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Drug eluting stent (DES) remain several problems, including stent thrombosis, stent fracture and neoatherosclerosis. Stent-less Percutaneous coronary intervention (PCI) using a drug coated balloon (DCB) is a stent-less strategy, and several trials have supported the efficacy of DCB. However, the optimal preparation before using DCB was uncertain. The aim of this study was to investigate the optimal preparation for plaque oppression/debulking before DCB dilatation for de novo coronary artery lesion.A total 936 patients were treated using DCB from 2014 to 2017 at our institution. Among them, we analyzed 247 patients who underwent PCI using DCB alone for de novo lesion. The primary end point of this study was target lesion failure (TLF).The area under the receiver operating characteristic (ROC) curve (AUC) was used to determine the optimal cutoff value of % plaque area to predict TLF. ROC curve analysis revealed plaque area ≥ 58.5% (AUC, 0.81) were associated with TLF. Eligible 188 patients were divided into 2 groups (plaque area ≥ 58.5% [n = 38] and58.5% [n = 150]) according to IVUS data before using DCB. TLF was significantly higher in plaque area ≥ 58.5% group than in58.5% group (P 0.01). Multivariable analysis selected plaque area ≥ 58.5% as an independent predictor of TLF (hazard ratio 7.59, P 0.01).Lesion preparation achieving plaque area 58.5% was important in stent-less PCI using DCB.

Purpose: The endovascular approach for eccentric calcified lesions of the no-stenting zone is challenging. This study aimed to investigate the effect of a novel technique for these lesions. Methods: We performed EVT for severe and eccentric calcified lesions using the technique, which is presented previously and named aggressive wire recanalization in calcified atheroma and dilatation (ARCADIA). In brief, a guidewire is passed to the residual lumen firstly. Next, another guidewire is advanced into and cross through the calcified plaque and returned to the distal original lumen with intravascular ultrasound (IVUS) guided. The calcified plaque is dilated by using a scoring-balloon or non-compliant balloon. Results: Consecutive 14 peripheral artery disease patients with isolated and eccentric calcification in a no-stenting zone were treated using ARCADIA technique between January 2018 and March 2020. In IVUS data, lumen cross-section area was significantly increased from 5.2 ± 2.0 mm2 to 18.1 ± 6.9 mm2 (p < 0.01), lumen area was expanded roundly evaluating as symmetry index from 0.45 ± 0.09 to 0.81 ± 0.12 (p < 0.01). There were no distal embolization and perforation after ARCADIA technique. One-year target lesion revascularization occurred in only 2 cases. The primary patency of 1 year was 85.7%. Conclusion: ARCADIA technique is safe and appropriate, and can be 1 option to treat for eccentric calcified lesions of the no-stenting zone as an optimal wire crossing method.

BACKGROUND Chronic vessel enlargement (CVE) of the coronary artery is observed in patients who undergo percutaneous coronary intervention (PCI) for severely stenotic or occluded lesions. Recently, the presence of a peri-medial high-echoic band (PHB) identified by intravascular ultrasound (IVUS) has been reported to correlate with this phenomenon. We sought to assess the incidence, predictive factors of CVE, and association between CVE and PHB. METHODS From January 2017 to December 2018, 97 patients, with 101 severely stenotic and occluded lesions, who underwent IVUS-guided PCI and a 9-month follow-up angiography were enrolled. CVE was defined as more than a 10% increase of distal lumen gain at follow-up angiography. All lesions were stratified into 2 groups: CVE group and non-CVE group. Clinical outcomes were compared and predictive factors for CVE were assessed. Relationships between PHB angle and CVE were also assessed. RESULTS At follow-up angiography, CVE was observed in 27 lesions (26.7%, 27/101). PHBs were frequently observed in the CVE group (88.9%), which was significantly higher than that in the non-CVE group (40.5%). The multivariate logistic regression analysis revealed that the presence of PHB was the only predictive factor for CVE (odds ratio, 11.3; 95% confidence interval, 2.95-43.0; p

Background Interventionists' experience and skills are essential factors for successful chronic total occlusion-percutaneous coronary intervention (CTO-PCI). However, the construction of theoretical strategy independent from interventionists' procedure may also improve it. We sought to assess the feasibility of CTO-PCI using an educational system supported by a single expert proctor. Methods A total of 160 patients underwent CTO-PCI between 2009 and 2016 at 92 Japanese centers in the Hands-on proctorship project. The CTO-PCI strategy was discussed with all participants and their specialists, before and during the procedure. We divided patients into 2 groups based on the CTO-PCI experience of their interventionist: (1) the less experienced group (CTO-PCI ≤ 50 cases, n = 65) and (2) the more experienced group (CTO-PCI > 50 cases, n = 95). Baseline characteristics, procedural complications, and clinical outcomes were compared between groups. Results No significant differences in patient age, sex, prevalence for coronary risk factors, and lesion complexity was observed between groups. The retrograde approach was used equivalently between groups (55.4% vs. 60.0%, p = 0.56), and procedural success rates were similar (96.9% vs. 90.5%, p = 0.12). The rate of proctor's bailout for recanalization were not frequent between groups (4.6% vs. 5.3%, p = 0.85). No procedure-related mortality was noted in either group. In addition, no significant differences in procedural cardiac complications, including coronary dissection, perforation, or tamponade, were observed between groups (10.8% vs. 14.7%, p = 0.47). Conclusions The expert-supported CTO-PCI maintained high success rates regardless of interventionists' experience. This highlights the importance of theoretical strategy for the management patients undergoing CTO-PCI.

