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Zero contrast optical coherence tomography–guided percutaneous coronary intervention for in-stent restenosis of the saphenous vein graft using a non-contrast flush medium
摘要： Percutaneous coronary intervention (PCI) is often denied for individuals with coronary artery disease who are prone to develop contrast-induced acute kidney injury. We report a 73-year-old, stage 3 chronic kidney disease patient (CKD), who underwent coronary artery bypass surgery and saphenous vein graft (SVG) stenting in the past, presented with in-stent restenosis (ISR) of SVG stent. Zero contrast optical coherence tomography (OCT) guidedePCI was successfully performed using low molecular weight dextran-40 (LMWD-40) as the ?ush medium. Our report suggests the safety and feasibility of LMWD-40 ebased OCT-guided zero contrast PCI in ISR of SVG in a CKD patient, although further prospective studies are needed to evaluate this technique.
关键词： Zero contrast,Chronic kidney disease,Dextran-40,Contrast induced-Acute kidney injury,Percutaneous coronary intervention,Optical coherence tomography
更新于2025-09-23 15:23:52
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Intracoronary Imaging
摘要： Coronary angiography represents both the gold standard for diagnosis of coronary artery disease and the main guidance for percutaneous coronary intervention (PCI). Yet, coronary angiography is well known to not be optimal in appreciating the whole spectrum of lesions that may cause clinical problems in patients with coronary artery disease. Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) represent the 2 contemporary invasive intracoronary imaging modalities aimed at improving the detection of coronary details. Their potential is extraordinary but their use for improving coronary disease diagnosis is not standardized. Moving from diagnosis to treatment, PCI based on drug-eluting stent (DES) implantation often requires a series of manipulations with different techniques and devices. Last generation DES types have similar technical features and share a comparable ability to scaffold coronary lesions. Not surprisingly, lesion complexity is known to be associated with increased procedure challenges that may be tackled by different strategies. The selection of devices and the assessment of appropriate DES implantation may be based on either angiography or intracoronary imaging techniques like IVUS or OCT. Both techniques have evolved over time and offer the possibility to see details of coronary lesions and stent/vessel interactions that are impossible to be captured and measured by angiography. So far, thousands of studies with different designs have been performed, but they have not been able to make interventional cardiologists act in a homogeneous way. Consequently, intravascular imaging is selected on the basis of individual yield, with an impressive variability across different countries and operators. Reimbursement issues are part of the game but do not entirely explain the overall underutilization of intravascular imaging (especially in Western countries where a lot of expensive devices are routinely incorporated in interventional practice). In reality, the application of intracoronary imaging adds complexity to PCI, requires adequate technical skills, and by itself does not necessarily improve the clinical outcome. As compared with angiography guidance, IVUS and OCT are able to provide (in real time) many more coronary details. Such angiographically invisible details need to be recognized by the operator to properly react to improve the clinical outcome of treated patients. Because of the impressive amount of details and possible measures/cutoffs, the identification of both impactful features (deserving attention) and best reactions (additional technical steps with corrective efficacy) is pivotal. Yet, data collected by IVUS studies have not been concordant and this has resulted in overall limited clinical penetration: many catheterization laboratories are actually working without any access to intracoronary imaging. Furthermore, although rare, imaging catheter-related complications may occur so that a safety issue has to be considered any time the expected benefit is not well established in clinical practice. On the bases of these concepts, it is evident that the intracoronary imaging clinical impact may come from the correct identification and appropriate processing of those details that may help (1) to improve the PCI strategy (technique/device selection, that is, PCI planning) and (2) to facilitate the achievement of improved stenting result (ie, PCI optimization). As shown in the Figure, among all the information captured by intracoronary imaging, a limited series of imaging-based pre-PCI findings can be easily incorporated in the PCI planning (lesion preparation and stent selection). Similarly, some key intra-PCI findings (stent underexpansion, stent edge dissections, and strut malapposition) can be searched in order to optimize the stent implantation