Abstract Objectives This study sought to evaluate the optimal percutaneous coronary intervention techniques using drug-eluting stents for bifurcation coronary lesions. Background The optimal ...bifurcation stenting technique needs to be evaluated. Methods The trial included 2 randomization studies separated by the presence of side branch (SB) stenosis for patients having non–left main bifurcation lesions. For 306 patients without SB stenosis, the routine final kissing balloon or leave-alone approaches were compared. Another randomization study compared the crush or single-stent approaches for 419 patients with SB stenosis. Results Between the routine final kissing balloon and leave-alone groups for nondiseased SB lesions, angiographic restenosis occurred in 17.9% versus 9.3% (p = 0.064), comprising 15.1% versus 3.7% for the main branch (p = 0.004) and 2.8% versus 5.6% for the SB (p = 0.50) from 214 patients (69.9%) receiving 8-month angiographic follow-up. Incidence of major adverse cardiac events including death, myocardial infarction, or target vessel revascularization over 1 year was 14.0% versus 11.6% between the routine final kissing balloon and leave-alone groups (p = 0.57). In another randomization study for diseased SB lesions, 28.2% in the single-stent group received SB stents. From 300 patients (71.6%) receiving angiographic follow-up, between the crush and single-stent groups, angiographic restenosis rate was 8.4% versus 11.0% (p = 0.44), comprising 5.2% versus 4.8% for the main branch (p = 0.90) and 3.9% versus 8.3% for the SB (p = 0.12). One-year major adverse cardiac events rate between the crush and single-stent groups was 17.9% versus 18.5% (p = 0.84). Conclusions Angiographic and clinical outcomes were excellent after percutaneous coronary intervention using drug-eluting stents with any stent technique for non–left main bifurcation lesions once the procedure was performed successfully.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
The purpose of this study was to determine the effect of the addition of cilostazol to aspirin plus clopidogrel on platelet aggregation after intracoronary stent implantation. Twenty patients who ...underwent coronary stent placement were randomly assigned to therapy with aspirin plus clopidogrel (dual-therapy group, n = 10) or aspirin plus clopidogrel plus cilostazol (triple-therapy group, n = 10). A loading dose of clopidogrel (300 mg) and cilostazol (200 mg) was administered immediately after stent placement, and clopidogrel (75 mg/day) and cilostazol (100 mg twice daily) were given for 1 month. Platelet aggregation in response to adenosine diphosphate (ADP; 5 and 20 μmol/L) or collagen and P-selectin (CD-62P) expression was assayed at baseline, 2 hours, 24 hours, 1 week, and 1 month after stent placement. Inhibition of ADP-induced platelet aggregation was significantly higher in patients receiving triple therapy than those receiving dual therapy from 24 hours after stent placement, and inhibition of collagen-induced platelet aggregation was significantly higher in the triple-therapy group beginning 1 week after stent placement. P-Selectin expression was significantly lower in the triple-therapy than dual-therapy group at 1 week and 30 days. In conclusion, compared with dual antiplatelet therapy, triple therapy after coronary stent placement resulted in more potent inhibition of platelet aggregation induced by ADP and collagen. These findings suggest that triple therapy may be used clinically to prevent thrombotic complications after coronary stent placement.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Despite the widespread adoption of drug-eluting stent (DES) implantation, the optimal treatment of DES failures remains challenging. The present study evaluated the relation between quantitative ...angiography and the fractional flow reserve (FFR) in restenotic lesions after DES implantation and the efficacy of FFR in determining whether to treat these lesions. To assess their functional significance, the coronary pressure-derived FFR was measured in 50 DES restenotic lesions (49 patients). Additional intervention was performed in lesions with a FFR <0.8. Major adverse cardiac events were assessed at 12 months after the reintervention procedure. The mean percent diameter stenosis (%DS) was 58 ± 13%. Of the 50 lesions, 20 (40%) were deferred without additional intervention. The FFR and %DS had a negative correlation (r = −0.61, p <0.001). However, when only the lesions with diffuse-type restenosis (15 lesions) were analyzed, the degree of correlation decreased (r = −0.56, p = 0.12). Although most lesions (89%) with a %DS of ≥70 had significant functional ischemia, among 41 lesions with a %DS <70, only 20 (49%) had demonstrated functional patency. The incidence of adverse events during the 12 months of follow-up after FFR-guided treatment was 18.0% (23.3% in the FFR <0.80 group and 10.0% in FFR ≥0.80 group). In conclusion, a discrepancy was found between functional ischemia measured by the FFR and the angiographic %DS, in particular, in moderate- or diffuse-type restenotic lesions after DES implantation. The outcome of FFR-guided deferral in patients with DES in-stent restenosis seems favorable.