While primary percutaneous coronary intervention (PCI) has significantly contributed to improve the mortality in patients with ST segment elevation myocardial infarction even in cardiogenic shock, primary PCI is a standard of care in most of Japanese institutions. Whereas there are high numbers of available facilities providing primary PCI in Japan, there are no clear guidelines focusing on procedural aspect of the standardized care. Whilst updated guidelines for the management of acute myocardial infarction were recently published by European Society of Cardiology, the following major changes are indicated; (1) radial access and drug-eluting stent over bare metal stent were recommended as Class I indication, and (2) complete revascularization before hospital discharge (either immediate or staged) is now considered as Class IIa recommendation. Although the primary PCI is consistently recommended in recent and previous guidelines, the device lag from Europe, the frequent usage of coronary imaging modalities in Japan, and the difference in available medical therapy or mechanical support may prevent direct application of European guidelines to Japanese population. The Task Force on Primary Percutaneous Coronary Intervention of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) has now proposed the expert consensus document for the management of acute myocardial infarction focusing on procedural aspect of primary PCI.

Background Following the development of breakthrough techniques for percutaneous coronary intervention (PCI) in the treatment of chronic total occlusions (CTO), the initial success rate of PCI in CTO lesions (CTO-PCI) has improved; however, there are few reports regarding the effects of successful CTO revascularization on long-term mortality in Japan. The aim of this study was to compare the long-term clinical outcomes of patients with successful versus failed CTO recanalization and to identify related factors. Methods and results From all PCI procedures performed in our hospital between 2006 and 2013, CTO-PCIs were extracted and classified into two groups: PCI success (n = 656 patients) and PCI failure (n = 82 patients). Patients with successful procedures only on a second attempt, CTO-PCI in small branches, or CTOs in more than one vessel were excluded. Survival was determined from a telephone interview or the consultation history in the outpatient clinic. Initial angiographic success was achieved in 88.9% of the patients. A Kaplan–Meier plot with log-rank analysis showed that cumulative all-cause death was significantly lower in the success group than in the failure group (p = 0.0003; average follow-up duration in success group vs. failure group was 1531.3 ± 33.5 vs. 1565.3 ± 97.5 days, p = 0.7). Moreover, the rate of evident cardiac death was significantly lower in the success group than in the failure group (3.5% [23/656] vs. 15.9% [13/82], p Conclusions This study suggests that successful revascularization in patients with CTO improves their long-term clinical outcomes.

Objectives We sought to evaluate the efficacy of plaque debulking by directional coronary atherectomy (DCA) before 2nd generation drug-eluting stent (DES) implantation for bifurcated coronary lesions. Background Percutaneous coronary intervention (PCI) for bifurcated lesions still remains complex and challenging in terms of restenosis or stent thrombosis regardless of whether simple or complex stenting used. Methods Patients with bifurcated lesions were enrolled in this prospective multicenter registry. Pre-2nd generation DES plaque debulking with a novel DCA was conducted. All patients were scheduled to perform a follow up (9–12 months) angiography (coronary angiography or coronary computed tomography). The primary end point was the target vessel failure (TVF) at follow-up. Secondary end points were procedure-related events and major adverse cardiac events at 1 year. Results A total of 77 patients with bifurcated lesions were enrolled. PCI with DCA was performed successfully in all without any major procedure-related event and only 1 case needed complex stenting. TVF rate at 9–12 months follow up was 3.9% (3 of 77) and those were all associated with revascularization of the target vessel. Restenosis was only observed at ostial of main-branch in 3cases. No death, no coronary artery bypass grafting, and no myocardial infarction were reported in the patients within the first year. Figure1 Conclusion DCA before 2nd generation DES implantation can possibly avoid complex stenting and provide a good mid-term outcome in patients with bifurcated lesions. Acknowledgement/Funding None

Background For recanalization of coronary chronic total occlusion (CTO) lesions, subintimal guidewire tracking in both antegrade and retrograde approaches are commonly used. Purpose This study aimed to assess the impact of subintimal tracking on long-term clinical outcomes after recanalization of CTO lesions. Methods Between January 2009 and December 2016, 474 CTO lesions (434patients) were successfully recanalized in our center. After guidewire crossing in a CTO lesion, those lesions were divided into intimal tracking group (84.6%, n=401) and subintimal tracking group (15.4%, n=73) according to intravascular ultrasound (IVUS) findings. Long-term clinical outcomes including death, target lesion revascularization (TLR), target vessel revascularization (TVR) were compared between the two groups. In addition, the rate of re-occlusion after successful revascularization was also evaluated. Results The median follow-up period was 4.7 years (interquartile range, 2.8–6.1). There was no significant difference of the rate of cardiac death between the two groups (intimal tracking vs. subintimal tracking: 7.0% vs. 4.1%; hazard ratio, 0.61; 95% confidence interval [CI], 0.19 to 2.00; p=0.41), TLR (14.3% vs. 16.2%; hazard ratio, 1.34; 95% CI, 0.71 to 2.53; p=0.37), and TVR (17.5% vs. 20.3%; hazard ratio, 1.27; 95% CI, 0.72 to 2.23; p=0.42). However, the rate of re-occlusion was significantly higher in the subintimal tracking group than intimal tracking group at 3-years re-occlusion (4.2% vs. 14.5%; log-rank test, p=0.002, Figure). In the multivariate COX regression, subintimal guidewire tracking was an independent predictor of re-occlusion after CTO recanalization (HR: 5.40; 95% CI: 2.11–13.80; p Figure 1 Conclusions Subintimal guidewire tracking for recanalization of coronary CTO was associated with significantly higher incidence of target lesion re-occlusion during long-term follow-up period.

