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A 29-year-old woman who worked as a KAATSU (a type of body exercise that involves blood flow restriction) instructor visited our emergency room with a chief complaint of swelling and left upper limb pain. Chest computed tomography (CT) showed non-uniform contrast images corresponding to the site from the left axillary vein to the left subclavian vein; vascular ultrasonography of the upper limb revealed a thrombotic obstruction at the same site, leading to a diagnosis of Paget-Schroetter syndrome (PSS). We herein report our experience with a case of PSS derived from thoracic outlet syndrome (TOS), in a patient who was a KAATSU instructor.

Introduccion y objetivos En estudios previos se ha descrito que la intervencion coronaria aplicada a lesiones complejas presenta una correlacion independiente con las hemorragias mayores. La puntuacion SYNTAX es un instrumento angiografico utilizado para evaluar el grado de complejidad de las enfermedades arteriales coronarias. El objetivo de este estudio es evaluar la capacidad de la puntuacion SYNTAX para predecir hemorragias mayores tras el implante de stents liberadores de farmacos. Metodos Se analizo a un total de 722 pacientes sometidos a implante de stents liberadores de farmacos de una poblacion de pacientes consecutivos incluidos en el estudio entre enero de 2007 y abril de 2010. Se investigo la incidencia de hemorragias mayores y trombosis del stent durante un periodo de 2 anos. La hemorragia mayor se evaluo mediante la puntuacion CRUSADE y los criterios del Bleeding Academic Research Consortium. Se estratifico a los pacientes en los siguientes grupos segun los criterios del ensayo SYNTAX: baja (= 22; n = 484), intermedia (23-32; n = 128) y alta (= 33; n = 110). Resultados Se observaron hemorragias mayores en 47 pacientes (6,5%) en el periodo de estudio de 2 anos, y hubo 12 episodios de trombosis del stent (1,7%). Las tasas de hemorragia mayor en los pacientes de los terciles bajo, intermedio y alto de la puntuacion SYNTAX fueron del 2,9, el 7,8 y el 20,9% respectivamente (p < 0,0001). La puntuacion SYNTAX mostro una hazard ratio ajustada de hemorragia mayor a los 2 anos de 1,81 (intervalo de confianza del 95%, 1,27-2,57). El valor predictivo del area bajo la curva de caracteristicas operativas del receptor ajustada por hemorragia mayor mejoro significativamente tras la inclusion de la puntuacion CRUSADE (estadistico C, 0,890 frente a 0,812). Conclusiones Aunque la puntuacion SYNTAX puede predecir el riesgo de hemorragias mayores, el valor predictivo de la puntuacion CRUSADE fue superior. Estas puntuaciones pueden resultar de utilidad en la toma de decisiones clinicas respecto a las estrategias de revascularizacion y la duracion optima del tratamiento antiagregante plaquetario doble tras implante de stents liberadores de farmacos.

Previous studies have reported that coronary intervention for complex lesions is independently correlated with major bleeding. The SYNTAX score is an angiographic tool used to grade the complexity of coronary artery diseases. The aim of this study was to assess the ability of the SYNTAX score to predict major bleeding following drug-eluting stent implantation.We analyzed 722 patients who underwent drug-eluting stent implantation in an all-comers population between January 2007 and April 2010. The incidence of major bleeding and stent thrombosis was investigated during a 2-year period. Major bleeding was evaluated using the CRUSADE score and Bleeding Academic Research Consortium criteria. Patients were stratified into the following groups according to the SYNTAX trial: low (≤ 22; n=484), intermediate (23-32; n=128), and high (≥ 33; n=110).Major bleeding was observed in 47 patients (6.5%) during the 2-year period, and there were 12 incidents of stent thrombosis (1.7%). Major bleeding rates for patients in the low, intermediate, and high SYNTAX score tertiles were 2.9%, 7.8%, and 20.9%, respectively (P.0001). The SYNTAX score had an adjusted hazard ratio of 1.81 (95% confidence interval, 1.27-2.57) for 2-year major bleeding. The predictive value of the adjusted area under the receiver operating characteristic curve for major bleeding significantly improved after inclusion of the CRUSADE score (C statistic, 0.890 vs 0.812).Although the SYNTAX score can predict major bleeding risk, the predictive value of the CRUSADE score was higher. These scores may be useful in clinical decision-making on revascularization strategies and on the optimal duration of dual antiplatelet therapy following drug-eluting stent implantation.

