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Recent retrospective investigations have suggested that optical coherence tomography (OCT) enables the diagnosis of underlying acute coronary syndrome (ACS) causes such as plaque rupture, plaque erosion, and calcified nodule. The relationships of these etiologies with clinical outcomes, and the clinical utility of OCT-guided primary percutaneous coronary intervention (PCI) are not systematically studied in real-world ACS treatment settings. The TACTICS registry is an investigator-initiated, prospective, multicenter, observational study to be conducted at 21 hospitals in Japan. A total of 700 patients with ACS (symptom onset within 24 h) undergoing OCT-guided primary PCI will be enrolled. The primary endpoint of the study is to identify the underlying causes of ACS using OCT-defined morphological assessment of the culprit lesion. The key secondary clinical endpoints are hazard ratios of the composite of cardiovascular death, non-fatal myocardial infarction, heart failure, or ischemia-driven revascularization in patients with underlying etiologies at the 12- and 24-month follow-ups. The feasibility of OCT-guided primary PCI for ACS will be assessed by the achievement rates of optimal post-procedural results and safety endpoints. The TACTICS registry will provide an overview of the underlying causes of ACS using OCT, and will reveal any difference in clinical outcomes depending on the underlying causes. The registry will also inform on the feasibility of OCT-guided primary PCI for patients with ACS. The TACTICS (Tokyo, Kanagawa, Chiba, Shizuoka, and Ibaraki active OCT applications for ACS) registry. ACS, acute coronary syndrome; OCT, optical coherence tomography; PCI, percutaneous coronary intervention. [Display omitted] • TACTICS is an investigator-initiated prospective multicenter observational study. • Optical coherence tomography (OCT)-guided primary percutaneous coronary intervention (PCI) will be performed. • The primary endpoint is to identify the underlying causes of acute coronary syndrome (ACS). • Clinical outcomes and feasibility of OCT-guided PCI will be clarified. [ABSTRACT FROM AUTHOR]

Background and Aims: Peripheral artery disease (PAD), intermittent claudication, and impaired mobility contribute to the loss of skeletal muscle. This study investigated the impact of endovascular treatment (EVT) in patients suffering from PAD above the knee and its relation to baseline glycemic control.Methods and Results: Mid-thigh muscle volume was measured before EVT, 3 months after EVT and 6 months after EVT. Mid-thigh muscle volumes of ipsilateral PAD patients with ischemic and non-ischemic legs were compared. Correlations between total thigh muscle volume and clinical characteristics were analyzed using univariable and multivariable analysis. Overall, thigh muscle volume increased after EVT. The mid-thigh muscle volume was significantly lower in patients with ipsilateral lesions and in those with ischemic lower limbs. The thigh muscle volume of those with ischemic lower limbs increased after EVT. Baseline glycated hemoglobin was the only factor that was negatively correlated with changes in the muscle volume after EVT. Muscle volume significantly increased in normoglycemic HbA1c<6.5% (47 mmol/mol) patients. There was no significant alteration in the muscle volume of hyperglycemic HbA1c ≥ 6.5% patients.Conclusion: Ischemic muscle atrophy was ameliorated after EVT in normoglycemic patients. There is a need for a large-scale trial to investigate whether EVT can protect or delay skeletal muscle loss. [ABSTRACT FROM AUTHOR]

Abstract: Background: Relationships between plaque morphology on optical coherence tomography (OCT) and biomarker levels in the patients with acute coronary syndrome (ACS) have not been fully investigated. Methods: ACS patients (n=128) were prospectively enrolled and their plasma levels of soluble lectin-like oxidized LDL receptor-1 (sLOX-1), high-sensitivity C-reactive protein (hs-CRP), and high-sensitivity troponin T (hs-TnT) were measured. Another set of 20 patients with stable angina pectoris (SAP) without plaque rupture or erosion served as controls. Among 128 ACS patients, 75 patients underwent OCT procedure to evaluate culprit plaque morphology, and were categorized into two groups; ACS with plaque rupture (ruptured ACS; R-ACS, n=54) and ACS without plaque rupture (non-ruptured ACS; N-ACS, n=21). Results: Levels of sLOX-1 (p<0.001), hs-CRP (p=0.048) and hs-TnT (p<0.001) were significantly higher in R-ACS than SAP. Levels of sLOX-1 were also significantly higher in R-ACS than in N-ACS (p<0.001); whereas levels of hs-CRP (p=0.675), as well as those of hs-TnT (p=0.055), were comparable between R-ACS and N-ACS. Comparison of receiver operating characteristic (ROC) curves among sLOX-1, hs-CRP and hs-TnT to differentiate R-ACS from N-ACS revealed that the area under the curve (AUC) values of sLOX-1, hs-CRP and hs-TnT were 0.782, 0.531 and 0.643, respectively. ROC curves, generated for these biomarkers, to differentiate ACS with thin-cap fibroatheroma (TCFA) from those without demonstrated that the AUC values of sLOX-1, hs-CRP and hs-TnT were 0.718, 0.506 and 0.524, respectively. Conclusion: sLOX-1, but not hs-CRP or hs-TnT, can differentiate ACS with plaque rupture from those without, and ACS with TCFA from those without. [Copyright &y& Elsevier]

