Impact of radiation dose on late clinical outcome after intracoronary radiation therapy: three-year follow-up of Long WRIST.

To determine the safety and efficacy, including the impact, on the late recurrence rate of an incremental gamma-radiation dose from 15 to 18 Gy, we report the 3-year clinical outcome of Washington Radiation for In-Stent Restenosis Trial for Long Lesions (Long WRIST). One hundred eighty patients with recurrent in-stent restenosis (ISR) were enrolled in the Long WRIST series and treated with (192)Ir with 1 month of antiplatelet therapy. Between 6 months and 3 years, the need for repeat revascularization was low and similar among the three groups. At 3 years, target lesion revascularization (TLR) and major adverse cardiac events (MACE) were less frequent in the 18 Gy group than in the 15 Gy group (P = 0.12 for TLR, P < 0.05 for MACE) and less frequent in the 15 Gy group as compared to the placebo group (P < 0.05 for TLR and MACE). At 3 years, a higher dose of 18 Gy with (192)Ir continues to improve the outcome of patients treated for ISR when compared to patients treated with 15 Gy or placebo.     

Percutaneous high-speed rotational atherectomy (Rotablator™) of a restenosed ostial renal artery: A case report

This case report describes the feasibility and potential benefit of the use of a high-speed rotational atherectomy device (the Rotablator?) in the treatment of renovascular hypertension in a patient with a recorded restenosis of an ostial renal artery lesion following standard balloon angioplasty.     

血清肝素辅助因子II 活性与下肢动脉硬化闭塞症介入术后再狭窄相关

目的：观察血清肝素辅助因子II(heparin cofactor II,HC II)活性与下肢动脉硬化闭塞症介入术后再狭窄的 关系。方法：因股浅动脉闭塞性疾病而成功施行支架植入术的患者62例,根据患者血清HC II活性高低,将患者分为 两组：HC II活性≥100%组(n=40)及HC II活性<100%组(n=22)。收集患者相关临床资料,随访观察6个月,观察术后 支架内狭窄、闭塞情况。结果：两组患者基线资料比较差异无统计学意义(P>0.05)。随访至第6个月月末时,HC II活 性<100%组支架内再狭窄程度较HC II活性≥100%组严重(P<0.05)。HC II活性<100%组支架内再狭窄发生率较HC II活 性≥100%组高(P<0.05)。进一步对危险因素行多元回归分析,结果显示血清HC II活性升高是减少术后再狭窄发生的 独立因素(OR=0.982,P=0.048)。结论：血清HC II活性与下肢动脉硬化症介入术后再狭窄相关;HC II活性越低,术后 发生再狭窄的危险越大。     

Insufficient tissue ablation by rotational atherectomy leads to worse long-term results in comparison with balloon angioplasty alone for the treatment of diffuse in-stent restenosis: insights from the intravascular ultrasound substudy of the ARTIST randomized multicenter trial.

The ARTIST trial demonstrated a worse outcome for patients with in-stent restenosis (ISR) treated with rotational atherectomy (RA) and adjunctive balloon angioplasty (PTCA) as compared to PTCA alone. This intravascular ultrasound (IVUS) substudy compares effects of lumen enlargement and examines reasons for failure of RA in this setting. IVUS (n = 56) was performed after each interventional step and at follow-up. Volumetric lumen gain measured 79 +/- 68 mm(3) after PTCA (13 +/- 4 atm) as compared to 44 +/- 26 mm(3) after RA and adjunctive PTCA (7 +/- 3 atm; P < 0.0001). RA itself enlarged lumen by only 19 +/- 17 mm(3) and stent volume was 47% smaller as compared to high-pressure PTCA. Low-pressure strategy after RA did not prevent tissue growth during follow-up (19 +/- 25 vs. 36 +/- 38 mm(3); RA vs. PTCA; P = 0.09). Consequently, net lumen gain after PTCA was 82% higher compared to RA (46 +/- 54 vs. 25 +/- 24 mm(3); P = 0.09). Further stent expansion is the key mechanism to achieve luminal gain by PTCA of ISR. Neointimal ablation by RA has only minor effects. Low-pressure PTCA does not prevent recurrent tissue growth and failed for treatment of ISR due to insufficient stent expansion.     

Ultrasound velocity criteria for carotid in-stent restenosis.

