was to compare the diagnostic value of dual-source computed tomography （DSCT） and Doppler color echocardiography for the assessment of coronary artery lesions caused by KD.Methods Sixteen patients,12 with typical KD and 4 with atypical KD,underwent DSCT and Doppler color echocardiography.The position and internal diameter of each coronary artery lesion was measured.Correlation analysis was used to compare the diagnostic value of the two imaging modalities.Results ln the typical KD group, seven patients did not have any coronary artery Iesion as confirmed by both DSCT scans and Doppler color echocardiography;in four patients proximal coronary artery injuries were identified by both modalities;in one patient an aneurysm in the middle and distal segments of the coronary artery was detected by DSCT but was negative in Doppler color echocardiography.In the atypical KD group,three cases showed the same results with both modalities,while one case with coronary artery stenosis in the middle segment was identified by DSCT but not detected by Doppler color echocardiography.There was a good correlation between the two imaging modalities（Kappa value,0.768（≥0.75））.Conclusion DSCT coronary artery angiography is an accurate,non-invasive,and valuable technique for detecting and following up coronary artery lesions in patients with KD.     

Smoking and hyperlipidemia are important risk factors for coronary artery spasm

Objective To investigate the role of coronary artery spasm in the etiology of chest pain lacking significant coronary stenosis and to identify the clinical risk factors related to coronary artery spasm.Methods Two hundred and seventy five patients with chest pain, but without significant coronary artery stenosis underwent the intracoronary acetylcholine test. Coronary artery spasm was diagnosed while coronary artery stenosis increased to 90% and was accompanied by the usual chest pain with or without ischemic changes on electrocardiogram. Logistic regression was employed to investigate the relationships between coronary artery spasm and sex, age, hypertension, diabetes mellitus, smoking,hyperlipidemia and results of electrocardiographic treadmill stress test. Left ventricular ejection fraction and end diastolic pressure were compared between spasm group and non-spasm group.Results Coronary artery spasm was detected in 103 out of 271 patients, a rate of 38%. Logistic regression analysis showed that smoking and hyperlipidemia increased the relative risk of coronary artery spasm 4.2 times and 2.3 times, respectively. There was a significantly negative relationship between diabetes mellitus and coronary artery spasm. Furthermore, there was no coronary artery spasm detected in left ventricular ejection fraction and end diastolic pressure.Conclusions Coronary artery spasm was one of the important etiological factors for patients with chest pain but no coronary artery stenosis. Smoking and hyperlipidemia were the main clinical risk factors for coronarv arterv spasm.     

Short and long-term outcomes of two drug eluting stents in bifurcation lesions

Background Because no large prospective studies are available, this study evaluated the clinical outcomes of two drug eluting stents in bifurcation lesions. Methods Lesions with diameter of side branch ≥2.5 mm were selected. From October 2003 to June 2005, 112 patients with 113 bifurcation lesions were treated by two drug eluting stents （DESs）, technique. The location of bifurcation lesions were left anterior descending coronary artery/diagonal in 62 patients, left main distal bifurcation in 32, left circumflex coronary artery/obtute marginal branch in 18 and right coronary artery distal bifurcation in 1. Procedures for bifurcation lesions were crush or modified crush technique in 64, ＂T＂ stenting technique in 27, modified ＂Y＂ stenting, kiss stenting, ＂V＂ stenting as well as culotte stenting technique in 11, 5, 3 and 3, respectively. Among 226 lesions, 91 Cypher or Cypher select stents, 74 TAXUS and 67 Firebird were used. Final kiss balloon dilation was performed in 60 （93.7%） with crush technique after stenting. Results Success rate of percutaneous coronary intervention for the bifurcation lesions was 100%. One patient, who developed inhospital acute myocardial infarction due to subacute thrombosis, was successfully treated by a second intervention. Major adverse cardiac events rate in-hospital was 0.89% （1/112） and during followup was 7.14% （8/112）, No death occurred during the followup of all patients. Angiographic followup was effected for 46 patients, restenosis for eight, coronary artery bypass grafting for 1 and a repeat intervention for 5. Restenosis involving TAXUS, Cypher and Firebird was 5 （5/18, 27.8%）, 2 （2/17, 11.8%） and 1 （1/11, 9.1%）, respectively （P〉0.05）. Total restenotic rate was 17.4% （8/46）. Conclusions When ostium of side branch has severe stenosis and 〉12.5 mm in diameter, two-stent strategy in this bifurcation lesion is safe and effective, and the outcomes are satisfactory. Restenotic rates were not different between TAXUS, Cypher and Firebird DESs.     