This study aimed to assess the prognosis and deleterious effects of chronic kidney disease (CKD) on future renal function, in patients who had undergone chronic total occlusion-percutaneous coronary intervention (CTO-PCI).The treatment effects were studied in 739 patients who underwent CTO-PCI. The patients were divided into 3 groups according to estimated glomerular filtration rate (eGFR): non-CKD (eGFR≥60ml/min/1.73m(2), n=562), CKD-1 (45≤eGFR60ml/min/1.73m(2), n=90), and CKD-2 (eGFR45ml/min/1.73m(2), n=87). Future hemodialysis (HD) rates and the prevalence of acute kidney injury (AKI) except for 45 patients undergoing regular HD, and other clinical and prognostic outcomes were compared between the 3 groups.Procedural success rates showed trends toward lower prevalence across the 3 groups (89.5%, 84.4%, and 81.6%, p=0.060). The prevalence of AKI significantly differed between the 3 groups (4.6%, 8.9%, and 16.7%, p=0.001), whereas no patients were introduced to regular HD at discharge. During a median follow-up period of 51.2±28.9months, newly required HD significantly differed between the 3 groups (0.7%, 0%, and 7.1%, p0.001). When compared with unsuccessful CTO-PCI, successful CTO-PCI was found to improve cardiovascular mortality in the non-CKD and CKD-1 (Log-rank test: p=0.025, p=0.024, respectively) and to improve both cardiovascular and all-cause mortality in the CKD-2 (Log-rank test: p=0.027, p=0.0022, respectively).Although CTO-PCI for patients with advanced CKD was associated with a high risk of future HD introduction, not directly owing to CTO-PCI and AKI, successful treatment of CTO might contribute to better survival benefit regardless of the presence or absence of CKD.

Aims Despite development of drug eluting stents (DES), percutaneous coronary intervention (PCI) for bifurcation lesions using DES alone remains challenging. The aim of this study was to report on the initial clinical experience with a novel directional coronary atherectomy (DCA) catheter. Methods and Results Patients with de novo bifurcation lesions were entered into a prospective registry and a novel DCA catheter was used. Device, procedural success and in-hospital outcomes were evaluated. A total of 14 patients with bifurcation lesions were enrolled. DCA was performed successfully in all cases without any major procedure-related events (device success rate: 100%, procedural success rate: 100%). Four patients (29%) were treated without stent implantation and simple stenting was achieved in the other 10 patients. No in-hospital major adverse cardiac event was observed. Conclusions PCI with a novel DCA catheter for bifurcation lesions may be safe and effective. The clinical significance of these findings needs to be determined in future studies. This study was performed to evaluate the safety and efficacy of a novel directional coronary atherectomy catheter for bifurcation lesions. Both the device and procedural success rates were 100%. Complex stenting could be avoided in all cases. No inhospital major adverse cardiac event was observed. The novel directional coronary atherectomy catheter may be safe and effective for bifurcation lesions, even in this drug eluting stent era. © 2016 Wiley Periodicals, Inc.

Objectives This study was performed to determine the complications occurring during retrograde percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) based on analysis of the multicenter, prospective, nonrandomized Retrograde Summit registry. Background Retrograde PCI for CTO has improved treatment success rates, but several complications related to the retrograde approach have been reported, including collateral channel injury and donor artery injury due to their use as retrograde roots. Methods This registry included data from 1,166 patients who underwent retrograde PCI for CTO in 28 Japanese centers between January 2009 and December 2011. Results Overall procedure success and retrograde procedure success were achieved in 985 (84.5%) and 838 (71.9%) of the 1,166 patients, respectively. In-hospital major adverse cardiac and cerebrovascular events (MACCE) occurred in 18 (1.5%) of the 1,166 patients. With regard to complications related to the retrograde approach, channel injury occurred in 111 (9.5%) of the 1,166 patients, but treatment was required in only 24 (2.1%) patients and subsequent cardiac tamponade occurred in only 4 (0.3%) patients. Donor artery problems occurred in only 10 (0.9%) of the 1,166 patients. In sub-analysis regarding the types of collateral channels, the septal channel was significantly safer than epicardial channel because of the lower frequency of non-Q-wave myocardial infarction (non-QMI) and channel injury requiring treatment. Conclusions The MACCE rate during retrograde PCI for CTO determined from the Retrograde Summit registry was low and the frequency of complications related to the retrograde approach was acceptable. © 2015 Wiley Periodicals, Inc.