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background context To our knowledge, no large series comparing the risk of vertebral artery injury by C1–C2 transarticular screw versus C2 pedicle screw have been published. In addition, no ...comparative studies have been performed on those with a high-riding vertebral artery and/or a narrow pedicle who are thought to be at higher risk than those with normal anatomy. Purpose To compare the risk of vertebral artery injury by C1–C2 transarticular screw versus C2 pedicle screw in an overall patient population and subsets of patients with a high-riding vertebral artery and a narrow pedicle using computed tomography (CT) scan images and three-dimensional (3D) screw trajectory software. Study design Radiographic analysis using CT scans. Patient sample Computed tomography scans of 269 consecutive patients, for a total of 538 potential screw insertion sites for each type of screw. Outcome measures Cortical perforation into the vertebral artery groove of C2 by a screw. Methods We simulated the placement of 4.0 mm transarticular and pedicle screws using 1-mm-sliced CT scans and 3D screw trajectory software. We then compared the frequency of C2 vertebral artery groove violation by the two different fixation methods. This was done in the overall patient population, in the subset of those with a high-riding vertebral artery (defined as an isthmus height ≤5 mm or internal height ≤2 mm on sagittal images) and with a narrow pedicle (defined as a pedicle width ≤4 mm on axial images). Results There were 78 high-riding vertebral arteries (14.5%) and 51 narrow pedicles (9.5%). Most (82%) of the narrow pedicles had a concurrent high-riding vertebral artery, whereas only 54% of the high-riding vertebral arteries had a concurrent narrow pedicle. Overall, 9.5% of transarticular and 8.0% of pedicle screws violated the C2 vertebral artery groove without a significant difference between the two types of screws (p=.17). Among those with a high-riding vertebral artery, vertebral artery groove violation was significantly lower (p=.02) with pedicle (49%) than with transarticular (63%) screws. Among those with a narrow pedicle, vertebral artery groove violation was high in both groups (71% with transarticular and 76% with pedicle screws) but without a significant difference between the two groups (p=.55). Conclusions Overall, neither technique has more inherent anatomic risk of vertebral artery injury. However, in the presence of a high-riding vertebral artery, placement of a pedicle screw is significantly safer than the placement of a transarticular screw. Narrow pedicles, which might be anticipated to lead to higher risk for a pedicle screw than a transarticular screw, did not result in a significant difference because most patients (82%) with narrow pedicles had a concurrent high-riding vertebral artery that also increased the risk with a transarticular screw. Except in case of a high-riding vertebral artery, our results suggest that the surgeon can opt for either technique and expect similar anatomic risks of vertebral artery injury.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background context Facet joint orientation and facet tropism (FT) are presented as the potential anatomical predisposing factors for lumbar degenerative changes that may lead in turn to ...early degeneration and herniation of the corresponding disc or degenerative spondylolisthesis. However, no biomechanical study of this concept has been reported. Purpose To investigate the biomechanical influence of the facet orientation and FT on stress on the corresponding segment. Study design Finite element analysis. Methods Three models, F50, F55, and F60 were simulated with different facet joint orientations (50°, 55°, and 60° relative to coronal plane) at both L2–L3 facet joints. A FT model was also simulated to represent a 50° facet joint angle at the right side and a 60° facet joint angle at the left side in the L2–L3 segment. In each model, the intradiscal pressures were investigated under four pure moments and anterior shear force. Facet contact forces at the L2–L3 segment were also analyzed under extension and torsion moments and anterior shear force. This study was supported by 5000 CHF grant of 2011 AO Spine Research Korea fund. The authors of this study have no topic-specific potential conflicts of interest related to this study. Results The F50, F55, and F60 models did not differ in the intradiscal pressures generated under four pure moments: but under anterior shear force, the F60 and FT models showed increases of intradiscal pressure. The F50 model under extension and the F60 model under torsion each generated an increase in facet contact force. In all conditions tested, the FT model yielded the greatest increase of intradiscal pressure and facet contact force of all the models. Conclusions The facet orientation per se did not increase disc stress or facet joint stress prominently at the corresponding level under four pure moments, but FT could make the corresponding segment more vulnerable to external moments or anterior shear force.