Background Elevation of C‐reactive protein ( CRP ) as a marker of vascular inflammation at a late phase of drug‐eluting stent ( DES ) implantation may predict subsequent major adverse cardiac events ( MACE ). Methods and Results In 1234 consecutive patients undergoing DES implantation, CRP was measured both before (baseline) and 8 to 12 months after (late phase) stenting, and the relationship between elevation of CRP (>2.0 mg/L) and subsequent MACE (all cause death, nonfatal myocardial infarction, target lesion revascularization, and other additional revascularization) was assessed. As results, CRP was elevated in 38.0% of patients at baseline and in 23.6% during late phase ( P HR ) for MACE was 1.52 (95% confidence interval [95% CI ] 1.21–1.93, P =0.0004) at baseline versus 4.00 (95% CI 3.16–5.05, P CRP elevation ( HR 3.60, 95% CI : 2.78–4.68, P CKD ) ( HR 1.41, 95% CI : 1.10–1.84, P =0.01), and number of diseased segments ( HR 1.19, 95% CI : 1.08–1.30, P =0.0002) were positive predictors of MACE , whereas statin use ( HR 0.66, 95% CI 0.50–0.87, P =0.003) was a negative predictor. Propensity score–matched analysis also confirmed the effect of late‐phase CRP on MACE ( HR 3.39, 95% CI 2.52–4.56, P CRP elevation, CKD (odds ratio [ OR ] 1.71, 95% CI 1.24–2.36, P =0.001) and baseline CRP elevation ( OR 3.48, 95% CI 2.55–4.74, P DES ( OR 0.59, 95% CI 0.41–0.84, P =0.003) and statin therapy ( OR 0.68, 95% CI 0.47–0.97, P =0.03) were negative predictors. Conclusions Monitoring the late‐phase CRP may be helpful to identify a high‐risk subset for MACE among patients undergoing DES implantation.

Summary Background The best way to treat in-stent restenosis (ISR) after drug-eluting stent (DES) implantation remains unclear. The aim of this study was to evaluate angiographic restenosis and target lesion revascularization (TLR) at 8 months after intervention in patients with DES-ISR, and to identify predictive factors of subsequent TLR after treatment of DES-ISR. Methods and results A total of 100 patients with 105 lesions underwent subsequent intervention for DES-ISR between April 2004 and January 2009. At baseline, focal and diffuse ISR were observed in 76.2% and 23.8%. DES-ISR was treated by five modalities: sirolimus-eluting stent (n = 42); paclitaxel-eluting stent (n = 24); balloon angioplasty (n = 23); cutting balloon angioplasty (n = 14); and bare-metal stent (n = 2). Angiographic follow-up data were available for 95 lesions (91%). The rates of angiographic restenosis and TLR were 37.9% and 33.3%. Late loss of sirolimus-eluting stent, paclitaxel-eluting stent, cutting balloon, and balloon angioplasty were 0.50 mm, 0.49 mm, 0.93 mm, and 1.10 mm. By multivariate analysis, totally occluded ISR (OR 15.43, p = 0.0005), diabetes mellitus (OR 3.45, p = 0.02), and re-stenting with DES (OR 0.14, p = 0.0002) were identified as independent predictors of TLR. Conclusions The restenosis rate was significant in this cohort of patients with DES-ISR. Angiographic pattern of DES-ISR and diabetes mellitus are the most important predictors of TLR, whereas re-stenting with DES is protective.

