Prolonged high-pressure balloon angioplasty of femoropopliteal lesions: impact on stent implantation rate and mid-term outcome

Objectives To assess the impact on stent implantation rate and mid-term outcomes of prolonged high pressure angioplasty of femoropopliteal lesions. Methods We retrospectively enrolled 620 consecutive patients from January 2011 to December 2011 （75.6 ±12.3 years, 355 males, 76.5%in Rutherford class 5-6）, referred for critical limb ischemia and submitted to prolonged high-pressure angioplasty of femoropopliteal lesions. The definition of prolonged high-pressure angioplasty includes dilation to at least 18 atm for at least 120 s. Proce-dural data, and clinical and instrumental follow-up were analyzed to assess stent implantation rate and mid-term outcomes. Results The preferred approach was ipsilateral femoral antegrade in 433/620 patients （69.7%） and contralateral cross-over in 164/620 （26.4%） and pop-liteal retrograde＋femoral antegrade in 23/620 （3.7%）. Techniques included subintimal angioplasty in 427/620 patients （68.8%） and endolu-minal angioplasty in 193/620 patients （31.2%）. The prolonged high pressure balloon angioplasty procedure was successful in 86.2%（minor intra-procedural complications rate 15.7%）, stent implantation was performed in 74 patients （11.9%）, with a significant improvement of ankle-brachial index （0.29 ±0.6 vs. 0.88 ±0.3, P〈0.01） and Rutherford class （5.3 ±0.8 vs. 0.7 ±1.9, P〈0.01）, a primary patency rate of 86.7%, restenosis of 18.6%on Doppler ultrasound and a target lesion revascularization of 14.8%at a mean follow-up of 18.1 ±6.4 months （range 1-24 months）. Secondary patency rate was 87.7%. Conclusions Prolonged high pressure angioplasty of femoropopliteal lesions appears to be safe and effective allowing for an acceptable patency and restenosis rates on mid-term.     

Axl glycosylation mediates tumor cell proliferation, invasion and lymphatic metastasis in murine hepatocellular carcinoma

AIM: To investigate the effects of Axl deglycosylation on tumor lymphatic metastases in mouse hepatocellular carcinoma cell lines. METHODS: Western blotting was used to analyze the expression profile of Axl glycoprotein in mouse hepa-tocellular carcinoma cell line Hca-F treated with tunicamycin and PNGase F 3-(4,5)-dimethylthiazol(-zyl)-3,5- diphenyltetrazolium bromide (MTT) assay, extracellular matrix (ECM) invasion assay (in vitro ) and tumor metastasis assay (in vivo ) were utilized to evaluate the effect of Axl deglycosylation on the Hca-F cell proliferation, invasion and lymphatic metastasis. RESULTS: Tunicamycin and PNGase F treatment markedly inhibited Axl glycoprotein synthesis and expression, proliferation, invasion, and lymphatic metastasis both in vitro and in vivo . In the MTT assay, proliferation was apparent in untreated Hca-F cells compared with treated Hca-F cells. In the ECM invasion assay (in vitro ), treated cells passed through the ECMatrix gel in significantly smaller numbers than untreated cells (tunicamycin 5 μg/mL: 68 ± 8 vs 80 ± 9, P=0.0222; 10 μg/mL: 50 ± 6vs 80 ± 9,P=0.0003; 20 μg/mL: 41 ± 4 vs 80 ± 9, P=0.0001); (PNGase F 8 h: 66 ± 7 vs 82 ± 8, P=0.0098; 16 h: 49 ± 4 vs 82 ± 8, P=0.0001; 24 h: 34 ± 3 vs 82 ± 8, P=0.0001). In the tumor metastasis assay (in vivo ), average lymph node weights of the untreated Hca-F group compared with treated Hca-F groups (tunicamycin 5 μg/mL: 0.84 ± 0.21 g vs 0.72 ± 0.19 g, P=0.3237; 10 μg/mL: 0.84 ± 0.21 g vs 0.54 ± 0.11 g, P=0.0113; 20 μg/mL: 0.84 ± 0.21 g vs 0.42 ± 0.06 g, P=0.0008); (PNGase F 8 h: 0.79 ± 0.15 g vs 0.63 ± 0.13 g, P=0.0766; 16 h: 0.79 ± 0.15 g vs 0.49 ± 0.10 g, P=0.0022; 24 h: 0.79 ± 0.15 g vs 0.39 ± 0.05 g, P=0.0001). Also, average lymph node volumes of the untreated Hca-F group compared with treated Hca-F groups (tunicamycin 5 μg/mL: 815 ± 61 mm 3 vs 680 ± 59 mm 3 , P=0.0613; 10 μg/mL: 815 ± 61 mm 3 vs 580 ± 29 mm 3 , P=0.0001; 20 μg/mL: 815 ± 61 mm 3 vs 395 ± 12 mm 3 , P=0.0001); (PNGase F 8 h: 670 ± 56 mm 3 vs 581 ± 48 mm 3 , P=0.0532; 16 h: 670 ± 56 mm 3 vs 412 ± 22 mm 3 , P=0.0001; 24 h: 670 ± 56 mm 3 vs 323 ± 11 mm 3 , P=0.0001). CONCLUSION: Alteration of Axl glycosylation can at-tenuate neoplastic lymphatic metastasis. Axl N-glycans may be a universal target for chemotherapy.     