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background context Lumbar spinal stenosis (LSS) patients with diabetes mellitus (DM) are presumed to experience difficulty when performing regular daily exercise, although such exercise is ...of paramount importance for glucose homeostasis and control. Therefore, decompression surgery, which can help patients perform regular physical activity, would have indirect positive effects on blood glucose control in LSS patients with DM. Purpose To evaluate the indirect effects of spinal surgery on hemoglobin A1c (HbA1c ) levels in the patient with Type 2 DM and LSS. Study design Prospectively collected observational cohort data. Patient sample Patients with degenerative LSS and DM. Outcome measures The fasting total cholesterol (TC), fasting blood glucose (FBG), and HbA1c levels and visual analog scale (VAS) for back pain, VAS for leg pain, and Oswestry Disability Index (ODI). Methods According to the treatment methods, 31 and 37 patients were allocated to the surgical and conservative treatment groups, respectively. The HbA1c , TC, and FBG levels and the ODI and VAS for back/leg pain were recorded for all patients before surgical and conservative treatments. At the first and second follow-up assessments after surgical or conservative treatment, the data were reassessed for all patients. Results In both groups, the VAS for back/leg pain and the ODI scores significantly decreased after surgical or conservative treatment. In the surgical treatment group, the HbA1c levels were significantly decreased at the first and second assessments after surgery, whereas the conservative treatment group did not show significant reductions in HbA1c levels at the first and second follow-up assessments. In both groups, the FBG levels did not differ between the initial and follow-up assessments. The TC levels were significantly decreased at the second follow-up assessment, only in the surgical treatment group. The amount of ODI score reduction correlated positively with the degree of HbA1c level reduction at the first follow-up assessment. Conclusions The present study demonstrates the reduction in HbA1c level in patients with DM and LSS after decompression surgery with or without fusion. We believe this reduction in the HbA1c level may be a result of increased physical activity, subsequent to successful surgical decompression of the cauda equina.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background context To our knowledge, there is no clinical study analyzing the feasibility and complications of the routine insertion of the lateral mass screw via the posterior arch for ...C1 fixation in a live surgical setting. Purpose To evaluate the feasibility of routine insertion of the lateral mass screw via the posterior arch and related complications. Study design Prospective clinical-radiological analysis. Patient sample Fifty-two consecutive patients with 102 C1 lateral mass screws inserted via the posterior arch. Outcome measures Cortical perforation, vertebral artery injuries, and visual analog scale score of occipital neuralgia recorded on a prospective database. Methods All consecutive patients in whom lateral mass screw placement via the posterior arch was attempted as the first choice whenever C1 posterior fixation was necessary were enrolled. Prospective database, clinical records, questionnaires regarding occipital neuralgia, pre- and postoperative computed tomography (CT) angiograms, and follow-up radiographs and CT scans were analyzed. This study was supported by a $9,000 academic research grant by the first author's hospital. The last author receives royalties for a posterior cervical fixation system, which is not the topic of this study and is not used or mentioned in this article. Results One hundred two screws were attempted in 52 consecutive patients by a single surgeon. The height of 43 posterior arches (42%) was smaller than 4 mm on preoperative CT angiography. Lateral mass screws could be inserted via the posterior arch in all cases including eight with nine ponticuli posticus and seven with seven persistent first intersegmental arteries, but the posterior arch was perforated cranially by 7, caudally by 30, and craniocaudally (partially) by 3 screws and vertically split by 14 screws. Among the last 28 screws for which the authors' overdrilling technique was used, only one vertical split occurred, whereas among the first 74 screws without overdrilling, 13 vertical splits occurred. None of them led to screw loosening or nonunion. There were no vertebral artery injuries. Among the 19 patients with preoperative occipital neuralgia, 12 had complete resolution and seven had alleviation at the last follow-up. Among the 33 patients without preoperative neuralgia, seven developed new neuralgia postoperatively. Three of them underwent C2 root transection and the other four underwent C2 root dissection for intraarticular fusion of the facet joints. Of the seven, five had complete resolution and two had mild discomfort at the last follow-up. Conclusions Routine insertion of the lateral mass screw via the C1 posterior arch was feasible in even those with a small posterior arch, ponticulus posticus, or persistent first intersegmental artery. Although cortical perforation or vertical splitting of the posterior arch was often inevitable, it did not lead to significant weakening of the fixation or nonunion. Vertical split could be minimized by overdrilling the posterior arch. Vertebral artery injury was preventable by mobilization before screw insertion. Occipital neuralgia was not uncommon but thought to be unrelated to screw placement in most cases.