Abstract Background We sought to clarify the impact of final kissing inflation (FKI) after single stenting of bifurcation lesions on vessel healing. Methods From the J-REVERSE registry enrolling 303 ...bifurcation lesions treated with provisional single stenting using sirolimus- (SES) or everolimus-eluting stent (EES), 65 lesions treated with ( n = 30) and without ( n = 35) FKI underwent 9-month follow-up optical coherence tomography. Average stent eccentricity index (SEI: minimum/maximum stent diameter) and neointimal unevenness score (NUS: maximum/average neointimal thickness of the same cross-section) for the proximal, bifurcation, and distal segments were compared between FKI and non-FKI groups. Results At the proximal segment, the FKI group demonstrated significantly larger average stent area with greater asymmetric stent expansion, and average lumen area remained significantly larger at 9-month follow-up despite a tendency toward greater neointimal proliferation. Jailed strut and thrombus incidence were also significantly lower at the side branch orifice, and NUS was significantly smaller at the bifurcation and proximal segments in the FKI group. Conclusions Nine months after SES and EES treatment of bifurcation lesions, FKI reduced proximal-segment luminal narrowing. Considering its homogeneous neointimal distribution and fewer jailed struts, FKI may be beneficial for treating bifurcation lesions.
Abstract Background We aimed to clarify the differences in vessel healing after stenting of bifurcation lesions using sirolimus-eluting stents (SESs) or everolimus-eluting stents (EESs). Methods J ...apanese R egistry Study in Comparison Between Ever olimus-Eluting Stent and S irolimus- E luting Stent for the Bifurcation Lesion (J-REVERSE) is a prospective multicentre registry of 303 bifurcation lesions that were treated with provisional SES or EES with or without final kissing inflation. The first 115 lesions at selected study sites were predefined for inclusion in the optical coherence tomography (OCT) substudy, and 9-month follow-up OCT was conducted in 64 lesions (SES, n = 18; EES, n = 46). In addition to standard OCT parameters, stent eccentricity index (SEI; minimum divided by the maximum stent diameter), neointimal unevenness score (NUS; maximum neointimal thickness in the cross-section CS divided by the average neointimal thickness NIT of the same CS; uniformity of the neointima suppression) were averaged for each segment (proximal, bifurcation, and distal segments). Results Overall, the average stent and luminal area, NIT, and frequency of uncovered struts were similar. The frequency of malapposed struts and SEI were significantly lower in the EES group than in the SES group. The EES group had a significantly smaller NUS in the proximal and distal segments. Conclusions EESs offer homogeneous vessel healing with less malapposition in the treatment of bifurcation lesions.
Summary Background Continuous deep sedation (CDS) before death is a form of palliative sedation therapy that has become a focus of strong debate, especially with respect to whether it shortens ...survival. We aimed to examine whether CDS shortens patient survival using the propensity score-weighting method, and to explore the effect of artificial hydration during CDS on survival. Methods This study was a secondary analysis of a large multicentre prospective cohort study that recruited and followed up patients between Sept 3, 2012, and April 30, 2014, from 58 palliative care institutions across Japan, including hospital palliative care settings, inpatient palliative care units, and home-based palliative care services. Adult patients (aged ≥20 years) with advanced cancer who received care through the participating palliative care services were eligible for this secondary analysis. Patients with missing data for outcome variables or who lived for more than 180 days were excluded. We compared survival after enrolment between patients who did and did not receive CDS. We used a propensity score-weighting method to control for patient characteristics, disease status, and symptom burden at enrolment. Findings Of 2426 enrolled patients with advanced cancer, we excluded 289 (12%) for living longer than 180 days and 310 (13%) with missing data, leaving an analysis population of 1827 patients. 269 (15%) of 1827 patients received CDS. Unweighted median survival was 27 days (95% CI 22–30) in the CDS group and 26 days (24–27) in the no CDS group (median difference −1 day 95% CI −5 to 4; HR 0·92 95% CI 0·81–1·05; log-rank p=0·20). After propensity-score weighting, these values were 22 days (95% CI 21–24) and 26 days (24–27), respectively (median difference −1 day 95% CI −6 to 4; HR 1·01 95% CI 0·87–1·17; log-rank p=0·91). Age (pinteraction =0·67), sex (pinteraction =0·26), performance status (pinteraction =0·90), and volume of artificial hydration (pinteraction =0·14) did not have an effect modification on the association between sedation and survival, although care setting did have a significant effect modification (pinteraction =0·021). Interpretation CDS does not seem to be associated with a measurable shortening of life in patients with advanced cancer cared for by specialised palliative care services, and could be considered a viable option for palliative care in this setting. Funding Japanese National Cancer Center Research and Development Fund.