OBJECTIVE: To examine duplex ultrasound (US) criteria for carotid in-stent restenosis (ISR). BACKGROUND: Carotid artery stent (CAS) placement is an alternative to surgery for the treatment of carotid stenosis in high surgical risk patients. US is the primary method used to follow carotid stent patency. This study investigates US velocity measurements in carotid ISR. METHODS: Two hundred sixty consecutive patients with CAS placement from June 2000 to June 2004 were followed with serial US. ISR was determined by using the standard US velocity criteria for nonstented carotid artery using peak systolic velocity (PSV), end-diastolic velocity (EDV), and internal carotid artery to common carotid velocity ratio (ICA/CCA ratio). Patients suspected of having carotid ISR > or =50% by US, underwent invasive angiography with stenosis graded by NASCET criteria. Results were compared to patients with nonstented carotid artery stenosis using Two-tailed Student's t-test. RESULTS: PSV and ICA/CCA ratio increased to a greater degree in ISR. In 50-69% stenotic arteries, the mean ICA/CCA ratio was 2.76 +/- 0.7 in the ISR group compared to 2.04 +/- 0.3 in the nonstented carotid group (P < 0.05). In > or =70% stenotic arteries, there were increases in PSV (520 +/- 93 vs. 362 +/- 60, P < 0.05) and ICA/CCA ratio (7.58 +/- 2 vs. 4.51 +/- 1.3, P < 0.05) in ISR versus nonstented carotid arteries, respectively. CONCLUSION: PSV and ICA/CCA ratio in ISR increased to a greater extent for angiographic stenosis > or =50%. PSV 240 cm/sec and ICA/CCA ratio 2.45 are optimal thresholds for > or =50% ISR, and PSV 450 cm/sec and ICA/CCA ratio 4.3 are optimal thresholds for > or =70% ISR.     

Restenosis after elective coronary balloon angioplasty in patients with end stage renal disease: a case-control study using quantitative coronary angiography

Objective—To assess the rate of angiographic restenosis in patients with end stage renal disease after elective coronary angioplasty.
Design—A retrospective case-control study of 20 patients with end stage renal disease and 20 sex and age matched controls without renal disease, who had undergone primarily successful coronary angioplasty. Control coronary angiography was performed regardless of worsening or renewed incidence of anginal symptoms.
Main outcome measures—Group comparison of coronary morphology, as evaluated by quantitative coronary angiography, and of cardiovascular risk factors.
Results—The rate of angiographic restenosis was 60% in patients with renal disease and 35% in controls. In patients with end stage renal disease the following differences (mean (SD) were found versus controls: raised plasma fibrinogen (483 (101) v 326 (62) mg/dl, p < 0.001); raised plasma triglyceride (269 (163) v 207 (176) mg/dl, p < 0.01); smaller diameter of the coronary reference segment (2.59 (0.87) v 2.90 (0.55) mm, p < 0.10); smaller minimum luminal diameter of the dilated stenosis (0.77 (0.46) v 0.97 (0.27) mm, p < 0.05). Discriminant analysis showed that minimum luminal diameter before angioplasty (r = −0.79) and fibrinogen (r = +0.34) had the highest statistical association with restenosis.
Conclusions—The high rate of angiographic restenosis in patients with end stage renal disease seems to be related to the size of the vessel dilated and to an increased prothrombotic risk, as indicated by higher fibrinogen concentrations.

Keywords: renal disease;  coronary artery disease;  coronary angioplasty;  restenosis     

经皮冠状动脉介入治疗后患者血清长链非编码RNA GAS5水平与冠状动脉支架内再狭窄的相关性

目的 探究血清长链非编码RNA GAS5(lncRNA GAS5)水平与急性ST段抬高型心肌梗死(STEMI)患者冠状动脉支架内再狭窄的相关性。方法 选取接受择期经皮冠状动脉介入治疗(PCI)的STEMI患者144例,根据随访结果将患者分为支架内再狭窄(ISR)组27例和非ISR组109例,失访8例。收集STEMI患者临床资料。采用实时荧光定量PCR(qRT-PCR)检测所有患者PCI术后血清lncRNA GAS5水平。结果 与非ISR组相比,ISR组患者术前吸烟及合并糖尿病比例、总胆红素(TBIL)、血清总胆固醇(TC)、低密度脂蛋白胆固醇(LDLC)水平较高(P＜0.05),血清中lncRNA GAS5水平较低(P＜0.05);与lncRNA GAS5高水平者相比,lncRNA GAS5低水平者ISR发生率较高(P＜0.05),无再狭窄平均时间较短(P＜0.05);Logistic回归分析显示,低水平lncRNA GAS5是STEMI患者冠状动脉支架内再狭窄的危险因素。结论 lncRNA GAS5在STEMI冠状动脉支架内再狭窄患者血清中水平下调,低水平lncRNA GAS5是STEMI患者冠状动脉支架内再狭窄的危险因素。     