SYNTAX-score II as newer tool to assess patient co-morbidity in addition to lesion complexity may be useful to select candidate of PCI for chronic total occlusion (CTO-PCI). We investigated 321 patients who underwent CTO-PCI. The patients were assessed by both angiographic SYNTAX-score and SYNTAX

Both the presence of peripheral arterial disease and chronic kidney disease has been reported to be independent risk factors associating with poor prognosis. However, the impact of combination of peripheral arterial disease and chronic kidney disease remains unknown.The long-term outcome in 715 consecutive patients who had undergone coronary angiogram for the evaluation of chest pain was analyzed. Patients on haemodialysis were excluded from this analysis. Cohort patients were divided into four groups according to the Ankle Brachial Index (ABI0.9) and glomerular filtration rate (GFR60 mL/min per m(2)): group A (n= 498; ABI0.9, GFR60); B (n = 65, ABI0.9, GFR60); C (n = 99; ABI0.9, GFR60); and D (n = 53; ABI0.9, GFR60). The mean follow-up period was 620 +/- 270 days and evaluated the major cardiac adverse events included survival, stroke, acute coronary syndrome and heart failure.The mean follow-up period was 620 +/- 270 days. Total long-term event was present in 89 patients (groups A-D were 9.4%, 18.5%, 15.2% and 28.3%, respectively). Long-term event rate was 28.3% for patients with the presence of peripheral arterial disease and chronic kidney disease, compared to 9.4% for those without peripheral arterial disease and chronic kidney disease (P0.0001). Kaplan-Meier event-free survival curves also showed that the combination of peripheral arterial disease and chronic kidney disease predicted long-term event rate.The combination of chronic kidney disease and ABI of less than 0.9 undergoing coronary angiogram is strongly associated with long-term event rate.

Background: While preprocedural statin treatment for acute coronary syndrome (ACS) is widely regarded as beneficial, there has been no prospective randomized multicenter trial of patients with non-ST elevation ACS in the Japanese population to examine the efficacy of preprocedural aggressive statin use. The aim of this study was to confirm this effect by prospective randomized multicenter design. Methods: Fifty patients who presented with non-ST elevation ACS were enrolled, and randomly assigned to aggressive statin administration before percutaneous coronary intervention (PCI). Troponin-T (TnT), creatine phosphokinase (CK), CK-myocardial band (CK-MB), high-sense C-reactive protein (hs-CRP), and brain natriuretic peptide (BNP) were measured at baseline and/ or after procedure. Results: Three days after PCI, the statin group had significantly less CK elevation compared with the nonstatin group (84±17 IU/l versus 180±68 IU/l, respectively, p = 0.02). CK-MB elevation also tended to be lower in the statin group than in the nonstatin group (3.2±1.9 versus. 7.0±3.0, respectively, p = 0.07), as was BNP level (3.2±1.9 versus 7.0±3.0 pg/ml, respectively, p = 0.07). The change of serum LDL cholesterol was significantly correlated with CK ( p = 0.01) and TnT ( p = 0.02) at 1 day after PCI. Conclusions: Aggressive statin usage before PCI to Japanese patients with non-ST elevation ACS appears to reduce myocardial damage after procedure. The degree of serum lipid level reduction may reflect the vulnerability of atheromatous plaques that could cause cardiac damage after PCI.

We describe a patient with right common iliac artery occlusion who presented with intermittent claudication and underwent percutaneous transluminal angioplasty. The angiogram showed 100% occluded right common iliac artery with bridged collateral flow. After initial ballooning to the artery, the occluding plaque detached from the artery and resulted in multiple embolizations, not only to the distal external iliac artery, but also to the internal iliac artery and its branches, which supplied collateral flow to the right femoral artery. Circulation in the collateral networks from internal iliac artery and its branching to the right femoral artery diminished from the multiple embolizations. Repeat aspiration and stenting to the portion of dislodged plaque was attempted, but repeat ballooning to open the external iliac artery was unsuccessful because of decreased collateral flows and distal displacement of the embolus to the right femoral artery. Finally, all blood flow to the right femoral artery was occluded. Surgical embolectomy was successfully performed, but the patient succumbed to myonephropathic metabolic syndrome. Multiple embolizations occluding numerous collateral arteries caused acute fatal ischemia to the right limb. This case report highlights potentially fatal complication in the percutaneous intervention for chronic iliac artery occlusion.