Abstract: Background: Although several clinical trials have shown the superior efficacy and safety of second-generation everolimus-eluting stents (EES) in comparison with first-generation paclitaxel-eluting stents (PES), the differences in the vascular healing process between EES and PES in a human coronary artery during an early stage are unknown. Methods: A prospective optical coherence tomography (OCT) observation was performed for 25 EES in 21 patients and 27 PES in 21 patients at 6months after implantation. Cross-sections within single-stent segments were analyzed at intervals of 1mm. The neointimal (NI) thickness on each strut was measured. Uncovered struts (NI thickness=0μm), malapposed struts, NI area (%), uncovered strut ratio >0.3 (UCSR; number of uncovered struts/number of total struts) per cross-section, and in-stent thrombus were evaluated. Results: A total of 5198 EES struts in 514 cross-sections and 4243 PES struts in 469 cross-sections were identified. NI thickness and its area were smaller for EES than PES (80.0±84.8μm vs. 117.9±140.0μm and 19.1±8.9% vs. 23.7±11.5%, respectively; P<0.001). The frequencies of uncovered struts and malapposed struts were lower in EES compared to PES (2.3% vs. 5.2% and 2.1% vs. 5.7%, respectively; P<0.001). Patients who had cross-sections of UCSR >0.3 and thrombi were identified less frequently in EES than in PES group (5% vs. 57%; P<0.001, and 19% vs. 48%; P=0.05, respectively). Conclusions: Six-month OCT examination showed a favorable vessel healing response after the implantation of EES, demonstrating less in-stent late loss as well as fewer uncovered struts and better stent apposition to the vessel wall in comparison with PES. [Copyright &y& Elsevier]

Background: Sleep disordered breathing (SDB) is highly prevalent in patients with cardiovascular disease, although it is not clear whether SDB has any link to coronary atherosclerotic burden in patients with stable coronary artery disease (CAD). This study sought to analyze the links between SDB, coronary atherosclerotic burden, and cardiac biomarkers in stable CAD patients. Methods and results: We studied 83 consecutive patients who underwent coronary angiography or scheduled percutaneous coronary intervention. SDB was evaluated by an ambulatory polysomnographic monitoring device. Coronary atherosclerotic burden was evaluated by the Gensini score, and myocardial stress/injury were assessed by measuring plasma levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high sensitivity troponin T (hs-TnT). Patients with an apnea hypopnea index (AHI)> 15events/h (n = 32) showed significantly higher Gensini score (35.7 ±38.0 vs 20.1 ± 19.7, p = 0.033) than those with AH1 < 15. The higher AH I group showed significantly higher NT-proBNP (275.8 ± 402.6 pg/ml vs 131.9 ± 146.3 pg/ml, p = 0.047) and hs-TnT levels (0.011 ± 0.005 ng/ml vs 0.008 ±0.003 ng/ml, p = 0.015). Furthermore it was revealed that AHI significantly correlated with the Gensini score (r = 0.253, p = 0.036), NT-proBNP (r=0.266, p = 0.027), and hs-TnT (r=0.274, p = 0.023), and multiple stepwise linear regression analysis revealed that AHI (β = 0.257, p = 0.029) and history of smoking (β = 0.244, p = 0.038) were independently correlated with Gensini score among clinical and SDB-related parameters. Conclusions: Severity of SDB has a significant link to the severity of coronary atherosclerotic burden, which also reflected elevated NT-proBNP and hs-TnT as silent myocardial ischemia and minute myocardial injury even in stable CAD patients. [ABSTRACT FROM AUTHOR]