Background The histopathological validation of optical coherence tomography (OCT) in visualizing atherosclerotic plaques has been reported only in ex vivo studies. We sought to evaluate the accuracy of OCT in tissue characterization in vivo. Methods and results A total of 25 patients with stable angina pectoris who underwent directional coronary atherectomy (DCA) were included in the investigation, whereby OCT was performed before and after a single debulking. The debulked region was determined on OCT and classified into fibrous tissue, lipid, calcification, thrombus, and macrophage accumulation, which were compared with histology. Changes in OCT signal intensity in the deeper intimal region after DCA were also visually evaluated. Fibrous tissues were detected in all cases, while thrombus was identified only in 1 case, by both OCT and histology. The sensitivity, specificity, positive and negative predictive values, and predictive accuracy for lipid detection by OCT were 88.9%, 75.0%, 66.7%, 92.3%, and 80.0%; those for calcification were 50.0%, 100%, 100%, 91.3%, and 92.0%; and those for macrophage accumulation were 85.7%, 88.9%, 75.0%, 94.1%, and 88.0%, respectively. The false positive diagnoses for lipid were mostly attributed to the extracellular matrix accumulation containing less collagen. The false negative diagnoses for calcification were explained by the presence of lipid around the calcification. The OCT signal intensity in the deeper intimal region substantially increased after DCA in all cases. Conclusions The current study showed excellent predictive accuracy of in vivo OCT in tissue characterization, whereas the limitations of OCT were highlighted by an over-detection of lipid, under-detection of calcification, and underestimation of the deeper intimal matrix.

Objectives This registry evaluated the current trends and outcomes associated with retrograde percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). Background Since its introduction, several techniques and technologies have been introduced for retrograde PCI for CTO. Methods Eight hundred and one patients who underwent retrograde PCI for CTO in 28 Japanese centers between January 2009 and December 2010 were enrolled in this registry. Results Overall procedural and clinical success rates were 84.8 and 83.8%, respectively, of which, retrograde procedures accounted for 71.2 and 70.3%, respectively. The use of channel dilators increased in 2010 compared to that in 2009 (36 vs. 95.3%, P

Calcification is usually identified by a well-delineated, low back-scattering heterogeneous region without signal attenuation on optical coherence tomography (OCT), whereas red-thrombus is characte...

BACKGROUND Optimal medical therapy (OMT) and the management of coronary risk factors are necessary for secondary prevention of major adverse cardiac and cerebrovascular events (MACCE) in post-acute coronary syndrome (ACS) patients. However, the effect of post-discharge patient adherence has not been investigated in Japanese patients. METHODS AND RESULTS The Prevention of AtherothrombotiC Incidents Following Ischemic Coronary Attack (PACIFIC) registry was a multicenter, prospective observational study of 3,597 patients with ACS. Death or MACCE occurred in 229 patients between hospitalization and up to 1 year after discharge. Among 2,587 patients, the association between OMT adherence and risk factor control at 1 year and MACCE occurring between 1 and 2 years after discharge was assessed. OMT was defined as the use of antiplatelet agents, angiotensin-converting enzyme inhibitors, β-blockers, and statins. Risk factor targets were: low-density lipoprotein-cholesterol

The data regarding the risk and benefits associated with live demonstrations at interventional cardiology congresses are scarce and controversial. We aimed to assess the clinical safety of chronic total occlusion percutaneous coronary intervention (CTO-PCI) procedures during live demonstrations. From January 2008 to December 2013, 739 consecutive patients underwent CTO-PCI at our center, and 199 patients were scheduled to undergo live CTO-PCI demonstrations at cardiology congresses that were globally transmitted to international meetings. The baseline characteristics, procedural complications, and clinical outcomes were compared between the live demonstration group and nonlive demonstration group. The procedural success rates were similar in the live demonstration group than in the nonlive demonstration group (91.5% vs 86.7%, p = 0.076), although the CTO lesions were longer and more tortuous in the live demonstration group (p = 0.029, p = 0.022, respectively). No cases of 30-day mortality were noted in the live demonstration group (0% vs 0.7%, p = 0.28), and no significant differences in procedural complications, such as coronary dissection, coronary perforation, and cardiac tamponade, were observed between the groups (p = 0.53, p = 0.12, and p = 0.40, respectively). The survival rates were similar in the 2 groups at a median follow-up duration of 51.2 ± 28.9 months (log-rank test: p = 0.45). Compared with cases of unsuccessful CTO-PCI, the cases of successful CTO-PCI exhibited improved all-cause survival in both the live and nonlive demonstration groups (log-rank test: p = 0.045, p = 0.0056, respectively). In conclusion, we found that procedural and clinical outcomes of live demonstration CTO-PCI were not significantly different compared with cases undergoing routine CTO-PCI procedures.

Despite development of drug eluting stents (DES), percutaneous coronary intervention (PCI) for bifurcation lesions using DES alone remains challenging. The aim of this study was to report on the initial clinical experience with a novel directional coronary atherectomy (DCA) catheter.Patients with de novo bifurcation lesions were entered into a prospective registry and a novel DCA catheter was used. Device, procedural success and in-hospital outcomes were evaluated. A total of 14 patients with bifurcation lesions were enrolled. DCA was performed successfully in all cases without any major procedure-related events (device success rate: 100%, procedural success rate: 100%). Four patients (29%) were treated without stent implantation and simple stenting was achieved in the other 10 patients. No in-hospital major adverse cardiac event was observed.PCI with a novel DCA catheter for bifurcation lesions may be safe and effective. The clinical significance of these findings needs to be determined in future studies. This study was performed to evaluate the safety and efficacy of a novel directional coronary atherectomy catheter for bifurcation lesions. Both the device and procedural success rates were 100%. Complex stenting could be avoided in all cases. No inhospital major adverse cardiac event was observed. The novel directional coronary atherectomy catheter may be safe and effective for bifurcation lesions, even in this drug eluting stent era. © 2016 Wiley Periodicals, Inc.