Drug-coated balloon strategy following orbital atherectomy for calcified coronary artery compared with drug-eluting stent: One-year outcomes and optical coherence tomography assessment

Background

Percutaneous coronary intervention (PCI) for calcified coronary artery remains challenging in the drug-eluting stent (DES) era. While recent studies reported the efficacy of orbital atherectomy (OA) combined with DES for calcified lesion, the effectiveness of drug-coated balloon (DCB) following OA has not been fully elucidated.

Methods

Between June 2018 and June 2021, 135 patients who received PCI for calcified de novo coronary lesions with OA were enrolled and divided into two groups; OA followed by DCB (n = 43) if the target lesion achieved acceptable preparation, or second- or third-generation DESs (n = 92) if the target lesion showed suboptimal preparation between June 2018 and June 2021. All patients underwent PCI with optical coherence tomography (OCT) imaging. The primary endpoint was 1-year major adverse cardiac event (MACE), that was a composite of cardiac death, nonfatal myocardial infarction, or target lesion revascularization.

Results

Mean age was 73 years and 82% was male. In OCT analysis, maximum calcium plaque was thicker (median: 1050 µm [interquartile range (IQR): 945–1175 µm] vs. 960 µm [808–1100 µm], p = 0.017), calcification arc tended to larger (median: 265° [IQR: 209–360°] vs. 222° [162–305°], p = 0.058) in patients with DCB than in DES, and the postprocedure minimum lumen area was smaller in DCB compared with minimum stent area in DES (median: 3.83 mm² [IQR: 3.30–4.52 mm²] vs. 4.86 mm² [4.05–5.82 mm²], p < 0.001). However, 1 year MACE free rate was not significantly different between 2 groups (90.3% in DCB vs. 96.6% in DES, log-rank p = 0.136). In the subgroup analysis of 14 patients who underwent follow-up OCT imaging, late lumen area loss was lower in patients with DCB than DES, despite lower lesion expansion rate in DCB than DES.

Conclusions

In calcified coronary artery disease, DCB alone strategy (if acceptable lesion preparation was performed with OA) was feasible compared with DES following OA with respect to 1-year clinical outcomes. Our finding indicated using DCB with OA might be reduce late lumen area loss for severe calcified lesion.     

Optical coherence tomography-derived predictors of stent expansion in calcified lesions

Background

Severe coronary artery calcification is associated with stent underexpansion and subsequent stent failure.

Aims

We aimed to identify optical coherence tomography (OCT)-derived predictors of absolute (minimal stent area [MSA]) and relative stent expansion in calcified lesions.

Methods

This retrospective cohort study included patients who underwent percutaneous coronary intervention (PCI) with OCT assessment before and after stent implantation between May 2008 and April 2022. Pre-PCI OCT was used to assess calcium burden and post-PCI OCT was used to assess absolute and relative stent expansion.

Results

A total of 361 lesions in 336 patients were analyzed. Target lesion calcification (defined as OCT-detected maximum calcium angle ≥ 30°) was present in 242 (67.0%) lesions. Following PCI, median MSA was 5.37 mm² in calcified lesions and 6.24 mm² in noncalcified lesions (p < 0.001). Median stent expansion was 78% in calcified lesions and 83% in noncalcified lesions (p = 0.325). In the subset of calcified lesions, average stent diameter, preprocedural minimal lumen area, and total calcium length were independent predictors of MSA in multivariable analysis (mean difference 2.69 mm²/mm², 0.52 mm²/mm, and −0.28 mm²/5 mm, respectively, all p < 0.001). Total stent length was the only independent predictor of relative stent expansion (mean difference −0.465% per mm, p < 0.001). Calcium angle, thickness, and the presence of nodular calcification were not significantly associated with MSA or stent expansion in multivariable analyses.