Background: Although very late stent thrombosis occurs several years after implantation of sirolimus-eluting stent (SES), the morphologic changes of the stent beyond 2 years have not yet been systematically studied in living patients. The late vascular response to SES was therefore evaluated by serial angioscopic studies at 2 and 5 years after stent implantation. Methods: A total of 17 patients with 17 SES underwent a repeated angioscopy procedure at 2 and 5 years. Neointimal stent coverage (NSC) was classified as follows: grade 0, presence of uncovered struts; grade 1, visible struts through a thin neointima; or grade 2, complete neointimal coverage without visible struts. For each patient, the minimum and maximum NSC grade and the existence of in-stent thrombus were recorded. Results: The minimum and maximum NSC grade did not increase between the 2 and 5 years (0.59 ± 0.51 vs 0.88 ± 0.70, P = .17, and 1.82 ± 0.39 vs 1.94 ± 0.24, P = .30, respectively). The prevalence of patients with uncovered struts did not significantly decrease from 2 to 5 years (41% vs 29%, P = .49). During the follow-up period, 3 of 6 thrombi disappeared, whereas new thrombus formation was found in 3 patients without any clinical symptoms. In-stent thrombus did not decrease (35% vs 35%, P > .99). Conclusions: The current serial angioscopic study suggests that incomplete NSC and the prevalence of latent thrombus within the SES segments did not decrease from 2 to 5 years. The risk of stent thrombosis related to incomplete healing of SES may continue for an extended period. [Copyright &y& Elsevier]

Objectives: We examined the neointimal characteristics of bare-metal stents (BMS) in extended late phase by the use of optical coherence tomography (OCT). Background: The long-term neointimal features after BMS implantation have not yet been fully characterized. Methods: Intracoronary OCT observation of BMS segments was performed during the early phase (<6 months, n = 20) and late phase (≥5 years, n = 21) after implantation. Internal tissue of the BMS was categorized into normal neointima, characterized by a signal-rich band without signal attenuation, or lipid-leaden intima, with marked signal attenuation and a diffuse border. In addition, the presence of disrupted intima and thrombus was evaluated. Neovascularization was defined as small vesicular or tubular structures, and the location of the microvessels was classified into peristent or intraintima. Results: Normal neointima proliferated homogeneously, and lipid-laden intima was not observed in the early phase. In the late phase, lipid-laden intima, intimal disruption, and thrombus frequently were found in comparison with the early phase (67% vs. 0%, 38% vs. 0%, and 52% vs. 5%, respectively; p < 0.05). Peristent neovascularization demonstrated a similar incidence between the 2 phases. The appearance of intraintima neovascularization was more prevalent in the late phase than the early phase (62% vs. 0%, respectively; p < 0.01) and in segments with lipid-laden intima than in nonlipidic segments (79% vs. 29%, respectively; p = 0.026). Conclusions: This OCT study suggests that neointima within the BMS often transforms into lipid-laden tissue during an extended period of time and that expansion of neovascularization from peristent to intraintima contributes to atherosclerotic progression of neointima. [Copyright &y& Elsevier]

Background: Delayed neointimal coverage after the implantation of a drug-eluting stent (DES) is thought to be related to their potential for developing late-stent thrombosis. However, few studies have shown which factor affects the neointimal coverage after DES implantation. We hypothesized that the extent of neointimal coverage after DES implantation is affected by the underlying lesion characteristics because arterial wall components are reported to determine the transport and distribution of the drugs. Methods: Thirty-seven coronary artery lesions treated with a single sirolimus-eluting stent (SES) were evaluated in 37 patients with stable coronary artery disease. Angioscopy was performed before, immediately after, and 6 months after stenting to examine the existence of yellow plaque, thrombus, complex plaque, and intramural hemorrhage and the degree of neointimal coverage at 6-month follow-up. This was classified either as a noncoverage group (stent struts were predominantly exposed or visible through a thin neointima) or as a coverage group (stent struts were predominantly covered by neointimal hyperplasia and thus invisible). Results: Twenty-one lesions were classified into the noncoverage group, and 16 lesions the coverage group. The frequency of preexistent yellow plaques was significantly higher in the noncoverage group than that in the coverage group (67% vs 19%, P = .007). A multivariate logistic regression analysis showed the preexistence of yellow plaque was the only independent factor behind less neointimal coverage at 6 months after SES implantation (odds ratio 19.5, 95% confidence interval 1.58-240.50, P = .020). Conclusions: The preexistence of yellow plaque may be associated with decreased neointimal coverage of SES. [Copyright &y& Elsevier]