Objectives We sought to report the results of both bench-testing and our first clinical experience with this novel technique. Background The optimal stenting technique for bifurcation lesions has yet to be defined. Methods This technique works by flaring the proximal side of the stent in side branch out like a flower petal. We tested it in vitro and the resultant stent structure and stent polymer damage was observed in both main branch and side branch with an optical microscopy, multislice computer tomography, intravascular ultrasound, endoscopy, and by electron microscopy. We also applied this technique in 33 patients and assessed patient outcomes up to 9 months prospectively. Drug-eluting stents were used for the bench tests and for all patients. Results Bench-testing showed complete coverage of the bifurcation with minimal stent-layer overlapping. There was little polymer damage by electron microscopy. Procedural success was achieved in all cases and restenosis occurred in 2 cases. In both restenosis cases, “petal” stenting technique was done reluctantly after another stent had already been deployed in the main branch before any stenting of the side branch. There were no incidences of restenosis when this technique was used electively. Conclusions In terms of damage to the polymer and ostial strut coverage, this new “flower petal stenting” technique is effective for treatment of bifurcation lesion and it may well be superior to other available techniques.

Objectives The aim of this study was to evaluate the safety and feasibility of a new concept for chronic total occlusion (CTO) recanalization—using a bilateral approach that utilizes a Controlled Antegrade and Retrograde subintimal Tracking (CART) technique. Background Successful percutaneous recanalization of coronary CTOs results in improved long-term outcomes. The recanalization of CTOs in native coronary arteries no doubt represents one of the most technically challenging of interventional procedures. Methods A total of 224 consecutive patients (mean age 61 ± 9 years; 86.2% men) were enrolled in this prospective multicenter registry. This technique combines the simultaneous use of antegrade and retrograde approaches. A subintimal dissection is created in both antegrade and retrograde fashion, thereby limiting the extension of the subintimal dissection within the CTO portion. Results Of 224 CTO lesions (>3 months in duration) undergoing attempted recanalization using the CART technique, 145 cases (64.7%) had undergone previous CTO recanalization attempts. The success rates of crossing in a retrograde fashion with a wire and a balloon were 87.9% and 79.9%, respectively. The overall technical and procedural success rates achieved in this registry were 92.4% and 90.6%, respectively. Conclusions A bilateral approach for CTO lesions using the CART technique is feasible, safe, and has a higher success rate than previous approaches. These results indicate that a bilateral technique can solve a major dilemma that commonly affects CTO procedures.

BACKGROUND Optical coherence tomography (OCT) is a new imaging modality with resolution of approximately 10 microm and can be employed to visualize intracoronary characteristics. Sirolimus-eluting stents (SES) are susceptible to late thrombosis due to delayed re-endothelialization over the stent struts, which may result in acute myocardial infarction or death. This study was designed to evaluate the re-endothelialization and neointimal coverage of SES with OCT 6 months and 12 months after implantation. METHODS A total of 36 patients enrolled in the study underwent OCT examination 6 months (17 patients) and 12 months (19 patients) after SES implantation. The strut apposition to the vessel wall and neointimal coverage on SES struts were evaluated by OCT. RESULTS Forty-six SES and 6561 struts were analyzed. At 6 months, 3041 struts (98.7%) were well-apposed and 39 struts (1.3%) were malapposed. At 12 months, 3434 struts (98.6%) were well-apposed and 47 struts (1.4%) were malapposed. Furthermore, only 4 SES at 6 months (18.2%) and 10 SES at 12 months (41.7%) were fully covered by neointimal growth. The average neointimal thicknesses covering the analyzed struts at 6 months and 12 months were (42+/-28) microm and (88+/-32) microm, respectively. There were 1989 struts at 6 months (72.1%) and 1461 struts at 12 months (45.6%) with neointimal thickness

OBJECTIVES: This study sought to evaluate the diagnostic accuracy of coronary binary in-stent restenosis (ISR) with angiography using 64-slice multislice computed tomography coronary angiography (CTCA) compared with invasive coronary angiography (ICA). BACKGROUND: A noninvasive detection of ISR would result in an easier and safer way to conduct patient follow-up. METHODS: We performed CTCA in 81 patients after stent implantation, and 125 stented lesions were scanned. Two sets of images were reconstructed with different types of convolution kernels. On CTCA, neointimal proliferation was visually evaluated according to luminal contrast attenuation inside the stent. Lesions were graded as follows: grade 1, none or slight neointimal proliferation; grade 2, neointimal proliferation with no significant stenosis ( or =50%); and grade 4, neointimal proliferation with severe stenosis (> or =75%). Grades 3 and 4 were considered binary ISR. The diagnostic accuracy of CTCA compared with ICA was evaluated. RESULTS: By ICA, 24 ISRs were diagnosed. Sensitivity, specificity, positive predictive value, and negative predictive value were 92%, 81%, 54%, and 98% for the overall population, whereas values were 91%, 93%, 77%, and 98% when excluding unassessable segments (15 segments, 12%). For assessable segments, CTCA correctly diagnosed 20 of the 22 ISRs detected by ICA. Six lesions without ISR were overestimated as ISR by CTCA. As the grade of neointimal proliferation by CTCA increases, the median value of percent diameter stenosis increased linearly. CONCLUSIONS: Binary ISR can be excluded with high probability by CTCA, with a moderate rate of false-positive results.