Percutaneous transluminal stenting in patients with carotid artery stenosis

ObjectiveTo assess the efficacy and safety of percutaneous transluminal stenting for pati ents with carotid artery stenosis.Methods Selective percutaneous transluminal stenting was performed for patients with sym ptomatic carotid artery stenosis (luminal narrowing ≥70%). Success rates and c omplications associated with the procedures were observed. During six months of follow-up, both recurrent symptom and restenosis rates were recorded. Results There were 17 bifurcating lesions among 27 stenoses in 26 patients, of whom 18 had concomitant coronary artery diseases. The acute procedural success rate was 96.3% (26/27), and the degree of stenosis was reduced from 88.6%±8.9% （ran ge 70-100） to 0.4%±2.0% （range 0-10）. Six patients developed severe brady cardia and hypotension, and 3 experienced transient loss of consciousness during balloon dilatation. During hospitalization, 2 patients experienced loss of con sciousness and convulsion, respectively, due to hyperperfusion, and both recover ed 12 hours later. There were 2 minor stroke cases (7.4%) but no cases of majo r stroke or death. At the 6-month follow-up, there were no cases of TIA or ne w onset of stroke. There was no restenosis detected in 16 cases using angiograp hy and in 10 cases using MRI in 6 to 16 months of follow-up. Conclusions Percutaneous transluminal stenting for patients with carotid artery stenosis has a high procedural success rate with few and acceptable complications. Few pati ents suffered from recurrent symptoms or showed restenosis in long-term follow -up.     

Safety and efficacy of transulnar approach for coronary angiography and intervention

Background Transradial approach, which is now widely used in coronary angiography and intervention, may be advantageous with respect to the femoral access due to the lower incidence of vascular complications. Transulnar approach has been proposed for elective procedures in patients not suitable for transradial approach. The objective of this study was to evaluate the safety and efficacy of the transulnar approach versus the transradial approach for coronary angiography and intervention. Methods Two hundred and forty patients undergoing coronary angiography, followed or not by intervention, were randomized to transulnar （TUA） or transradial approach （TRA）. Doppler ultrasound assessments of the forearm vessels were scheduled for all patients before procedures, 1 day and 30 days after procedures. The primary end point was access site vascular complications during hospitalization and 30 days follow-up. Major adverse cardiac events （MACE） as secondary end point was recorded till 30 days follow-up. Results Successful puncture was achieved in 98.3% （118/120） of patients in the TUA group, and in 100% （120/120） of patients in the TRA group. Coronary angiographies were performed in 40 and 39 patients in TUA and TRA group. Intervention procedures were performed in 78 and 83 patients in TUA and TRA group, respectively. The incidence of artery stenosis 1 day and 30 days after procedures was 11.0% vs.12.3% and 5.1% vs. 6.6% in TUA and TRA group, respectively. Asymptomatic access site artery occlusion occurred in 5.1% vs.1.7% of patients 1 day and 30 days after transulnar angioplasty, and in 6.6% vs. 4.9% of patients 1 day and 30 days after transradial angioplasty. Minor bleeding was still observed at the moment of the ultrasound assessment in 5.9% and 5.7% of patients in TUA and TRA group, respectively （P=0.949）. No big forearm hematoma, and A-V fistula were observed in both groups. Freedom from MACE at 30 days follow-up was observed in all patients. Conclusions The transulnar approach is as safe and effective as the transradial approach for coronary angiography and intervention. It is an attractive opinion for experienced operators who are skilled in this technique, particularly in cases of anatomic variations of the radial artery, radial artery small-caliber or thin radial pulse.     