No detailed data regarding neointimal coverage of bare-metal stents (BMSs) at 3 months after implantation was reported to date. This investigation was designed to evaluate the neointimal coverage of BMSs compared with sirolimus-eluting stents (SESs) using optical coherence tomography. A prospective optical coherence tomographic follow-up examination was performed 3 months after stent implantation for patients who underwent BMS (n = 16) or SES implantation (n = 24). Neointimal hyperplasia (NIH) thickness on each stent strut and percentage of NIH area in each cross section were measured. Malapposition of stent struts to the vessel wall and the existence of in-stent thrombi were also evaluated. There were 5,076 struts of SESs and 2,875 struts of BMSs identified. NIH thickness and percentage of NIH area in the BMS group were higher than in the SES group (351 ± 248 vs 31 ± 39 μm; p <0.0001; 45.0 ± 14% vs 10.0 ± 4%; p <0.0001, respectively). The frequency of uncovered struts was higher in the SES group than the BMS group (15% vs 0.1%; p <0.0001). Malapposed struts were observed more frequently in the SES group than the BMS group (15% vs 1.1%; p <0.0001). In conclusion, there was no difference in incidence of in-stent thrombus between the 2 groups (14% vs 0%; p = 0.23). The present study showed almost all BMS struts to be well covered at a 3-month follow-up, suggesting that patients receiving BMS stents may not require dual-antiplatelet therapy >3 months after implantation. [Copyright &y& Elsevier]

Atherosclerotic yellow plaques identified by coronary angioscopy are considered as vulnerable plaques. However, characteristics of yellow plaques are not well understood. Optical coherence tomography (OCT) provides accurate tissue characterization in vivo and has the capability to measure fibrous cap thickness covering a lipid plaque. Characteristics of yellow plaques identified by angioscopy were evaluated by OCT. We examined 205 plaques of 41 coronary arteries in 26 patients. In OCT analysis, plaques were classified as fibrous or lipid. Minimal lumen area of the plaque, arch of the lipid, and fibrous cap thickness on the lipid plaque were measured. Yellow grade of the plaque was defined as 0 (white), 1 (light yellow), 2 (medium yellow), or 3 (dark yellow) based on the angioscopy. A total of 149 plaques were diagnosed as lipid plaques. Neither the minimal lumen area nor the arch of the lipid was related to the yellow grade. There was an inverse relationship between color grade and the fibrous cap thickness (grade 0 [n = 45] 218 ± 89 μm, grade 1 [n = 40] 101 ± 8 μm, grade 2 [n = 46] 72 ± 10 μm, and grade 3 [n = 18] 40 ± 14 μm; p <0.05). Sensitivity and specificity of the angioscopy-identified yellow plaque for having a thin fibrous cap (thickness ≤110 μm) were 98% and 96%, respectively. In conclusion, angioscopy-identified yellow plaques frequently were lipid tissue with an overlying thin fibrous cap. Fibrous caps of the intense yellow plaques were very thin, and these plaques might be structurally vulnerable. [Copyright &y& Elsevier]

Confirming complete neointimal coverage after implantation of a drug-eluting stent is clinically important because incomplete stent coverage is responsible for late thrombosis and sudden cardiac death. Optical coherence tomography is a high-resolution (≈10 μm) imaging technique capable of detecting a thin layer of neointimal hyperplasia (NIH) inside a sirolimus-eluting stent (SES) and stent malapposition. This investigation evaluated stent exposure and malapposition 3 months after SES implantation using optical coherence tomography in a different clinical presentations, such as acute coronary syndrome (ACS) and non-ACS. Motorized optical coherence tomographic pullback (1 mm/s) was performed at 3-month follow-up to examine consecutive implanted 31 SESs in 21 lesions in 21 patients (9 with ACS and 12 with non-ACS). NIH thickness inside each strut and percent NIH area in each cross section were measured. In total, 4,516 struts in 567-mm single-stented segments were analyzed. Overall, NIH thickness and percent NIH area were 29 ± 41 μm and 10 ± 4%, respectively. Rates of exposed struts and exposed struts with malapposition were 15% and 6%, respectively. These were more frequent in patients with ACS than in those with non-ACS (18% vs 13%, p <0.0001; 8% vs 5%, p <0.005, respectively). In conclusion, neointimal coverage over a SES at 3-month follow-up is incomplete in ACS and non-ACS. Our study suggests that dual antiplatelet therapy might be continued >3 months after SES implantation. [Copyright &y& Elsevier]