OBJECTIVES The goal of the present study was to compare the accuracy of in vivo tissue characterization obtained by intravascular ultrasound (IVUS) radiofrequency (RF) data analysis, known as Virtual Histology (VH), to the in vitro histopathology of coronary atherosclerotic plaques obtained by directional coronary atherectomy. BACKGROUND Vulnerable plaque leading to acute coronary syndrome (ACS) has been associated with specific plaque composition, and its characterization is an important clinical focus. METHODS Virtual histology IVUS images were performed before and after a single debulking cut using directional coronary atherectomy. Debulking region of in vivo histology image was predicted by comparing pre- and post-debulking VH images. Analysis of VH images with the corresponding tissue cross section was performed. RESULTS Fifteen stable angina pectoris (AP) and 15 ACS patients were enrolled. The results of IVUS RF data analysis correlated well with histopathologic examination (predictive accuracy from all patients data: 87.1% for fibrous, 87.1% for fibro-fatty, 88.3% for necrotic core, and 96.5% for dense calcium regions, respectively). In addition, the frequency of necrotic core was significantly higher in the ACS group than in the stable AP group (in vitro histopathology: 22.6% vs. 12.6%, p = 0.02; in vivo virtual histology: 24.5% vs. 10.4%, p = 0.002). CONCLUSIONS Correlation of in vivo IVUS RF data analysis with histopathology shows a high accuracy. In vivo IVUS RF data analysis is a useful modality for the classification of different types of coronary components, and may play an important role in the detection of vulnerable plaque.

Background Multislice computed tomography (MSCT) is a promising noninvasive method of detecting coronary artery disease (CAD). However, most data have been obtained in selected series of patients. The purpose of the present study was to investigate the accuracy of 64-slice MSCT (64 MSCT) in daily practice, without any patient selection. Methods and Results Using 64-slice MSCT coronary angiography (CTA), 69 consecutive patients, 39 (57%) of whom had previously undergone stent implantation, were evaluated. The mean heart rate during scan was 72 beats/min, scan time 13.6 s and the amount of contrast media 72 mL. The mean time span between invasive coronary angiography (ICAG) and CTA was 6 days. Significant stenosis was defined as a diameter reduction of >50%. Of 966 segments, 884 (92%) were assessable. Compared with ICAG, the sensitivity of CTA to diagnose significant stenosis was 90%, specificity 94%, positive predictive value (PPV) 89% and negative predictive value (NPV) 95%. With regard to 58 stented lesions, the sensitivity, specificity, PPV and NPV were 93%, 96%, 87% and 98%, respectively. On the patient-based analysis, the sensitivity, specificity, PPV and NPV of CTA to detect CAD were 98%, 86%, 98% and 86%, respectively. Eighty-two (8%) segments were not assessable because of irregular rhythm, calcification or tachycardia. Conclusion Sixty-four-MSCT has a high accuracy for the detection of significant CAD in an unselected patient population and therefore can be considered as a valuable noninvasive technique. (Circ J 2006; 70: 564 - 571)

The study aimed to evaluate the efficacy of a novel penetration catheter for severe coronary artery disease. Severe coronary artery diseases such as chronic total occlusions or severe calcified stenoses sometimes obstruct the subsequent crossing of balloon catheter after successful wire crossing. A novel penetration over-the-wire catheter has been developed for severe coronary artery disease. The main shaft is a coreless stainless coil that consists of eight stranded stainless wires to cross through a severe stenosis by manual rotation. This device was applied during percutaneous coronary intervention for patients with severe coronary artery disease obstructing the subsequent crossing of balloon or microcatheters after successful wire crossing. Initial results were examined. Fourteen eligible patients were enrolled consecutively. Among those, 10 patients had chronic total occlusion and 7 patients showed severe angiographical calcification. The device was successfully crossed through the lesion and enabled subsequent dilatation in all patients without any complication. This new device enables the crossing of severe coronary artery stenoses and therefore favors further dilatation in this lesion subset.

We report on two cases of IVUS-guided wiring technique performed on chronic total occlusion using stiffer wires and low-profile intracoronary ultrasound catheter. This technique helped improve a success rate of chronic total occlusion case.

This study was performed to determine the complications occurring during retrograde percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) based on analysis of the multicenter, prospective, nonrandomized Retrograde Summit registry.Retrograde PCI for CTO has improved treatment success rates, but several complications related to the retrograde approach have been reported, including collateral channel injury and donor artery injury due to their use as retrograde roots.This registry included data from 1,166 patients who underwent retrograde PCI for CTO in 28 Japanese centers between January 2009 and December 2011.Overall procedure success and retrograde procedure success were achieved in 985 (84.5%) and 838 (71.9%) of the 1,166 patients, respectively. In-hospital major adverse cardiac and cerebrovascular events (MACCE) occurred in 18 (1.5%) of the 1,166 patients. With regard to complications related to the retrograde approach, channel injury occurred in 111 (9.5%) of the 1,166 patients, but treatment was required in only 24 (2.1%) patients and subsequent cardiac tamponade occurred in only 4 (0.3%) patients. Donor artery problems occurred in only 10 (0.9%) of the 1,166 patients. In sub-analysis regarding the types of collateral channels, the septal channel was significantly safer than epicardial channel because of the lower frequency of non-Q-wave myocardial infarction (non-QMI) and channel injury requiring treatment.The MACCE rate during retrograde PCI for CTO determined from the Retrograde Summit registry was low and the frequency of complications related to the retrograde approach was acceptable. © 2015 Wiley Periodicals, Inc.