Conclusion

Calcium length appeared to be the most important OCT-derived predictor of MSA, whereas stent expansion was mainly determined by total stent length.     

Clinical outcomes with Biolimus (A9)™ eluting stent, ‘BioMatrix’ in diabetic patients – interim results from multicenter post market surveillance registry in India

Objective

The objective of this registry is to establish safety and efficacy of BioMatrix, BioMatrix™-Biolimus A9™ eluting stent in diabetic population in India.

Background

Diabetes mellitus is a major predisposing factor for coronary artery disease. Prognosis for diabetic population patients presenting with coronary artery disease who undergo coronary revascularization is inferior to non diabetics and remains an independent risk factor of restenosis, need for revascularization, and overall mortality. Stent thrombosis is a potential complication of first generation, permanent polymer drug-eluting stents. Biodegradable polymer is a good relief in this era and its utility in diabetic patients will be a major advantage for them.

Methods

334 patients with diabetes mellitus and requiring angioplasty, implanted with BioMatrix stent were followed at 1, 6, 12 and 24 months who entered in a multicenter registry in India. We analyzed the incidence of major adverse cardiac events (MACE) and stent thrombosis (ST) at 1, 6, 12 and 24 months.

Results

The mean age was 58.71 ± 9.2 years, 81% were males, comorbidity index was 1.6 ± 1.02, and 59.1% presented with acute coronary syndrome. The incidence of adverse event rates was: MACE 1.27%. There were no incidences of myocardial infarction (MI) and target vessel revascularization (TVR). Definite stent thrombosis occurred only in 2 patients.

Conclusion

In this registry of diabetic population treated with BioMatrixTM-Biolimus A9TM eluting stent (BioMatrix), the reported incidence of MACE and ST were much lower than previously published results. The 1- and 2-year follow-up result supports favorable clinical outcomes of using BioMatrix stents as a suitable alternative to contemporary DES available during PCI in diabetic patients.     

Clinical Predictors of Fulminant Colitis in Patients with Clostridium difficile Infection

Background/Aim:

Clostridium difficile infection (CDI) can affect up to 8% of hospitalized patients. Twenty-five percent CDI patients may develop C. difficile associated diarrhea (CDAD) and 1–3% may progress to fulminant C. difficile colitis (FCDC). Once developed, FCDC has higher rates of complications and mortality.

Patients and Methods:

A 10-year retrospective review of FCDC patients who underwent colectomy was performed and compared with randomly selected age- and sex-matched non-fulminant CDAD patients at our institution. FCDC (n=18) and CDAD (n=49) groups were defined clinically, radiologically, and pathologically. Univariate analysis was performed using Chi-square and Student''s t test followed by multivariate logistic regression to compute independent predictors.

Results:

FCDC patients were significantly older (77 ± 13 years), presented with triad of abdominal pain (89%), diarrhea (72%), and distention (39%); 28% had prior CDI and had greater hemodynamic instability. In contrast, CDAD patients were comparatively younger (65 ± 20 years), presented with only 1 or 2 of these 3 symptoms and only 5% had prior CDI. No significant difference was noted between the 2 groups in terms of comorbid conditions, use of antibiotics, or proton pump inhibitor. Leukocytosis was significantly higher in FCDC patients (18.6 ± 15.8/mm³ vs 10.7 ± 5.2/mm³; P=0.04) and further increased until the point of surgery. Use of antiperistaltic medications was higher in FCDC than CDAD group (56% vs 22%; P=0.01).

Conclusions:

Our data suggest several clinical and laboratory features in CDI patients, which may be indicative of FCDC. These include old age (>70 years), prior CDI, clinical triad of increasing abdominal pain, distention and diarrhea, profound leukocytosis (>18,000/mm³), hemodynamic instability, and use of antiperistaltic medications.     