Objectives: Changes of ruptured plaques in nonculprit lesions were evaluated using coronary angioscopy. Background: The concept of multiple coronary plaque ruptures has been established. However, no detailed follow-up studies of ruptured plaques in nonculprit lesions have yet been reported. Methods: Forty-eight thrombi in 50 ruptured coronary plaques in nonculprit lesions in 30 patients were identified by angioscopy. The percent diameter stenosis (%DS) at the target plaques on quantitative coronary angiographic analysis and the serum C-reactive protein (CRP) level were measured. Results: The mean angioscopic follow-up period was 13 ± 9 months. Thirty-five superimposed thrombi still remained at follow-up, and the predominant thrombus color changed from red (56%) at baseline to pinkish-white (83%) at follow-up. The healing rate increased according to the angioscopic follow-up period (23% at ≤12 months vs. 55% at >12 months, p = 0.044). The %DS at the healed plaque increased from baseline to follow-up (12.3 ± 5.8% vs. 22.7 ± 11.6%, respectively; p = 0.0004). The serum CRP level in patients with healed plaques (n = 10) was lower than that in those without healed plaques (n = 19; 0.07 ± 0.03 mg/dl vs. 0.15 ± 0.11 mg/dl, respectively; p = 0.007). Conclusions: The present study demonstrated that: 1) ruptured plaques in nonculprit lesions tend to heal slowly with a progression of angiographic stenosis; and 2) the serum CRP level might reflect the disease activity of the plaque ruptures. [Copyright &y& Elsevier]

: ObjectivesChanges in coronary plaque color and morphology by statin therapy were evaluated using coronary angioscopy.: BackgroundCoronary plaque stabilization by statin therapy has not been clarified in humans.: MethodsThirty-one patients with coronary artery disease were divided into either the comparison group (n = 16) or the atorvastatin group (n = 15). Before treatment and 12 months after, the color and complexity of 145 coronary plaques were determined according to angioscopic findings. The yellow score of the plaque was defined as 0 (white), 1 (light yellow), 2 (yellow), or 3 (dark yellow), and its disrupted score was defined as 0 (smooth surface) or 1 (irregular surface) and as 0 (without thrombus) or 1 (with thrombus). In each patient, the mean yellow score and mean disrupted score were calculated.: ResultsMean low-density lipoprotein cholesterol (LDL-C) decreased by 45% in the atorvastatin group, whereas an increase of 9% was seen in the comparison group. The mean yellow score decreased from 2.03 to 1.13 in the atorvastatin group, whereas it increased from 1.67 to 1.99 in the comparison group. There was a good correlation between the change in the mean yellow score and the change in LDL-C levels (r = 0.81, p < 0.0001). The change in the mean yellow score and mean disrupted score differed significantly between the two groups (p = 0.002 and p = 0.03, respectively).: ConclusionsThis is the first report clarifying detailed changes in coronary plaque by statin in humans. This study indicated that lipid-lowering therapy changes plaque color and morphology and should then lead to coronary plaque stabilization. [Copyright &y& Elsevier]

Abstract: In-stent restenosis (ISR) after sirolimus-eluting stent (SES) implantation rarely occurs, and these lesions are commonly recognized as focal restenosis on angiograms. Optical coherence tomography (OCT) is able to distinguish from several components of intracoronary structures by different signal patterns. We herein report three cases of various OCT images from ISR lesions in spite of similar angiographic findings. Our OCT findings suggested that ISR lesions that develop after SES implantation might be composed of not uniform but various tissues. [Copyright &y& Elsevier]

Summary: Neointimal proliferation after sirolimus-eluting stent (SES) implantation is generally inhibited by the pharmacological effects of sirolimus in comparison to bare metal stent (BMS). Neointimal hyperplasia after BMS implantation is mainly composed of vascular smooth muscle cells, and is usually observed as a white mass by angioscopy and as a layer of uniform signal intensity without attenuation on optical coherence tomography (OCT). In this case, angioscopic color of the neointima covering the SES was obviously yellow and OCT signal patterns of the neointima showed rapid attenuation similar to lipid tissues in atherosclerotic lesions. These findings suggest that neointima within the SES is quite different from that of the BMS and may contain atherosclerotic components. [Copyright &y& Elsevier]

Abstract: Background: Although measurement of stent strut by optical coherence tomography (OCT) is important as an index for evaluating incomplete stent apposition, the effects of drug-eluting stents (DES) polymer on it are unknown. Methods and results: DES and bare-metal stents (BMS) as platforms of DES were implanted in an artificial artery. Thickness of stent strut, defined as a distance from inner surface of the strut to the adjacent surface of the tube, and thickness of high-signal band were measured by OCT. Each measurement of DES was significantly larger comparing with BMS. Conclusion: This in-vitro study demonstrates that DES polymer may influence OCT measurement for the stent strut. [ABSTRACT FROM AUTHOR]