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Objectives The purpose of this study is to compare the efficacy of the treatment strategies for in-stent restenosis (ISR) of drug-eluting stents (DES) according to the morphologic pattern of ...restenosis. Background Optimal treatment strategies for ISR within DES have not been adequately addressed yet. Methods Patients with ISR of DES were randomized according to the lesion length to compare outcomes of sirolimus-eluting stent (SES) versus cutting balloon angioplasty for focal type (≤10 mm) and SES versus everolimus-eluting stent (EES) for diffuse type (>10 mm). The primary endpoint was in-segment late loss at 9 months. Overall 162 patients, 96 with focal ISR and 66 with diffuse ISR, were enrolled. Results In focal lesions, in-segment late loss was significantly higher in the cutting balloon group (n = 48) than in the SES group (n = 48; 0.25 mm, interquartile range IQR: −0.01 to 0.68 mm vs. 0.06 mm, IQR: −0.08 to 0.17 mm; p = 0.04). Consequently, in-segment restenosis rate tended to be higher in the cutting balloon group than in the SES group (20.7% vs. 3.1%, p = 0.06) with comparable incidences of the composite of death, myocardial infarction, or target vessel revascularization at 12 months of clinical follow up (6.3% vs. 6.3%, p > 0.99). In 66 cases of diffuse ISR, in-segment late loss (0.11 mm, IQR: −0.02 to 0.30 mm; vs. 0.00 mm, IQR: −0.08 to 0.25 mm; p = 0.64), in-segment restenosis rate (5.0% vs. 14.3%, p = 0.32), and the composite incidence of death, myocardial infarction, or target lesion revascularization (9.6% vs. 8.8%, p > 0.99) did not differ between SES group (n = 32) and EES group (n = 34). Conclusions For lesions of focal DES restenosis, repeat implantation of SES is more effective in reducing late luminal loss and subsequent restenosis rate than cutting balloon angioplasty. For diffuse DES restenosis, implantation of SES or EES is comparably effective in terms of angiographic and clinical outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract Background context Facet joint orientation and tropism influence the biomechanics of the corresponding segment. Therefore, the sagittal orientation or tropism of the facet joint adjacent to ...the fusion segment seems a potential risk factor for adjacent segment degeneration. However, there have been no biomechanical studies regarding this issue. Purpose To investigate the association between adjacent facet orientation and facet tropism and stress in adjacent disc/facet joints using finite element (FE) analysis. Study design An FE analysis. Methods Four intact (F50, F55, F60, and FT facet tropism) and matched L3–L4 fusion (F50, F55, F60, and FT fusion) models with different facet joint orientation (50°, 55°, 60° relative to the coronal plane, and facet tropism, respectively) at both L2–L3 facet joints were simulated. In each model, intradiscal pressures and facet contact force at the L2–L3 segment were investigated under pure moments and anterior shear force. Results Compared with the matched-intact model, the F60 fusion model yielded the highest and largest percentage increase of intradiscal pressure at the L2–L3 segment under flexion, torsion moment, and anterior shear force among the F50, F55, and F60 fusion models. F60 fusion model also demonstrated the largest facet contact force under torsion moment among the F50, F55, and F60 fusion models. In all conditions tested, the FT fusion model demonstrated the highest intradiscal pressure and facet contact force of all the models. Conclusions Facet joint orientation and tropism at the adjacent segment influences the overstress of the adjacent segment, especially under the clinical circumstance of increased anterior shear force.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Objectives The purpose of this study was to determine the impact of adjunctive cilostazol in patients with high post-treatment platelet reactivity (HPPR) undergoing coronary stenting. Background ...Although addition of cilostazol to dual antiplatelet therapy enhances adenosine diphosphate (ADP)-induced platelet inhibition, it is unknown whether adjunctive cilostazol can reduce HPPR. Methods Sixty patients with HPPR after a 300-mg loading dose of clopidogrel were enrolled. HPPR was defined as maximal platelet aggregation (Aggmax ) >50% with 5 μmol/l ADP. Patients were randomly assigned to receive either adjunctive cilostazol (triple group; n = 30) or high maintenance dose (MD) clopidogrel (high-MD group; n = 30). Platelet function was assessed at baseline and after 30 days with conventional aggregometry and the VerifyNow assay. Results Baseline platelet function measurements were similar in both groups. After 30 days, significantly fewer patients in the triple versus high-MD group had HPPR (3.3% vs. 26.7%, p = 0.012). Percent inhibitions of 5 μmol/l ADP-induced Aggmax and late platelet aggregation (Agglate ) were significantly greater in the triple versus high-MD group (51.1 ± 22.5% vs. 28.0 ± 18.5%, p < 0.001, and 70.9 ± 27.3% vs. 45.3 ± 23.4%, p < 0.001, respectively). Percent inhibitions of 20 μmol/l ADP-induced Aggmax and Agglate were consistently greater in the triple versus high-MD group. Percent change of P2Y12 reaction units demonstrated a higher antiplatelet effect in the triple versus high-MD group (39.6 ± 24.1% vs. 23.1 ± 29.9%, p = 0.022). Conclusions Adjunctive cilostazol reduces the rate of HPPR and intensifies platelet inhibition as compared with a high-MD clopidogrel of 150 mg/day.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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