Despite recent high success rates owing to the development of new strategies such as the retrograde approach, the procedural complications and their management related percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) have not been fully evaluated. The aim of this study

OBJECTIVES This study focused on 1) the determination of the optimal preconditioning (PC) duration, and 2) the protective effect of nicorandil (NC), a hybrid nitrate with a K atp channel opening effect, during a percutaneous transluminal coronary angioplasty (PTCA) model in humans. BACKGROUND The ischemic PC effect is induced in 180 s ischemia, but not in 120 s ischemia in rabbit hearts. However, the duration of ischemia that induces PC effect and the role of the K atp channel in the PC effect in humans are still unclear. METHODS Forty-six patients with stable angina were randomly allocated to four groups: the duration of the first inflation as PC ischemia was 60 s in the PC60 group (n = 12), and 180 s in the PC180 group (n = 12). In the other groups, NC (80 μg/kg) was intravenously given for 1 min in the NC group (n = 12), and isosorbide dinitrate (ISDN) (40 μg/kg) was given in the ISDN group (n = 10). Five minutes after first inflation or drug administration, a second inflation was conducted for 120 s in each group. In the ECG, the lead with the largest shift in ST segment (deltaST max), and the sum of elevated ST levels in all leads (sigmaST) were determined. RESULTS In the PC60 group, no significant difference was observed in either deltaST max or sigmaST between the first and second inflation. However, the second inflation in the PC180 group showed significantly lower levels of deltaST max and sigmaST compared with those of the first inflation. In the NC group, both deltaST max and sigmaST measured at 30 s and 60 s after balloon inflation were significantly lower than those of the first inflation in the PC60 and PC180 control groups. In the ISDN group, no significant difference was observed in deltaST max or sigmaST. CONCLUSION In human PTCA models, a PC effect is observed in 180 s ischemia, but not in 60 s ischemia. A pharmacological PC effect is induced by NC, a K atp channel opener with a nitrate-like effect but not ISDN. This suggests that the opening of K atp channels plays an important role in the protecting effect of NC.

Background —The process of progression in coronary artery disease is unknown. Methods and Results —The subjects were 36 patients with 36 objective vessels with clinically significant progression of coronary artery disease (≥15% per year) in whom 4 serial coronary arteriograms (CAGs) were performed at intervals of ≈4 months in a 1-year period. The degree of progression of percent stenosis between each of 2 serial CAGs was classified as marked (M: ≥15%), slight (S: 5% to 14%), and no progression (N: P P Conclusions —Two types of stenosis progression provide a new insight into the mechanism of coronary artery disease.

Percutaneous treatment of a bifurcation lesion still shows a significant complication rate, mainly because of restenosis at the ostial site of the side branch vessel. Different techniques, such as V-stenting, culottes-stenting or crush stenting, allow full ostial coverage and may therefore achieve uniform drug distribution within the lesion. The crush technique results in a strong mechanical constraint on the side branch stent. A case of stent strut fracture-induced restenosis in a bifurcation lesion treated with the crush stenting technique is described. (Circ J 2006; 70: 936 - 938)

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, p0.001). 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, p0.001). In conclusion, lipid-lowering therapy by ezetimibe + fluvastatin could increase the fibrous cap thickness of lipid-rich plaque compared with fluvastatin monotherapy.

Background: Japanese patients have been at low risk for cardiovascular events compared with Western countries, but the data regarding current treatment status and rate of subsequent atherothrombotic events after acute coronary syndrome (ACS) are limited in Japanese patients. The objective of this study was to clarify the treatment status and long-term outcomes in Japanese ACS patients. Methods and Results: The Prevention of AtherothrombotiC Incidents Following Ischemic Coronary attack (PACIFIC) registry is a multicenter, prospective observational study of Japanese ACS patients. Consecutive patients aged ≥20 years hospitalized for ACS were enrolled from 96 hospitals and followed up for 2 years (n=3,597). ST-segment elevation myocardial infarction (STEMI) was the most frequent type of ACS (59.4%). The vast majority (93.5%) of patients underwent percutaneous coronary intervention (PCI), with a success rate of 93.9%. Frequent use of guideline-recommended pharmacological treatments was also indicated. Cumulative incidence of major adverse cardiac and cerebrovascular events (MACCE) was 6.4% (7.5% for STEMI and 4.8% for non-STEMI or unstable angina), and all-cause mortality was 6.3%. Conclusions: The PACIFIC registry has identified an incidence of MACCE of 6.4% and that of mortality at 6.3% in Japanese ACS patients at 2-year follow-up. A high proportion of patients underwent PCI, and the PCI success rate was high. Proactively performed successful PCI was considered to have contributed to favorable outcomes in these patients. (Circ J 2013; 77: 934–943)