Abstract: A 67-year-old male was admitted because of acute myocardial infarction (AMI). An emergent coronary angiography showed a total occlusion in the left anterior descending artery, and a stent was deployed. Moderate lesion stenosis was found in the right coronary artery (RCA). Fractional flow reserve indicated 0.96, and percutaneous coronary intervention was not performed. Six months later, the patient visited an emergency room due to AMI. Angiograms showed a patency of the previous stent and progressed stenosis with filling delay of the RCA. Protruding red thrombi and plaque disruption of thin-cap fibroatheroma (TCFA) were identified by optical coherence tomography. Mild to moderate lesions are physiologically benign but morphologically malignant in cases of TCFA. [Copyright &y& Elsevier]

Summary: We present the case of a 48-year-old man with unstable angina who underwent drug-eluting stent (DES) implantation for the left circumflex artery (LCx). Red thrombi within the stent were clearly found by coronary angioscopy. Dual antiplatelet therapy was orally given before the stenting. Twenty-two months after the procedure, the patient visited because of severe chest pain. The patient had stopped taking all prescriptions including antiplatelet drugs for the previous 18 months. The occurrence of late stent thrombosis (LST) derived from previously implanted DES in the LCx was strongly suspected. Unexpectedly, the left coronary angiograms showed neither in-stent restenosis nor thrombotic occlusion. Angioscopic images for the DES segment showed that there were no uncovered stent struts without neointimal coverage. Notably, red thrombi identified immediately after stenting by angioscopy had completely disappeared. Mural red thrombi at the first observation completely disappeared despite premature cessation of dual antiplatelet therapy. Early neointimal coverage may occasionally occur even under the condition of acute coronary syndrome. The leading cause of LST was not only the cessation of dual-antiplatelet therapy and multiple factors contribute to LST of DES. Relatively early and adequate neointimal stent coverage may reduce the risk of thrombus formation including LST even though anti-platelet therapy was discontinued prematurely. [ABSTRACT FROM AUTHOR]

Summary: Very late stent thrombosis (VLST) after implantation of a drug-eluting stent (DES) is a rare but catastrophic complication and the mechanisms are not completely understood. We describe a 76-year-old patient with recurrent VLST of DES that developed at 13 and 23 months after the initial catheter procedure of DES implantation under the cessation of dual antiplatelet therapy. Optical coherence tomography (OCT) observation revealed small stent area of a DES. Based on the OCT findings, balloon angioplasty for expansion of the DES was performed and angiographic Thrombolysis In Myocardial Infarction grade 3 flow was subsequently obtained. Small stent area is considered a significant factor in acute or subacute stent thrombosis according to previous reports. The present report shows that small stent area of DES may be regarded as a key factor in recurrent VLST as well as cessation of dual antiplatelet therapy. [ABSTRACT FROM AUTHOR]

Abstract: The AngioSculpt™ scoring balloon catheter (AngioScore, Inc., Fremont, California) has recently been developed for percutaneous intervention in coronary and peripheral arteries. This device is composed of two major components, a minimally compliant balloon and three nitinol wore. The three wires encapsulate the low-compliant balloon in a spiral configuration. The concept is for the spiral wires to score the lumen surface during balloon expansion. However, the precise mechanisms and efficacy of this scoring technology in humans had not yet to be determined. In this case, both a de novo coronary lesion and an in-stent restenosis lesion were treated with the scoring balloon and were subsequently observed via optical coherence tomography (OCT) with high-resolution images (≈15 μm). OCT clearly demonstrated the effects of this device on plaque and neointimal hyperplasia scoring, as well as its ability to achieve sufficient lumen sizes after coronary artery dilatation. [Copyright &y& Elsevier]

Abstract: Recent instrumental and technical developments have improved the outcomes of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions. Recently, several cases of PCI in patients with stable coronary artery disease (CAD) using a retrograde approach through the collateral vessels of the CTO have been reported. We herein describe firstly a successful PCI for a CTO lesion using a retrograde approach in the clinical setting of acute coronary syndrome (ACS). [Copyright &y& Elsevier]

Abstract: Randomized follow-up studies revealed that sirolimus-eluting stent (SES) has an effect on reducing in-stent restenosis resulting from inhibition of neointimal proliferation comparing with bare metal stent (BMS). These data were obtained from separate patients. However, the response against different kinds of these two stents in the same patient had not yet been described. The present case was planned overlapping hybrid stenting with a SES and a BMS in tandem lesions. Not only intravascular ultrasound but also coronary angioscopy at three months follow-up studies showed that neointimal proliferation had been inhibited both in the SES alone segment and in the overlapping segment comparing with BMS alone segment. Our images clearly demonstrated the different degree of neointimal proliferation between the SES and the BMS in the same patient. [Copyright &y& Elsevier]