Background: While some therapies implemented for newly diagnosed Diabetes Mellitus (DM) or impaired Glucose Tolerance (IGT) are effective in preventing cardiovascular events, investigations of coronary plaque in patients with newly diagnosed DM or IGT are lacking. Methods: We evaluated 96 patients with acute coronary syndrome. The External Elastic Membrane (EEM), Lumen Cross-Sectional Area (CSA), plaque CSA, and plaque burden in the Left Anterior Descending (LAD) artery proximal to the lesion, diagnosed as normal by Coronary Angiography (CAG), were measured using Intravascular Ultrasound (IVUS). Patients were divided according to DM status (DM=35, non-DM=61). Non-DM patients underwent a 75g Oral Glucose Tolerance Test (OGTT) and were further divided into abnormal glucose tolerance (AGT; n=29) and Normal Glucose Tolerance (NGT) groups (n=32). Results: Quantitative Coronary Angiography (QCA) showed no significant differences in EEM or vessel diameter between groups. However, the lumen CSA was significantly smaller in the DM group than in the NGT group. The plaque CSA and plaque burden were significantly greater in the DM and AGT groups than in the NGT group. Total insulin and glucose values and insulin and glucose values at 120 min after the OGTT correlated with plaque CSA; insulin values at 120 min after the OGTT showed the strongest correlation (R=0.505, P

The aim of this study is to demonstrate initial results and long-term outcomes of patients after receiving cutting balloon angioplasty (CBA), balloon angioplasty (BA), or stenting for small vessel diseases. We studied a total of 327 lesions of small coronary disease treated either by CBA (n=87), BA (n=130), or stenting (n=110) in two affiliated institutes. A small coronary artery was defined as a reference vessel

OBJECTIVE The efficacy of coronary stenting of aorto-ostial atherosclerotic lesions is still unclear. We investigated the frequency and mechanism of stent restenosis at this particular lesion. METHODS Fifty-five consecutive patients with 64 native aorto-ostial lesions in the right coronary artery (RCA, n = 38) and the left main trunk (LM, n = 26) were treated by conventional stenting. Determinants of angiographic restenosis were established. The mechanism of stent restenosis was evaluated using post-stenting and follow-up intravascular ultrasound (IVUS) findings. RESULTS Restenosis was more frequent in the RCA than in the LM (50% compared with 19%, P < 0.03) and determinants included diabetes mellitus (63% compared with 21%, P < 0.03), calcium deposition (58% compared with 5%, P < 0.003), smaller stent cross-sectional area (SA) (as demonstrated by post-stenting IVUS studies, 8.1 +/- 1.4 mm compared with 10.2 +/- 2.2 mm, P < 0.01), larger plaque burden (64 +/- 6% compared with 57 +/- 8%, P < 0.03) and less circular expansion at the aorto-coronary junction. Serial IVUS examination was performed in 11 patients with restenosis of the right coronary ostium. The mean reduction in the SA was 21% at the aorto-coronary junction (6.4 +/- 1.9 mm, P < 0.003), whereas the SA at the distal edge was unchanged. Thirty-three per cent of late luminal loss was due to chronic stent recoil. CONCLUSION These findings suggest that stenosis of the right coronary ostium is a high-risk lesion for stent restenosis. In addition to excessive intimal growth, chronic stent recoil might be an important etiologic factor at this particular location.