Objectives This study sought to compare the initial success rate of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in a native coronary artery (NCA) in patients with and ...without previous coronary artery bypass grafting (CABG) and to assess predictive factors. Background Landmark novel wiring techniques for CTO-PCI have contributed to improvement in the initial success of CTO-PCI. However, challenges persist in CTO-PCI in NCA in pCABG patients. Methods Patients who underwent CTO-PCI in an NCA were selected and classified into 2 groups: pCABG (206 PCIs in 153 patients) and nCABG (1,431 PCIs in 1,139 patients). Results CTO was located more often in the left anterior descending artery (p = 0.0003), and severe calcified lesions were observed more frequently in the pCABG group (p < 0.0001). Although the retrograde attempt was tried more frequently in the pCABG group, the CTO-PCI success rate was significantly lower in the pCABG patients than in the nCABG patients (71% vs. 83%). Longer procedural time and greater radiation exposure were needed in the pCABG patients. Logistic regression analysis among the pCABG patients revealed that intravascular ultrasound use and parallel wiring were positive factors, and lesion tortuosity was a negative factor. Conclusions The initial success rate of CTO-PCI of an NCA in the pCABG group was significantly decreased compared with that in the nCABG group. Anatomic complexity and unstable hemodynamic state were unfavorable conditions. This study reveals that the issues to be overcome are lying with CTO revascularization in an NCA in pCABG patients.
Abstract Context Plasma C-reactive protein (CRP) levels are elevated in patients with advanced cancer. Objectives To investigate CRP as a prognostic marker in palliative settings. Methods This ...multicenter prospective cohort study comprised 2426 patients. Laboratory data were obtained at baseline, and all patients were followed until death or six months after their enrollment. A total of 1511 patients were eligible for the analyses. They were divided into four groups: low-CRP (CRP < 1 mg/dL), moderate-CRP (1 ≤ CRP <5 mg/dL), high-CRP (5 ≤ CRP <10 mg/dL), and very high-CRP (10 mg/dL ≤ CRP) groups. Survival was investigated by the Kaplan-Meier method with the log-rank test. The 30-, 60-, and 90-day mortality rates were tested by Chi-squared tests. Univariate- and multivariate-adjusted hazard ratios (HRs) and 95% CIs in each group were calculated using Cox proportional hazard models. Results Survival rate decreased and mortality rate increased with increasing CRP level. The differences in survival and 30-, 60-, and 90-day mortality rates among the groups were statistically significant ( P < 0.001). Baseline CRP level was significantly associated with a higher risk of mortality after adjustment for age, gender, primary tumor site, metastasis, chemotherapy, Eastern Cooperative Oncology Group Performance Status, and setting of care (moderate-CRP: HR 1.47 95% CI 1.24–1.73, high-CRP: HR 2.09 95% CI 1.74–2.50, and very high-CRP: HR 2.55 95% CI 2.13–3.05 vs. low-CRP). Conclusion Clear dose-effect relationships between elevated CRP levels and prognoses indicate that CRP could be useful in predicting prognoses in patients with advanced cancer.
Objective This study evaluated the safety and efficacy of total percutaneous endovascular aortic aneurysm repair (PEVAR) with a single Perclose ProGlide device (Abbot Vascular, Santa Clara, Calif) ...compared with endovascular aortic repair with surgical cutdown (SEVAR). Methods The study included 50 abdominal aortic aneurysm patients who were treated with PEVAR with a single Perclose ProGlide device and 96 patients treated with SEVAR. Technical success was defined as successful arterial closure of the common femoral artery without the need for adjunctive surgical or endovascular procedures. The rates of complications, including bleeding requiring transfusion, infection, pseudoaneurysm, paresthesia, and lymphocele, as well as the operating room time and hospital duration were compared between the PEVAR and SEVAR groups. Results Technical success was obtained in all patients in the PEVAR group. One patient in the SEVAR group needed surgical repair due to access site bleeding. Complication rates were similar between the groups (4% in the PEVAR vs 8% in the SEVAR; P = .495). The PEVAR group had significantly shorter operating room times (153 ± 47 minutes vs 211 ± 88 minutes, P < .001) and hospital lengths of stay (6.7 ± 6.8 days vs 9.3 ± 4.5 days, P < .001). Conclusions Compared with SEVAR, PEVAR with a single ProGlide device is a safe procedure with a shorter operating room time and hospital stay, without increasing access site complications.