Association of Polymorphisms in Angiotensin-converting Enzyme and Type 1 Angiotensin Ⅱ Receptor Genes with Coronary Heart Disease and the Severity of Coronary Artery Stenosis

To explore the relation of angiotensin-converting enzyme （ACE） and angiotensin Ⅱ type 1 receptor （AT1R） gene polymorphism with coronary heart disease （CHD） and the severity of coronary artery stenosis, 130 CHD patients who underwent coronary angiography were examined for the number of affected coronary vessels （≥75% stenosis） and coronary Jeopardy score. The insertion/deletion of ACE gene polymorphism and AT1R gene polymorphism （an A→C transversion at nucleotide position 1166） were detected by using polymerase chain reaction （PCR） and restriction fragment length polymorphism （RFLP） in CHD patients and 90 healthy serving as controls. The resuits showed that DD genotype and of ACE were more frequent in CHD patients than that in control group （38.5% vs 14.4%, P〈0.001）. The frequency of the ATIR A/C genotypes did not differ between the patients and the controls （10% vs 13.1%, P〉0.05）. The relative risk associated with the ACE-DD was increased by AT1R-AC genotype. Neither the number of affected coronary vessels nor the coronary score differed among the ACE I/D genotypes （P〉0.05）. But the number of affected coronary vessels and the coronary score were significantly greater in the patients with the AT1R-AC genotype than in those with the AA genotype （P〈0.05）. In conclusion, DD genotype may be risk factor for CHD and MI in Chinese people, and is not responsible for the development of the coronary artery stenosis. The AT1R-C allele may increase the relative risk associated with the ACE-DD genotype, and may be involved in the development of the stenosis of coronary artery.     

Comparison of 99mTc-methoxyisobutylisonitrile myocardial single-photon emission computed tomography and electron beam computed tomography for detecting coronary artery disease in patients with no myocardial infarction

Background Previous studies have compared single-photon emission computed tomography (SPECT) and electron beam computed tomography (EBCT) in detection of coronary artery disease (CAD) in patients with myocardial infarction (MI). The purpose of this study was to compare SPECT with EBCT in detection of CAD in patients with no MI.Methods One hundred and forty-seven patients with suspected CAD underwent stress-rest 99mTc-methoxyisobutylisonitrile (99mTc-MIBI) myocardial SPECT, cardiac EBCT and coronary angiography (CAG) within one month. Of them, 73 patients (aged 52.6±10.6 years old) with no history of MI were included in this study. Coronary artery calcium (CAC) was defined as a CT value ≥130 HU within the boundary of coronary artery on EBCT. Results There were 35 and 38 patients with or without CAD according to CAG. Ninety-six percent of the patients with abnormal SPECT and CAC had a coronary arteries stenosis ≥50%, and 90.9% patients with normal SPECT and EBCT showed no CAD. The sensitivity of SPECT and EBCT in detection of CAD was comparable, and the specificity of SPECT (92.1%) was significantly higher than that of EBCT (55.3%) (P&lt;0.005). For the detection of individual coronary artery stenosis, both sensitivity and specificity of SPECT (75.0% and 93.7%) were significantly higher than those of EBCT (53.3% and 76.7%) (P&lt;0.025 and P&lt;0.005, respectively). In patients without chest pain, the sensitivity and specificity of SPECT (76.9% and 91.4%) were significantly higher than those of EBCT (23.1% and 69.0%) in detection of a coronary artery stenosis of ≥50% (P&lt;0.01 and P&lt;0.005, respectively). However, in patients with chest pain, both sensitivity and specificity of SPECT were comparable to those of EBCT. In patients ≤45 years old, the sensitivity of SPECT (77.8%) was significantly higher than that of EBCT (27.8%) in assessing a coronary artery stenosis of ≥50% (P&lt;0.005), and the specificity of SPECT was comparable to that of EBCT. In patients &gt;45 years old, the specificity of SPECT (94.3%) was significantly higher than that of EBCT (70.5%) (P&lt;0.005), and the sensitivity of SPECT was comparable to that of EBCT. Conclusion 99mTc-MIBI myocardial perfusion SPECT has higher accuracy than that of EBCT in detection of CAD in patients without MI.     