The role of elastic recoil after balloon angioplasty of rabbit arteries and its prevention by stent implantation

Elastic recoil, neointima formation and vessel narrowing afterballoon angioplasty or stent implantation were compared in 17non-atherosclerotic New Zealand White rabbits. The implantationof a balloon-expandable Palmaz-Schatz stent was performed inone iliac artery and a balloon angioplasty alone was performedin the contralateral artery (n=34 arteries). Quantitative histomorphometrywas performed by a computer-assisted analysis 1 h and 4, 10and 24 weeks after the initial procedure. The histological appearanceof the neointima was similar to that of human restenosis. Theamount of the neointima was increased within sten ted vesselsas compared to balloon angioplasty alone (1·0±0·1vs 0·4±0·1 mm² at 4 weeks, P<0·001).However, the neointimal lumen narrowing was smaller in the stentedvessels due to persistent increase in vessel perimeter as comparedto balloon angio plasty alone (16·5±0·9vs 34·7±16·5% lumen narrowing at 4 weeks,P<0·05). In conclusion, stent implantation enhancesneointima formation as compared to angioplasty in non-atheroscleroticrabbits. The prevention of elastic recoil after stent implantation,however, reduces the neointimal lumen narrowing. This studysupports clinical observations demonstrating lower restenosisrates after stent implantation compared to standard balloonangioplasty.     

Stent expansion: a combination of delivery balloon underexpansion and acute stent recoil reduces predicted stent diameter irrespective of reference vessel size

Background

There is a strong inverse relationship between final vessel diameter and subsequent risk of treatment failure after coronary stent deployment. The aim of this study was to investigate the magnitude by which stent delivery balloon underexpansion and stent elastic recoil contributed to suboptimal final vessel geometry.

Methods

A prospective angiographic study recruiting 499 lesions (385 patients) undergoing coronary stent implantation was performed. Quantitative coronary angiography (QCA) was used to measure the minimal lumen diameters of the delivery balloon during stent deployment (MLD1) and of the stented segment following balloon deflation (MLD2). The expected balloon diameter for the deployment pressure was determined from the manufacturer''s reference chart. Delivery balloon deficit was measured by subtracting the MLD1 from the expected balloon size and stent recoil was calculated by subtracting MLD2 from MLD1. Delivery balloon deficit and stent recoil were examined as a function of reference vessel diameter (RVD) and balloon–vessel (BV) ratio.

Results

The final stent MLD was a mean 27.2% (SD = 7.2) less than the predicted diameter. The mean delivery balloon deficit was 0.65 mm (SD = 0.27) and the mean stent recoil was 0.28 mm (SD = 0.17). Percentage delivery balloon deficit and stent recoil were independent of RVD. Delivery balloon deficit increased with higher BV ratios. Stent recoil was independent of BV ratio and the use of predilatation.

Conclusion

Failure to achieve predicted final stent diameter is a real problem with contribution from delivery balloon underexpansion and stent recoil. On average the final stent MLD is only 73% of the expected diameter, irrespective of vessel size.Modern stent delivery systems use semicompliant balloons that are manufactured to have at a specific pressure, a certain nominal diameter. Inflation of the balloon at pressures greater than nominal results in a slight increase in the final diameter obtained. Manufacturers provide a compliance chart for each device, which describes the expected stent diameter for a range of deployment pressures. These values are derived from calliper or other measurements of balloons inflated in air or in a water bath. Some manufacturers report only the compliance data of the delivery balloon without the stent. These charts do not take into account the resistance encountered by compressing the atherosclerotic plaque and stretching the vessel wall during stent deployment.Failure of the delivery balloon to reach its target size during stent deployment and subsequent elastic recoil are two mechanisms that contribute to stent under‐deployment.¹ Both of these factors are a function of the vessel''s elastic properties and resistance to expansion. The relative contributions of these factors may be of particular relevance in vessels of small calibre. Bakhai et al.² reported that in vessels of small calibre, the delivery balloon size during stent deployment and the final stent minimal lumen diameter (MLD) were well below that predicted by manufacturers'' compliance charts. Elastic forces in small‐calibre vessels may restrict delivery balloon expansion to a greater degree than larger vessels. This study was undertaken to investigate the magnitude by which stent delivery balloon underexpansion and elastic recoil impacts on the final stent diameter. We also examined the influence of reference vessel diameter and the performance of predilatation on these parameters.     