result. The feasibility of this approach is supported by the daily experience of many high volume centers. Yet, the overall clinical impact of image guidance in PCI is still unrecognized, and large studies in the field are needed. Recently-collected data started shedding new light on both IVUS and OCT. The large study by Maehara et al, although not randomized, allowed to run a propensity-matched comparison between thousands of IVUS-guided and angiography-guided procedures. IVUS use was associated with different procedure conduction and reduced major adverse events incidence at up to 2 years. Of note, the clinical benefit comprised significant improvements of hard end points, namely stent thrombosis, myocardial infarction, and cardiac mortality. Such results fit well with the recent ULTIMATE prospective randomized trial (Intravascular Ultrasound Guided Drug Eluting Stents Implantation in 'All-Comers' Coronary Lesions). The ULTIMATE investigators randomized 1448 all-comer patients who required DES implantation to either IVUS guidance or angiography guidance. As compared with angiography, randomization to IVUS guidance was associated with different procedure course (higher contrast administration, larger and longer stents, and higher inflation pressures) and warranted lower target vessel failures with IVUS at 12 months. OCT, as compared with IVUS, represents a younger technique, but data are growingly been collected because it has the appeal of offering higher resolution. The specific image generation process of OCT translates into the need of dedicated experience but has the potential for shorter learning curve. The possible clinical impact of OCT use in PCI guidance has been started to be highlighted by the results of the CLI-OPCI II study (Centro per la Lotta Contro l'Infarto-Optimisation of Percutaneous Coronary Intervention II). In this large registry, specific definitions for OCT features of suboptimal stent results were found to be independently associated with adverse clinical outcome after PCI. For sure, more complex PCIs (where the risk of stent thrombosis and restenosis is higher), are expected to benefit more from PCI refinements. Thus, two large prospectively randomized trials (OCTOBER, and ILUMIEN IV, and URL: https://www.clinicaltrials.gov. Unique identifier: NCT03507777) comparing OCT and angiographic guidance are actually ongoing and have been powered to explore the benefit of OCT guidance (using rigorous OCT-based PCI optimization algorithms) in, respectively, bifurcated lesions and complex patients. In conclusion, intravascular imaging modalities are entering a new era because the recently collected data seem to show new thresholds and targets for PCI planning and optimization. Thus, IVUS and OCT are going to become the ideal glasses that interventional cardiologists should wear anytime something looks unclear before, during or after PCI. Appropriate education, standardization of operative protocols and definitions of best clinical settings for application represent the future challenges for the intravascular imaging clinical implementation.
关键词： intravascular ultrasound,angiography,myocardial infarction,Editorials,diagnosis,optical coherence tomography,coronary artery disease,percutaneous coronary intervention
更新于2025-09-23 15:22:29
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Novel predictor of target vessel revascularization after coronary stent implantation: Intraluminal intensity of blood speckle on intravascular ultrasound
摘要： Background: The difference in intraluminal intensity of blood speckle (IBS) on integrated backscatter-intravascular ultrasound (IB-IVUS) across the coronary artery stenosis (i.e., ΔIBS) has been reported to negatively correlate with fractional flow reserve. Fractional flow reserve after coronary stenting is known as a predictor of target vessel revascularization (TVR). However, the relation between ΔIBS and TVR is unclear. Methods: Seven hundred and three vessels which underwent percutaneous coronary intervention with stents were screened. Vessels without IVUS-guidance and follow-up information were excluded. Intraluminal IBS values were measured using IB-IVUS in cross-sections at the ostium of the target vessel and at the distal reference of implanted stent. ΔIBS was calculated as (distal IBS) ? (ostium IBS). Results: A total of 393 vessels were included. Mean ΔIBS at postprocedure was 6.22 (cid:1) 5.65. During the follow-up period (11.2 (cid:1) 3.1 months), 24 cases (6.1%) had TVR. ΔIBS was significantly greater in the vessels with TVR than in those without (11.10 (cid:1) 5.93 vs. 5.90 (cid:1) 5.49, P <0.001). In receiver operating characteristic curve analysis, ΔIBS significantly predicted TVR (AUC 0.74, best cut-off value 8.24, P < 0.001). Multiple logistic regression analysis showed use of drug eluting stent and ΔIBS ≥ 8.24 as independent predictors of TVR. Conclusions: ΔIBS at postprocedure was significantly associated with TVR. IVUS may be able to predict TVR by physiological assessment with measurement of ΔIBS.