Introduction: Takotsubo cardiomyopathy (TTC) is characterized by a transient systolic dysfunction of the left ventricle. A few case was reported about left ventricular apical hypertrophy (APH) during recovery from TTC. The purpose of this study was to investigate the incidence of transient APH and the differences in clinical characteristics in TTC patients. Methods: Forty seven TTC patients were enrolled in this study. Patients were divided into two groups as N-APH group which did not show APH like findings in the process of wall motion recovery and T-APH group which showed transient APH findings. Cardiac complications were defined as cardiac death, pump failure, sustained ventricular tachycardia or ventricular fibrillation and advanced atrioventricular block. Results: Twelve of 47 (25.5%) TTC patients demonstrate typical APH findings during recovery from wall motion abnormality. Finally, this APH findings disappeared and left ventricular morphology recovered to normal structure. There is no significant difference between two groups in clinical characteristics (table). Incidence of cardiac complication showed significantly lower in T-APH group than that in N-APH group (P< 0.005). Conclusions: Transient left ventricular APH were observed in 25.5% in TCC patient by serial echocardiographic observation. Incidence of cardiac complications in T-APH group is significantly lower than that in N-APH group. Detection of T-APH is useful as a prognostic indicator in patients with TTC.

Introduction: It is reported that aortic valve reconstruction (AVrC) by using autologous pericardium is useful in patients with various aortic valve diseases. This method may be more effective in preserving the natural motion of the aortic valve annulus. Significant dynamic changes in the aortic annulus have previously been reported in animal models and clinical studies. The purpose of this study is to analize the cyclic changes of the aortic annulus using speckle-tracking trans-esophageal echocardiography in patients who underwent AVrC surgery. Methods: The subjects were 35 patients underwent AVrC surgery for aortic regurgitation or aortic stenosis and 40 controls. Cyclic aortic annulus diameter of the maximum and minimum diameters were determined from a speckle-tracking displacement curve (figure). These data was used to calculate the absolute change in the diameter of the aortic annulus, which was defined as the difference in diameters throughout the cardiac cycle. Results: There was significant difference between maximum and minimum aortic annulus diameter in AVrC group (18.7±3.0 mm vs 16.1±2.9 mm, p Conclusions: Our study suggests that dynamic changes of the aortic annulus occur in the cardiac cycle and can be measured using speckle-tracking trans-esophageal echocardiography. AVrC may preserve the coordination of the left ventricle, aortic annulus, sinus of Valsalva and aorta compared with conventional aortic valve replacement.

神戸市外国語大学は1995年1月17日，阪神・淡路大震災を体験した。被災地域の中から外部への連絡手段の一つとしてインターネットは有効であることが実証された。災害時においてコンピュータネットワークを運用するためには何に留意すべきか，この3年間におけるインターネットをめぐる変化をふまえて，過去のメディアの形成過程と比較することにより，現在におけるより有効なインターネットの活用を考察した。

The benefits of treating patients with acute coronary syndrome (ACS) with statins are well established. This study investigated the effects of statins on patients who presented with low levels of low-density lipoprotein (LDL) cholesterol, were diagnosed with non-ST elevation ACS, and subsequently underwent percutaneous coronary interventions (PCI).From 2000 to 2003, 87 patients(mean age 68 +/- 10 years, 69 males, 18 females) underwent PCI because of non-ST elevation ACS, and had low LDL cholesterol on presentation. These patients were divided into two groups: those who had been taking statins (S-group, n = 46), and those not taking statins, or controls (C-group, n = 41). Only patients whose LDL cholesterol was100 mg/dl at admission (average: 82 +/- 12 mg/dl) were included in the study. Troponin-T (TnT), creatine kinase (CK), CK-MB, and high-sense C reactive protein (hs-CRP) were measured before and 6 hr after PCI. The two groups were evaluated at 6 months clinical follow-up.There was no difference in these markers before PCI in both groups. TnT and CK-MB in the S-group at 6 hr post-PCI were significantly decreased compared to those of the C-group (0.45 +/- 1.34 vs 1.40 +/- 2.37 ng/ml, respectively, for TnT, p = 0.04; 17.2 +/- 45.5 vs 81.3 +/- 157.2 IU/l, respectively, for CK-MB, p = 0.02). Major adverse cardiac events (MACE) defined as death, myocardial infarction, congestive heart failure and target lesion revascularization were evaluated after 6 months. There was no difference in MACE between the two groups.Statin treatment before PCI in patients with non-ST elevation ACS demonstrated beneficial effects such as less myocardial damage, even though both groups presented with low LDL cholesterol levels. However, no significant effect on MACE was seen at 6 months after PCI.