Frequency and time course of reocclusion and restenosis in coronary artery occlusions after balloon angioplasty versus Wiktor stent implantation: results from the Mayo-Japan Investigation for Chronic Total Occlusion (MAJIC) trial

Background

Compared with balloon angioplasty, stent implantation has been shown to reduce restenosis and reocclusion after treatment of chronic total coronary artery occlusions (CTOs). However, little is known about the time course of restenosis and reocclusion after the 2 procedures. The purpose of this study was to examine the frequency and time course of restenosis and reocclusion after treatment of CTOs with balloon angioplasty and Wiktor stent implantation.

Methods and results

A total of 221 patients with successfully recanalized CTOs were randomly assigned to either treatment with a coil stent implantation (Wiktor stent, n = 110) or standard balloon angioplasty (n = 111). Repeat angiography was performed the day after treatment and at 6 months. Patients undergoing balloon angioplasty showed 29.8% restenosis and 1.1% reocclusion the following day versus 2% restenosis and no reocclusion in stent patients the following day. The cumulative reocclusion rate was significantly lower in the stent group than in the balloon group at 6 months (2.1% versus 9.3%, P < .05). As a result of the more frequent need of target vessel revascularization (49.5% in the balloon group and 30.6% in the stent group, P < .005) and earlier final follow-up angiography in the balloon group, the frequency of angiographic restenosis at 6 months was similar in both groups (57.3% in the stent group and 54.5% in the balloon group).

Conclusions

The frequency and time course of reocclusion and restenosis after balloon angioplasty and stent placement differ within 24 hours of the procedure and remain different on angiography at 6 months.     

Culprit Vessel Only Versus “One-week” Staged Percutaneous Coronary Intervention for Multivessel Disease in Patients Presenting with ST-Segment Elevation Myocardial Infarction

Objective To explore the impact of a “one-week” staged multivessel percutaneous coronary intervention (PCI) versus culprit-only PCI on deaths and major adverse cardiac events (MACE). Methods We retrospectively analyzed 447 patients with multivessel disease who experienced a ST-segment elevation myocardial infarction (STEMI) within 12 h before undergoing PCI between July 26, 2008 and September 25, 2011. After completion of PCI in the infarct artery, 201 patients still in the hospital agreed to undergo PCI in non-infarct arteries with more than 70% stenosis for a “one-week” staged multivessel PCI. A total of 246 patients only received intervention for the culprit vessel. Follow-up ended on September 9, 2014. This study examined the differences in deaths from any cause (i.e., cardiac and noncardiac) and MACE between the two treatment groups. Results Compared to a culprit-only PCI treatment approach, the “one-week” staged multivessel PCI was strongly associated with greater benefits for 55-month all cause death [41 (16.7%) vs. 13 (6.5%), P = 0.004] and MACE [82 (33.3%) vs. 40 (19.9%), P = 0.002] rates. In addition, there were significant differences in the number of myocardial infarctions [43 (17.5%) vs. 20 (10.0%), P = 0.023], coronary-artery bypass grafting [CABG; 20 (8.1%) vs. 6 (3.0%), P = 0.021], and PCI [31 (12.6%) vs. 12 (6.0%), P = 0.018]. Patients undergoing culprit-only PCI compared to “one-week” PCI had the same number of stent thrombosis events [7 (2.8%) vs.3 (1.5%), P = 0.522]. Conclusions Compared to a culprit-only PCI treatment approach, “one-week” staged multi-vessel PCI was a safe and effective selection for STEMI and multi-vessel PCI.     

Hyperemic coronary flow after optimized intravascular ultrasound-guided balloon angioplasty and stent implantation

OBJECTIVES

This study evaluated the acute physiological gain of adjunctive intravascular ultrasound (IVUS) guided balloon angioplasty and stent implantation.

BACKGROUND

Recent studies indicate safe coronary luminal enlargement and “stent-like” long-term outcomes using upsized balloons guided by IVUS.

METHODS

After angiographically guided balloon angioplasty in 20 patients with 1-vessel disease and normal left ventricular function, IVUS was performed to determine the size of the adjunctive balloon using the mean of the maximal luminal diameter and the maximal diameter of the external elastic membrane measured in the adjacent proximal and distal reference segments. Serial adenosine-induced hyperemic blood flow velocity measurements were performed using a 0.014″ Doppler guide wire to determine the physiological lumen obstruction after standard balloon angioplasty, followed by IVUS-guided balloon angioplasty and stent implantation.