关键词： intravascular ultrasound,percutaneous coronary intervention,target vessel revascularization
更新于2025-09-23 15:21:01
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TCT-665 Experience With Excimer Laser in Percutaneous Coronary Intervention With Indications, Procedural Characteristics, Complications, and Outcomes in a Large University Teaching Hospital
摘要： Excimer laser coronary atherectomy (ELCA) has been around since the early 1980s. Previous studies, although documenting high complication rates and restenosis, actually predate the introduction of the smaller 0.9-mm catheter, which is now in frequent use. We established the indications, procedural characteristics, complications, and outcomes of ELCA in a contemporary coronary interventional practice.
关键词： percutaneous coronary intervention,Excimer laser coronary atherectomy,acute coronary syndromes,coronary artery disease,ELCA,cardiogenic shock
更新于2025-09-19 17:13:59
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Spontaneous Coronary Artery Dissection in a Man With a Novel Missense Mutation in SMAD2 Treated by Optical Coherence Tomography–Guided Percutaneous Coronary Intervention
摘要： A 52-year-old man was admitted with anterior ST-segment elevation myocardial infarction after lifting heavy weights. Urgent coronary angiography showed mild narrowing of the mid left anterior descending artery (LAD). However, 4 days later, ventricular fibrillation occurred. After resuscitation, the mid LAD appeared 'collapsed.' Intracoronary imaging with optical coherence tomography revealed a false lumen extending from the left main coronary artery to the distal LAD and 2 intimal tears at the distal LMCA and mid LAD. Optical coherence tomography–guided implantation of 3 drug-eluting stents was performed, aiming to seal both intimal tears and to strut the collapsed intima. Upon clinical examination, enlarged arm span, reduced upper segment–to–lower segment ratio, broad uvula, pes plani, pectus asymmetry, and mild scoliosis were observed. Additional magnetic resonance angiography did not show signs of fibromuscular dysplasia, aortic aneurysms, or arterial dilatation, but tortuosity of the common iliac arteries and circle of Willis was noted. On the basis of these clinical and vascular features, reminiscent of Loeys-Dietz syndrome, genetic analysis identified a novel missense mutation, c.1082A>C (p.[Asn361Thr]), in the MH2 domain of SMAD2. Myocardial infarction with nonobstructive coronary arteries was caused by a type 2 spontaneous coronary artery dissection (SCAD). Although conservative management is preferred because favorable healing occurs in the vast majority, and percutaneous coronary intervention is challenging, recurrence of myocardial infarction and sudden cardiac death are feared complications. Intravascular imaging by OCT might improve technical success and outcome of percutaneous coronary intervention for SCAD when needed (1–3). The underlying arteriopathy should always be sought. There is a strong association of fibromuscular dysplasia and SCAD. Inherited connective tissue disorders such as Marfan, Ehler-Danlos, and Loeys-Dietz syndromes should be considered as well. All patients with SCAD should undergo a thorough history, clinical examination, and imaging of the extracoronary arteries. Subsequent genetic testing can be considered in selected cases. Recently, loss-of-function SMAD2 mutations have been shown to cause a wide spectrum of aortic and arterial aneurysmal disease (4). This case represents the first documented SCAD in a SMAD2 mutation carrier.
关键词： spontaneous coronary artery dissection,optical coherence tomography,SMAD2,percutaneous coronary intervention,Loeys-Dietz Syndrome
更新于2025-09-09 09:28:46