Abstract: Aims: Postmortem series have reported that subjects with diabetes mellitus have coronary plaques with larger necrotic cores and increased macrophage infiltration. Optical coherence tomography (OCT) is a high-resolution imaging modality that allows in vivo characterization of atherosclerotic plaques. Using OCT imaging, we compared in vivo plaque characteristics between diabetic and non-diabetic subjects. Methods: Sixty-three patients undergoing cardiac catheterization were enrolled. OCT imaging was performed in culprit coronary arteries. Assessment of plaque lipid content, fibrous cap thickness and frequency of thin-cap fibroatheroma were made independently. Macrophage density was determined from the optical signal within fibrous cap. Results: Eighty-two plaques in total were imaged (19 diabetic vs. 63 non-diabetic). There were no significant differences in frequency of lipid-rich plaques (68% vs. 71%; P =0.78), thin-cap fibroatheroma (29% vs. 36%; P =0.76) or minimum fibrous cap thickness (66.6μm vs. 62.9μm; P =0.87) between diabetic and non-diabetic patients. Fibrous cap macrophage density was higher in lipid-rich plaques (P =0.01) but showed no difference between diabetic and non-diabetic patients (5.94% vs. 5.94%; P =0.37). Conclusions: There were no significant differences in culprit vessel plaque characteristics between diabetic and non-diabetic patients presenting with coronary artery disease. This represents the first study to characterize coronary plaques in diabetic patients using OCT. [Copyright &y& Elsevier]

South Asians, and Indians in particular, are known to have a higher incidence of premature atherosclerosis and acute coronary syndromes (ACS) with worse clinical outcomes, compared to populations with different ethnic backgrounds. However, the underlying pathobiology accounting for these differences has not been fully elucidated. ACS patients who had culprit lesion optical coherence tomography (OCT) imaging were enrolled. Culprit plaque characteristics were evaluated using OCT. Among 1315 patients, 100 were South Asian, 1009 were East Asian, and 206 were White. South Asian patients were younger (South Asians vs. East Asians vs. Whites: 51.6 ± 13.4 vs. 65.4 ± 11.9 vs. 62.7 ± 11.7; p < 0.001) and more frequently presented with ST-segment elevation myocardial infarction (STEMI) (77.0% vs. 56.4% vs. 35.4%; p < 0.001). On OCT analysis after propensity group matching, plaque erosion was more frequent (57.0% vs. 38.0% vs. 50.0%; p = 0.003), the lipid index was significantly greater (2281.6 [1570.8–3160.6] vs. 1624.3 [940.9–2352.4] vs. 1303.8 [1090.0–1757.7]; p < 0.001), and the prevalence of layered plaque was significantly higher in the South Asian group than in the other two groups (52.0% vs. 30.0% vs. 34.0%; p = 0.003). Compared to East Asians and Whites, South Asians with ACS were younger and more frequently presented with STEMI. Plaque erosion was the predominant pathology for ACS in South Asians and their culprit lesions had more features of plaque vulnerability. Clinical Trial Registration: http://www.clinicaltrials.gov , NCT03479723 [Display omitted] • South Asians with ACS were younger and more frequently presented with STEMI. • Plaque erosion was the predominant pathology for ACS in South Asians. • South Asian patients had more features of plaque vulnerability in culprit lesions. [ABSTRACT FROM AUTHOR]

The development of optical coherence tomography (OCT) has revolutionized our understanding of coronary artery disease. In vivo OCT research has paralleled with advances in computational fluid dynamics, providing additional insights in the various hemodynamic factors influencing plaque growth and stability. Recent OCT studies introduced a new concept of plaque healing in relation to clinical presentation. In addition to known mechanisms of acute coronary syndromes such as plaque rupture and plaque erosion, a new classification of calcified plaque was recently reported. This review will focus on important new insights that OCT has provided in recent years into coronary plaque development, progression, and destabilization, with a focus on the role of local hemodynamics and endothelial shear stress, the layered plaque (signature of previous subclinical plaque destabilization and healing), and the calcified culprit plaque. [ABSTRACT FROM AUTHOR]