RESULTS

Upsized balloon angioplasty (increase balloon size: 0.98 ± 0.26 mm; balloon:artery ratio 1.35 ± 0.21) resulted in an additional increase of arterial dimensions: minimal lumen diameter (MLD) 2.18 ± 0.38 mm to 2.73 ± 0.51 mm; percent diameter stenosis (%DS) 34 ± 13% to 19 ± 22%; IVUS assessed minimal lumen area (MLA) 7.53 ± 1.55 mm² to 10.24 ± 2.22 mm² (all p < 0.0001). Major dissections (≥ type C) did not occur. Hyperemic blood flow velocity increased from 49.8 ± 20.1 cm/s to 59.1 ± 22.9 cm/s (p < 0.05) after IVUS-guided balloon angioplasty. Adjunctive stent implantation resulted in a further increase of MLD to 3.84 ± 0.51 mm, %DS to −9 ± 21% and MLA to 13.39 ± 1.80 mm² (all p < 0.0001), while hyperemic blood flow velocity remained unchanged (61.2 ± 24.7 cm/s, p = 0.7).

CONCLUSIONS

Upsized IVUS-guided balloon angioplasty increases arterial coronary dimensions and the distal hyperemic blood flow velocity. Adjunctive stent implantation does not yield a further gain in the hyperemic blood flow velocity, indicating the absence of a functional residual lumen obstruction after IVUS-guided balloon angioplasty. This may explain a similar clinical outcome reported after those coronary interventions.     

B1a lymphocytes in the rectal mucosa of ulcerative colitis patients

AIM:To assess B1a cell expression in the rectal mucosa of ulcerative colitis (UC) patients in comparison with healthy controls.METHODS:Rectal mucosa biopsies were collected from 15 UC patients and 17 healthy controls.CD5 + B cells were analysed by three colour flow cytometry from rectal mucosal samples after mechanical disaggregation by Medimachine.Immunohistochemical analysis of B and T lymphocytes was also performed.Correlations between,on the one hand,rectal B1a cell concentrations and,on the other,erythrocyte sedimentation rate and C-reactive protein levels and clinical,endoscopic and histological disease activity indices were evaluated.RESULTS:Rectal B-lymphocyte (CD19 + /CD45 +) rate and concentration were higher in UC patients compared with those in healthy controls (47.85% ± 3.12% vs 26.10% ± 3.40%,P=0.001 and 501 ± 91 cells/mm 2 vs 117 ± 18 cells/mm 2,P 0.001);Rectal B1a cell density (CD5 + CD19 +) was higher in UC patients than in healthy controls (85 ± 15 cells/mm 2 vs 31 ± 6.7 cells/mm 2,P=0.009).Rectal B1a cell (CD5/CD19 +) rate correlated inversely with endoscopic classification (Rs=-0.637,P 0.05).CONCLUSION:B1a lymphocytes seem to be involved in the pathogenesis of UC,however,the role they play in its early phases and in disease activity,have yet to be defined.     

Ethyl pyruvate protects against experimental acute-on-chronic liver failure in rats