The aim of this study was to investigate the possibility of 64-slice multislice computed tomography (MSCT) to detect vulnerable plaque derived by optical coherence tomography. From September 2007 ...through December 2009, 122 lesions in 81 patients were evaluated by 64-slice MSCT and optical coherence tomography. Based on optical coherence tomographic findings, lesions were classified as thin-capped fibroatheroma (TCFA; n = 37) and non-TCFA (n = 85). Mean computed tomographic density value of the lesion was lower and remodeling index was larger in the TCFA group (44.9 ± 19.2 vs 78.7 ± 25.0 HU, p <0.0001; 1.14 ± 0.20 vs 0.95 ± 0.16, p <0.0001, respectively). Mean computed tomographic density value was correlated and remodeling index was inversely correlated with fibrous cap thickness (r = 0.605, p <0.0001; r = −0.591, p <0.0001, respectively). Optimal threshold of mean computed tomographic value and remodeling index identified by receiver operating characteristic curve were 62.4 HU and 1.08 (area under the curve 0.859 and 0.781). Signet ringlike appearance was observed more frequently in the TCFA group (65% vs 16%, p <0.0001). In multivariate analysis, independent predictors of TCFA were mean computed tomographic density value ≤62.4 HU (odds ratio 8.20, 95% confidential interval 2.49 to 27.0, p = 0.0005), remodeling index ≥1.08 (odds ratio 6.10, 95% confidential interval 2.04 to 18.2, p = 0.0012), and signet ringlike appearance (odds ratio 6.33, 95% confidential interval 2.03 to 19.7, p = 0.0014). In conclusion, based on comparisons with optical coherence tomographic findings, 64-slice MSCT may have the potential to detect vulnerable plaque.
Objectives The aim of this study was to report the initial experience with a novel catheter in the retrograde approach for chronic total occlusion (CTO). Background Although the use of the retrograde ...approach in percutaneous coronary intervention for CTO has been established, some procedural difficulties remain. Methods A novel over-the-wire catheter (channel dilator) specifically designed for the retrograde approach has been developed for the treatment of CTO. The channel dilator was used in 93 CTO lesions after successful wiring of collateral channels using the retrograde approach. Results Successful channel crossing of the catheter was achieved in 90 of the lesions (96.8%), and the channel dilator successfully advanced into the occlusion reversely during retrograde wiring in 85 lesions (94.4%). Of the 75 lesions with successful advancement of the retrograde wire into the proximal true lumen, the entire occlusion was crossed retrograde with the channel dilator in 63 lesions (84.0%). To evaluate the feasibility of the catheter, 93 CTO lesions in the preceding period were compared. Procedure and fluoroscopy time tended to be lower in the study group than in the control group. The success of the retrograde procedure was significantly higher in the study group than in the control group (98.9% vs. 92.5%, p = 0.030). Conclusions The channel dilator may facilitate the conventional retrograde approach with a high level of success.
Although lipid-lowering therapy with statin and ezetimibe has been reported to provide greater reduction in low-density lipoprotein cholesterol levels than statin monotherapy, the effect of ...supplemental therapy on plaque stabilization is yet to be fully elucidated. Cap thickness of fibroatheroma evaluated by optical coherence tomography (OCT) is a major determinant of vulnerable plaque. The primary objective of this study is to evaluate the effect of ezetimibe in addition to fluvastatin on the progression of coronary atherosclerotic plaque evaluated by OCT. Sixty-three patients with angina pectoris with intermediate, nonculprit, lipid-rich plaque lesions evaluated by OCT were enrolled. The patients were divided into 2 groups: ezetimibe (10 mg/day) + fluvastatin (30 mg/day), and fluvastatin (30 mg/day) alone, and serial OCT examinations were performed at baseline and 9-month follow-up. A total of 57 patients (ezetimibe + fluvastatin, n = 31; fluvastatin alone, n = 26) underwent serial OCT examinations. The change in low-density lipoprotein cholesterol level was significantly larger in the ezetimibe + fluvastatin group compared with fluvastatin-alone group (−34.0 ± 32.0 vs −8.3 ± 17.4 mg/dl, p <0.001). Fibrous cap thickness was significantly increased and the angle of the lipid plaque was significantly decreased in both groups. The change in the fibrous cap thickness was significantly greater in the ezetimibe + fluvastatin group (0.08 ± 0.08 mm vs 0.04 ± 0.06 mm, p <0.001). In conclusion, lipid-lowering therapy by ezetimibe + fluvastatin could increase the fibrous cap thickness of lipid-rich plaque compared with fluvastatin monotherapy.
Effect of Fluvastatin on Progression of Coronary Atherosclerotic Plaque Evaluated by Virtual Histology Intravascular Ultrasound Kenya Nasu, Etsuo Tsuchikane, Osamu Katoh, Nobuyoshi Tanaka, Masashi ...Kimura, Mariko Ehara, Yoshihisa Kinoshita, Tetsuo Matsubara, Hitoshi Matsuo, Keiko Asakura, Yasushi Asakura, Mitsuyasu Terashima, Tadateru Takayama, Junko Honye, Atsushi Hirayama, Satoshi Saito, Takahiko Suzuki The aim of this study was to evaluate the effect of treatment with statins on progression of coronary atherosclerotic plaques by serial volumetric virtual histology intravascular ultrasound. The volume of each plaque component was evaluated at baseline and 12-month follow-up. Fibro-fatty volume was significantly decreased and fibrous tissue volume was increased in the fluvastatin group. Change in fibro-fatty volume has a significant correlation with change in low-density lipoprotein cholesterol and high-sensitivity C-reactive protein levels. One-year lipid-lowering therapy by fluvastatin showed significant regression of plaque volume and alterations in atherosclerotic plaque composition with a significant reduction of fibro-fatty volume.
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