Clinical study of arterial anatomic variations for transradial coronary procedure in Chinese population

Background The radial artery is currently regarded as a useful approach for coronary intervention procedures. Adequate anatomical information of the radial artery should be helpful in performing transradial coronary procedures. Few data about the Chinese population have been obtained in this field. Therefore, we tried to evaluate the incidence and clinical significance of anomalous patterns, and their influence on the intervention procedure. Methods In an estimated sample of 3000 cases, radial artery and subclavical artery angiography were performed after insertion of the sheath and coronary angiography （CA）. The evaluable data including branch anomaly, tortuosity of the radial artery and procedural characteristics were analyzed. The procedure success was defined as CA or percutaneous coronary intervention （PCI） completed with the initial radial artery approach without changing to other routes. Results In this study, 1897 cases of CA was undertaken and 1103 cases of CA combined with PCI were performed. The success rate of transradial intervention （TRI） was 96.6% （2899/3000）. The approach in 44 cases was changed to the contralateral radial artery and 57 cases were changed to the brachial artery or femoral artery due to failure with the initial radial artery approach. The angiography of the upper limb artery was performed in all cases. Anatomic variations of upper limb arteries were noted in 610 patients （20.3%）, which included tortuous configurations of the radial artery （5.0%）, hypoplasias （2.2%）, radioulnar loop （1.1%）, abnormal origin of the radial artery （7.7%）, stenosis of radial artery （1.4%）, a tortuous configuration of the brachial artery （0.9%）, a tortuous configurations of the subclavian artery （1.9%）, lusoria subclavian artery （0.1%）, and subclavian artery occlusion （0.03%）. The procedural success rate in the normal population was higher than in the variation group （97.6% vs 93.0%, P 〈0.001）. In addition, other procedural outcomes and incidence of complications except radial artery occlusion were also significantly superior to variation group. Conclusions Anatomic variations of the radial artery were common, making up an important limitation in the trans- radial approach. Selection of appropriate instruments and understanding some tips and tricks were helpful to overcome the obstacles and effectively reduce the learning curve.     

Manifestation of lower extremity atherosclerosis in diabetic patients with high ankle-brachial index

Background The ankle brachial index （ABI） is a simple, inexpensive, noninvasive tool that correlates well with angiographic disease severity and functional symptoms. The aim of this study was to identify the manifestation of lower extremity atherosclerotic lesions in patients with high ABI by retrospective clinical study.Methods A cohort of 184 diabetic patients, （63±14） years old, 144 males, who underwent simultaneously ABI testing and low extremity arterial duplex ultrasound within one week, were enrolled randomly into this study. According to the ABI value, they were divided into three groups： the high, normal and low ABI groups. The severity and location of atherosclerotic lesions in the lower extremity were determined based on the results of low extremity artery duplex ultrasound. The chi-square test was used to compare the atherosclerosis severity grade and lesion location across the three groups.Results The prevalence of low extremity artery occlusion was significantly lower in the high ABI group than in the low ABI group （3.3% vs. 63.5%, P〈0.01）, and the main atherosclerotic lesions were diffuse dot-like hyperechogenicity spots or small plaques （86.7%）. In addition, the atherosclerotic lesions were mostly found in the distal segment of the lower extremity in patients with high ABI （46.3%）.Conclusion A high ABI may be an integrative marker for intimal and medial calcification, which has a high positive predictive value for artery calcification.     

Functional analysis of low-density lipoprotein receptor in homozygous familial hypercholesterolemia patients with novel 1439 C→T mutation of low-density lipoprotein receptor gene

Background Familial hypercholesterolemia （FH）, caused by low density lipoprotein （LDL） receptor （LDL-R） gene mutations, is associated with increased risk of premature coronary heart disease. Until now, limited molecular data concerning FH are available in China. The present study described the clinical profiles and cell biological defects of a Chinese FH kindred with novel LDL-R gene mutation. Methods The patient＇s LDL-R gene coding region was sequenced. The patient＇s lymphocytes were isolated and the LDL-R expression, binding and up-take functions were observed by immunohistochemistry staining and flow cytometry detection. The patient＇s heart and the major large vessels were detected by vessel ultrasound examination and myocardial perfusion imaging （MPI）. Results The patient＇s LDL-R expression, LDL binding and up-take functions were significantly lower than normal control （39%, 63% and 76% respectively）. A novel homozygous 1439 C→T mutation of the LDL-R gene was detected in the patient and his family. ECG showed atypical angina pectoris. Echocardiogram showed stenosis of the coronary artery and calcification of the aortic valve and its root. Blood vessel ultrasound examination showed the thickness of large vessel intima, and the vessel lumen was narrowed by 71%. MPI showed ischemic changes. Conclusions The LDL-R synthesis dysfunction of FH patients leads to arterial stenosis and calcification, which are the major phenotype of the clinical disorder. The mutation of the LDL-R gene is determined. These data increase the mutational spectrum of FH in China.