AIM:To investigate the protective effects of ethyl pyruvate(EP) on acute-on-chronic liver failure(ACLF) in rats.METHODS:An ACLF model was established in rats,and animals were randomly divided into normal,model and EP treatment groups.The rats in EP treatment group received EP(40 mg/kg) at 3 h,6 h,12 h and 24 h after induction of ACLF.Serum endotoxin,high mobility group box-1(HMGB1),alanine transaminase(ALT),tumor necrosis factor-(TNF-),interferon-(IFN-),interleukin(IL)-10 and IL-18 levels,changes of liver histology and HMGB1 expressions in liver tissues were detected at 48 h after induction of ACLF.The effects of EP on the survival of ACLF rats were also observed.RESULTS:Serum levels of endotoxin(0.394 ± 0.066 EU/mL vs 0.086 ± 0.017 EU/mL,P 0.001),HMGB1(35.42 ± 10.86 g/L vs 2.14 ± 0.27 g/L,P 0.001),ALT(8415.87 ± 3567.54 IU/L vs 38.64 ± 8.82 IU/L,P 0.001),TNF-(190.77 ± 12.34 ng/L vs 124.40 ± 4.12 ng/L,P 0.001),IFN-(715.38 ± 86.03 ng/L vs 398.66 ± 32.91 ng/L,P 0.001),IL-10(6.85 ± 0.64 ng/L vs 3.49 ± 0.24 ng/L,P 0.001) and IL-18(85.19 ± 3.49 ng/L vs 55.38 ± 1.25 ng/L,P 0.001) were significantly increased,and liver tissues presented severe pathological injury in the model group compared with the normal group.However,EP administration significantly improved hepatic histopathology and reduced the serum levels of endotoxin(0.155 ± 0.045 EU/mL vs 0.394 ± 0.066 EU/mL,P 0.001) and inflammatory cytokines(11.13 ± 2.58 g/L vs 35.42 ± 10.86 g/L for HMGB1,3512.86 ± 972.67 IU/L vs 8415.87 ± 3567.54 IU/L for ALT,128.55 ± 5.76 ng/L vs 190.77 ± 12.34 ng/L for TNF-,438.16 ± 38.10 ng/L vs 715.38 ± 86.03 ng/L for IFN-,3.55 ± 0.36 ng/L vs 6.85 ± 0.64 ng/L for IL-10,and 60.35 ± 1.63 ng/L vs 85.19 ± 3.49 ng/L for IL-18,respectively,P 0.001),and the levels of HMGB1 in liver tissues regardless of treatment time after induction of ACLF.EP treatment at the four time points prolonged the median survival time of ACLF rats(60 h) to 162 h,120 h,102 h and 78 h,respectively(2 = 41.17,P 0.0001).CONCLUSION:EP administration can protect against ACLF in rats,and is a potential and novel therapeutic agent for severe liver injury.     

Profile of Hepatic Encephalopathy in Children with Cirrhosis and Response to Lactulose

Background/Aim:

Hepatic encephalopathy (HE) is associated with a poor prognosis. There is paucity of data on the treatment of HE with lactulose in children with cirrhosis.

Patients and Methods:

Retrospective analysis of consecutive cirrhotic patients (<18 years) with HE was done. HE was defined according to West-Haven criteria. Response was defined as complete if patients recovered completely from HE, partial response was defined as improvement of encephalopathy by one or more grades from admission but not complete recovery, and defined as non response if patient did not show any improvement or deteriorated further even after 10 days of lactulose therapy.

Results:

A total of 300 patients were admitted with cirrhosis and HE (278 adults and 22 children). Of 22 patients, 16 (73%) patients had complete response to lactulose and six (27%) patients did not [three (13.5%) patients worsened (non response) and three (13.5%) did not recover fully even after 10 days of treatment (partial response)]. Comparing baseline characteristics of patients who had complete response (n=16) versus partial (n=3) and non response (n=3), there was significant difference in mean arterial pressure (78.1±10.7 vs 62.6±5.0 mmHg, P=0.003), serum sodium (131.3±3.2 vs 126.5±5.2, P=0.01) and serum creatinine (0.78±0.3 vs 1.1±0.3 mg/dl, P=0.02). We did not find any difference in baseline characteristics of these patients regarding CTP score (9.6±1.2 vs 10.6±1.2), MELD score (17.6±2.9 vs 17.1±3.4), severity of HE (2.5±0.6 vs 2.6±0.5) and etiology of precipitating factors (P=0.78).

Conclusions:

Lactulose therapy causes complete recovery from hepatic encephalopathy in 73% of pediatrics patients with cirrhosis.     

Preclinical Study of a Biodegradable Polymer-based Stent with Abluminal Sirolimus Release

Background

Bioabsorbable polymer stents with drug elution only on the abluminal surface may be safer than durable polymer drug-eluting stents.

Objective

To report the experimental findings with the Inspiron^TM stent - a bioabsorbable polymer-coated stent with sirolimus release from the abluminal surface only, recently approved for clinical use.

Methods

45 stents were implanted in the coronary arteries of 15 pigs. On day 28 after implantation, angiographic, intracoronary ultrasonographic and histomorphological data were collected. Five groups were analyzed: Group I (nine bare-metal stents); Group II (nine coated with bioabsorbable polymer on the luminal and abluminal surfaces); Group III (eight stents coated with bioabsorbable polymer on the abluminal surface); Group IV (nine stents with bioabsorbable polymer and sirolimus on the luminal and abluminal surfaces); and Group V (ten stents with bioabsorbable polymer and sirolimus only on the abluminal surface).