When performing intravascular ultrasound studies, the backward echo image can show marked attenuation, although there are no calcified deposits and it may be impossible to detect the intraplaque architecture. The pathology underlying this phenomenon was investigated in autopsy specimens. We hypothesize that the mechanism responsible for the attenuation involves micro‐calcification and lipid in unstable plaques causing ultrasonic wave reflection and dispersion.

A 68-year-old male hemodialysis patient presented with severe congestion in his left arm. Left arm venography showed a completely occluded left brachiocephalic vein. We chose a self-expandable stent for treating this vein. However, restenosis occurred once at 8 months and again after six additional months. The cause of the restenosis was considered to be a stent fracture. On the first restenosis, we performed redilation with a balloon; on the second restenosis, we chose stent-in-stent with a balloon-expandable stent. At least 9 months after the stent-in-stent procedure, there has been no edema in his left arm. Therefore, stent-in-stent is one of the useful strategies for stent fracture in central venous obstruction.

Provisional stenting of the side branch seems to be an attractive strategy even in the DES era. One of the technical problems in provisional side branch stenting is how to deliver the stent through a stent strut. In this case presentation, we suggest a novel method for deploying a stent through the use of a 5 Fr guiding catheter. A 5 Fr guiding catheter within a 7 Fr guiding catheter was advanced to the lesion, through a stent strut, facilitating the deployment of the stent. This system permits negotiation of the stent strut that otherwise obstructs stent passage.

Coronary lesion stenting with aspiration and distal balloon occlusion is more often associated with embolic occlusion of interposed side branches when the branch arises at an angle of/=45 degrees and the artery containing the lesion is large. However, this event is infrequent, often resolving during the procedure and uniformly resolving by 6 months.

Insulin resistance has been implicated as an important initiating factor in coronary atherosclerosis. However, associations between insulin resistance and specific morphologic features of atherosclerotic coronary arteries remain unclear. We ultrasonographically evaluated the morphologic features of atherosclerotic coronary arteries in nondiabetic patients with insulin resistance.Before intervention, 90 patients with 105 culprit lesions underwent intravascular ultrasound examination through which vessel area, lumen area and plaque area were evaluated. Expansive remodeling (lesion vessel area more than 5% greater than at the proximal reference segment) and constrictive remodeling (lesion vessel area more than 5% less than at the distal reference segment) were also evaluated. Insulin resistance was determined by homeostasis model assessment and defined as values above the 75th percentile (that is, 1.71).Insulin-resistant patients numbered 23, while nonresistant patients numbered 67. Culprit lesions in the insulin-resistant group showed larger vessel area (18.16 +/- 6.94 compared with 13.64 +/- 4.28 mm, P = 0.0001) and plaque area (16.64 +/- 6.78 compared with 12.05 +/- 4.12 mm, P = 0.0001) and more frequently showed expansive remodeling (56% compared with 14%, P0.0001) and calcific plaque (33% compared with 12%, P = 0.01). Multivariable logistic regression analysis identified only insulin resistance (odds ratio, 4.9, P = 0.008) as an independent predictor of expansive remodeling.Insulin resistance independently predicted expansive remodeling, underscoring the importance of insulin resistance in coronary atheroscrelosis.

Thrombotic occlusion in the culprit lesion of acute myocardial infarction was successfully recanalized using a 4.5 Fr thrombectomy catheter (RESCUE), which was also used to normalize the coronary blood flow. The retrieved specimens were white thrombi containing red thrombi and cholesterol crystals, indicating plaque rupture.

Drug-eluting stent (DES) with femoropopliteal lesions have improved patency results. However, long lesions were excluded from current study. The treatment of in-stent-restenosis in the femoropopliteal artery is still unsolved problem. Furthermore, there was no significant difference in patency for