Background: Lipid-rich plaque (LRP) is thought to be a precursor to cardiac events. However, its clinical significance in coronary arteries has never been systematically investigated.Objectives: This study investigated the prevalence and clinical significance of LRP in the nonculprit region of the target vessel in patients undergoing percutaneous coronary intervention (PCI).Methods: The study included 1,474 patients from 20 sites across 6 countries undergoing PCI, who had optical coherence tomography (OCT) imaging of the target vessel. Major adverse cardiac events (MACE) were defined as a composite of cardiac death, acute myocardial infarction, and ischemia-driven revascularization. Patients were followed for up to 4 years (median of 2 years).Results: Lipid-rich plaque was detected in nonculprit regions of the target vessel in 33.6% of patients. The cumulative rate of nonculprit lesion-related MACE (NC-MACE) over 48 months in patients with LRP was higher than in those without LRP (7.2% vs. 2.6%, respectively; p = 0.033). Acute coronary syndrome at index presentation (risk ratio: 2.538; 95% confidence interval [CI]: 1.246 to 5.173; p = 0.010), interruption of statin use ≥1 year (risk ratio: 4.517; 95% CI: 1.923 to 10.610; p = 0.001), and LRP in nonculprit regions (risk ratio: 2.061; 95% CI: 1.050 to 4.044; p = 0.036) were independently associated with increased NC-MACE. Optical coherence tomography findings revealed that LRP in patients with NC-MACE had longer lipid lengths (p < 0.001), wider maximal lipid arcs (p = 0.023), and smaller minimal lumen areas (p = 0.003) than LRPs in patients without MACE.Conclusions: Presence of LRP in the nonculprit regions of the target vessel by OCT predicts increased risk for future NC-MACE, which is primarily driven by revascularization for recurrent ischemia. Lipid-rich plaque with longer lipid length, wider lipid arc, and higher degree of stenosis identified patients at higher risk of future cardiac events. (The Massachusetts General Hospital Optical Coherence Tomography Registry; NCT01110538). [ABSTRACT FROM AUTHOR]

Objective This 8-year follow-up cohort study evaluated and compared the degree of coronary atherosclerosis in chronic kidney disease (CKD) according to the Kidney Disease: Improving Global Outcomes (KDIGO) classification using multivessel angioscopy and investigated the impact of the vulnerability of coronary arteries on the relationship between the classification and risk of acute coronary syndromes (ACS). Methods We studied 89 coronary artery disease patients who underwent angioscopic observation of multiple coronary arteries. The patients were divided into 3 groups: Risk 0, 1, and 2 were equivalent to low risk, moderately high risk, and high and severely high risk, respectively. We examined the frequencies of complex and yellow plaques. Furthermore, we followed all patients for de novo ACS, dividing into two groups according to the existence of vulnerable coronary atherosclerosis (VCA) based on angioscopic findings. Results The number of yellow plaques per vessel, maximum yellow grade, number of complex plaques per vessel, and cumulative incidence of ACS in all patients were significantly associated with Risk grade progression (p < 0.05 for trend). Among the patients with VCA, Risk 2 had a higher incidence of ACS than Risk0 (p < 0.014) and Risk 1 (p < 0.007), whereas Risk 0 and Risk 1 had similar outcomes. Among the patients without VCA, no de novo ACS events were seen regardless of the Risk group. Conclusions Coronary atherosclerosis progressed in the early stages of CKD, and once it reached to a vulnerable stage, advanced CKD patients had a synergistically increased risk of ACS. [ABSTRACT FROM AUTHOR]

Optical coherence tomography (OCT) is a fiber-optic technology that enables high-resolution intracoronary imaging. The aim of this study was to evaluate the safety and feasibility of intracoronary imaging with OCT in the clinical setting; 76 patients with coronary artery disease from 8 centers were enrolled. The OCT imaging system (ImageWire, Light Imaging Inc., Westford, Massachusetts) consists of a 0.006 inch fiber-optic core that rotates within a 0.016 inch transparent sheath. OCT imaging was performed during occlusion of the artery with a compliant balloon and continuous flushing. Intravascular ultrasound (IVUS) imaging was performed in the same segments. We assessed the safety and feasibility of the OCT imaging, compared with IVUS. Vessel occlusion time was 48.3 ± 13.5 seconds and occlusion-balloon pressure was 0.4 ± 0.1 atmospheres. Flushing with lactated Ringer’s solution was performed at a rate of 0.6 ± 0.4 ml/s. No significant adverse events, including vessel dissection or fatal arrhythmia, were observed. Procedural success rates were 97.3% by OCT and 94.5% by IVUS. The OCT image wire was able to cross 5 of 6 tight lesions that the IVUS catheter was unable to cross. Of the 98 lesions in which both OCT and IVUS were successfully performed, OCT imaging had an advantage over IVUS for visualization of the lumen border. Minimum lumen diameter and area measurements were significantly correlated between OCT and IVUS imaging (r = 0.91, p <0.0001 and r = 0.95, p <0.0001, respectively). In conclusion, this multicenter study demonstrates the safety and feasibility of OCT imaging in the clinical setting. [Copyright &y& Elsevier]