Results

The following results were observed for Groups I, II, III, IV and V, respectively: percentage stenosis of 29 ± 20; 36 ± 14; 33 ± 19; 22 ± 13 and 26 ± 15 (p = 0.443); late lumen loss (in mm) of 1.02 ± 0.60; 1.24 ± 0.48; 1.11 ± 0.54; 0.72 ± 0.44 and 0.78 ± 0.39 (p = 0.253); neointimal area (in mm²) of 2.60 ± 1.99; 2.74 ± 1.51; 2.74 ± 1.30; 1.30 ± 1.14 and 0.97 ± 0.84 (p = 0.001; Groups IV and V versus Groups I, II and III); and percentage neointimal area of 35 ± 25; 38 ± 18; 39 ± 19; 19 ± 18 and 15 ± 12 (p = 0.001; Groups IV and V versus Groups I, II and III). Injury and inflammation scores were low and with no differences between the groups.

Conclusion

The Inspiron^TM stent proved to be safe and was able to significantly inhibit the neointimal hyperplasia observed on day 28 after implantation in porcine coronary arteries.     

Prognostic value of high-sensitivity cardiac troponin T in patients with en-domyocardial-biopsy proven cardiac amyloidosis

Objective To investigate prognostic predictors of long-term survival of patients with cardiac amyloidosis （CA）, and to determine predictive value of high-sensitivity cardiac troponin T （hs-cTnT） in CA patients. Methods We recruited 102 consecutive CA cases and followed these patients for 5 years. We described their clinical characteristics at presentation and used a new, high-sensitivity assay to determine the concentration of cTnT in plasma samples from these patients. Results The patients with poor prognosis showed older age （56 ±12 years vs. 50 ±15 years, P=0.022）, higher incidences of heart failure （36.92%vs. 16.22%, P=0.041）, pericardial effusion （60.00%vs. 35.14%, P=0.023）, greater thickness of interventricular septum （IVS） （15 ±4 mm vs. 13 ±4 mm, P=0.034）, higher level of hs-cTnT （0.186 ±0.249 ng/mL vs. 0.044 ±0.055 ng/mL, P=0.001） and higher NT-proBNP （N-terminal pro-B-type natriuretic pep-tide） levels （11,742 ± 10,464 pg/mL vs. 6,031 ± 7,458 pg/mL, P=0.006）. At multivariate Cox regression analysis, heart failure （HR：1.78, 95%CI：1.09-2.92, P=0.021）, greater wall thickness of IVS （HR：1.44, 95%CI：1.04-3.01, P=0.0375） and higher hs-cTnT level （HR：6.16, 95%CI：2.20-17.24, P=0.001） at enrollment emerged as independent predictors of all-cause mortality. Conclusions We showed that hs-cTnT is associated with a very ominous prognosis, and it is also the strongest predictor of all-cause mortality in multivariate analysis. Examination of hs-cTnT concentrations provides valuable prognostic information concerning long-term outcomes.     

Does manual thrombus aspiration help optimize stent implantation in ST-segment elevation myocardial infarction?

AIM: To evaluate the impact of thrombus aspiration(TA) on procedural outcomes in a real-world ST-segment elevation myocardial infarction(STEMI) registry.METHODS: From May 2006 to August 2008, 542 consecutive STEMI patients referred for primary or rescue percutaneous coronary intervention were enrolled and the angiographic results and stent implantation characteristics were compared according to the performance of manual TA.RESULTS: A total of 456 patients were analyzable and categorized in TA group(156 patients; 34.2%) and non-TA(NTA) group(300 patients; 65.8%). Patientstreated with TA had less prevalence of multivessel disease(39.7% vs 54.7%, P = 0.003) and higher prevalence of initial thrombolysis in myocardial infarction flow 3(P 0.001) than NTA group. There was a higher rate of direct stenting(58.7% vs 45.5%, P = 0.009), with shorter(24.1 ± 11.8 mm vs 26.9 ± 15.7 mm, P = 0.038) and larger stents(3.17 ± 0.43 mm vs 2.93 ± 0.44 mm, P 0.001) in the TA group as compared to NTA group. The number of implanted stents(1.3 ± 0.67 vs 1.5 ± 0.84, P = 0.009) was also lower in TA group. CONCLUSION: In an "all-comers" STEMI population, the use of TA resulted in more efficient procedure leading to the implantation of less number of stents per lesion of shorter lengths and larger sizes.