Reduced incidence of clinical restenosis with newer generation stents, stent oversizing, and high-pressure deployment: single-operator experience

BACKGROUND: Over the last 4 years, several newer generation stents have become available, promising to change the scenery of coronary angioplasty (PTCA) with its attendant restenosis rate. HYPOTHESIS: The aim of this study was to review prospectively the results of a single operator adopting a uniform approach with approximately 0.5 mm stent oversizing and high-pressure (> or = 12-16 bar) deployment and compare them with conventional PTCA in a series of 244 consecutive patients. METHODS: The study included 203 men and 41 women, aged 59 +/- 11 years, who presented with stable angina and/or positive exercise testing (n = 75), unstable angina (n = 161), or acute myocardial infarction (n = 8). Dilated vessels included the left anterior descending artery (n = 139), the right coronary artery (n = 86), the left circumflex artery (n = 47), the ramus branch (n = 4), or venous grafts (n = 2). Stents were implanted for dissection, suboptimal PTCA result, and electively. Two groups were compared: 83 patients who underwent balloon PTCA alone and 161 patients who also received stent(s). RESULTS: The two groups had similar demographics, age (58 +/- 10 vs. 59 +/- 11 years), initial vessel stenosis (92 +/- 7 vs. 93 +/- 6%), and left ventricular ejection fraction (51 +/- 9 vs. 51 +/- 8%). Procedural success was also similar (97.6 vs. 99.4%), but as expected the residual stenosis was much lower in the stent group (< or = 0 vs. 17%). The following stents were employed: J & J (n = 1), NIR (n = 117), ACS (n = 59), AVE (n = 9), Inflow GoldFlex (n = 9), Crossflex (n = 5), Wictor (n = 1), Jostent (n = 16), R stent (n = 9), Seaquence (n = 2) and Wallstent (n = 1). Single stents were used in 118 patients, two stents in 31 patients, three in 6 patients, and four in 6 patients. There was one in-hospital death at 3 days unrelated to the procedure. There were no events of subacute stent thrombosis; all patients in the stent group received combined therapy with aspirin and ticlopidine, the latter for 1 month. During 18 +/- 14 months, the clinical restenosis rate was significantly lower in the stent group (6.9%) than in the PTCA group (28.4%) (p = 0.001). CONCLUSION: In a series of 244 consecutive patients, newer generation stents and a consistent approach of stent oversizing and high-pressure stent deployment by a single operator resulted in high procedural success (99%), lack of stent thrombosis (0%), and a very low clinical restenosis rate (7%).     

Safety and efficacy of angiography-guided stent placement in small native coronary arteries of < 3.0 mm in diameter

Background and hypothesis: Increased operator experience, greater insight in stent deployment techniques, and improved poststent medication regimen have significantly reduced the risk of thrombotic stent closure following stent placement in large coronary arteries ( 3.0 mm in diameter). Whether equally favorable results are afforded by stent placement in small vessels (> 3.0 mm), however, remains unclear. Accordingly, the aim of this study was the specific examination of the risk of stent placement in small native coronary vessels, using stent deployment technique consisting of supplementary dilatations with larger balloons or high-pressure inflations, and aggressive aspirin-ticlopidine and short-term oral anticoagulation poststent therapy. Methods: Forty-seven balloon-expandable stents (20 Gianturco-Roubin, 21 NIR, 6 Palmaz-Schatz) were successfully implanted without intravascular guidance in 45 native coronary arteries (mean reference diameter of 2.5 mm) in 44 consecutive patients (31 men, 13 women), the majority of whom (87%) were stented for the treatment of failed or suboptimal balloon angioplasty outcome. Results: Successful stent placement reduced the lesion diameter stenosis from 91 ± 9% to 3 ± 7% (p = 0.0001). There were no early stent thrombosis or major cardiovascular events prior to hospital discharge. During a 12-month follow-up period, most patients remained symptomatically improved and no myocardial infarction, stroke, or death was observed. Five-month angiographic reassessment revealed an in-stent restenosis rate of 41%, which was higher in vessels 2.5 mm in size (47 vs. 33% for vessels > 2.5 mm, p = 0.2747). Conclusions: In selected patients with small native coronary vessels < 3.0 mm in diameter, angiography-guided optimal stent placement is associated with a low risk of stent thrombosis and bleeding complications. However, the in-stent restenosis rate is high with the stents used in this study.