AIMS The retrograde approach to CTO is promising, but questions remain with regard to its wider application and the potential risks. This study evaluated the feasibility and efficacy of retrograde recanalisation of chronic total occlusion (CTO) of the coronary arteries. METHODS AND RESULTS A total of 378 consecutive patients (previously failed PCI 32.0%) who enrolled in 27 institutions in Japan underwent retrograde recanalisation for CTO. We analysed the data on lesion characteristics, procedural materials, technique used, complications and clinical outcomes. Successful retrograde recanalisation was achieved in 70.4% and the overall procedural success was 83.6%. Collateral crossing was achieved via a septal route in 68.9%, epicardial in 27.2% and bypass grafts in 2.6%, respectively. The retrograde approach was completed with implementation of reverse CART in 42.5%, direct wire crossing in 23.1%, bilateral wiring in 22.7%, and CART in 11.7%. Major and minor collateral injuries and coronary perforations were noted in 1.3%, 10.3% and 2.9% of cases, respectively. Stroke occurred in 0.3%, QWMI and emergency PCI in 0.3% of patients with successful recanalisation. CONCLUSIONS Wider application of retrograde CTO PCI achieved a high rate of success in recanalisation with an acceptable rate of complications in Japan.

糖尿病性腎症による透析導入患者は年々増加の一途を辿っているが, その生存率は低く, 心血管系合併症による死亡例が多い. 糖尿病血液透析患者 (DN) の心合併症は慢性腎炎血液透析患者 (CGN) に比較して, 無痛性心筋虚血や左室拡張機能障害を呈する症例が多く, また冠動脈病変はびまん性で多枝にわたるという特徴を有している. またDNでの予後に心臓自律神経障害の関与している可能性も示唆されているが, 定量的な試みは未だ行われていない. 今回, 我々は心臓交感神経障害の評価に有効であると報告されている123I-metaiodobenzylguanidine (MIBG) を用い, DNでの心臓交感神経障害について検討した.CGN (平均年齢52.6歳) 21名とDN (平均年齢53.9歳) 18名を対象に123I-MIBG心筋シンチグラフィーを施行し, 心臓交感神経障害について検討した. いずれの症例も心筋梗塞の既往がなく, また現在, 明らかな狭心症を呈さず, しかも安静時の201Thallium (TI) 心筋シンチグラムでdefectが証明されない症例である. なお両群の年齢, 透析期間に有意差を認めていない.CGNに比較してDNではSPECT (single-photon emission computed tomography) でdefectを呈する症例が多く認められ, 心臓/上縦隔 (H/M) は低値を示した.以上より, CGNに比較してDNでは心臓交感神経障害が高度かつ高頻度に認められた.

This registry evaluated the current trends and outcomes associated with retrograde percutaneous coronary intervention (PCI) for chronic total occlusion (CTO).Since its introduction, several techniques and technologies have been introduced for retrograde PCI for CTO.Eight hundred and one patients who underwent retrograde PCI for CTO in 28 Japanese centers between January 2009 and December 2010 were enrolled in this registry.Overall procedural and clinical success rates were 84.8 and 83.8%, respectively, of which, retrograde procedures accounted for 71.2 and 70.3%, respectively. The use of channel dilators increased in 2010 compared to that in 2009 (36 vs. 95.3%, P0.0001), attributed improving collateral channel crossing using a wire and catheter (70.6% vs. 81.1%, P = 0.0005) and increased availability of epicardial channels (27.6% vs. 36.9%). The use of the reverse controlled antegrade and retrograde tracking technique also increased (41.9 vs. 66.5%). Although these changes decreased procedure time (203.3 min vs. 187.9 min, P = 0.024), they did not significantly improve overall procedural success rate (84.1% vs. 85.3%, P = 0.63). Multivariate analysis identified age 65 years or more and lesion calcification as unfavorable factors and the use of a channel dilator as a favorable factor for retrograde procedural success.Increased availability of channel dilators has altered strategies for retrograde PCI for CTO. However, retrograde PCI for CTO could be improved by overcoming its main obstacle of severe calcification.

ObjectivesThis 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.BackgroundLandmark 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.MethodsPatients 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).ResultsCTO 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.ConclusionsThe 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.

In recent years, we attained higher procedural success in percutaneous coronary interventions (PCI) for chronic total occlusions (CTO) due to the development of new devices and techniques. We have established the Retrograde Summit with Japanese investigators for the purpose of promoting these

To evaluate the ability of low-dose dobutamine and isosorbite dinitrate (ISDN) gated blood pool scintigraphy (GBPS) and thallium SPECT with reinjection to identify viability in asynergic myocardium, both procedures were performed in 38 consecutive patients with chronic coronary artery disease and left ventricular dysfunction. Twenty-two of the 38 patients with successful revascularization were analyzed. GBPS was performed at the baseline and during continuous infusion of low dose dobutamine (5 micrograms/kg/min) and ISDN (2 micrograms/kg/min). Cine mode GBPS wall motion was scored from normal (0) to dyskinesis (4) semiquantitatively. Forty-seven of 110 segments with severe asynergy at the baseline were analyzed. Viability determined by GBPS was defined as wall motion score improvement by more than 1 grade. Thallium viability was defined as the segment with redistribution or fill in with severe initial perfusion defect. GBPS was 76.7% sensitive and 70.6% specific for predicting post vascularization wall motion improvement (p0.005). Of 47 segments with severe asynergy, concordance of judgement was obtained in 40 segments (85.1%), and reversibility was correctly diagnosed in 34 of 40 patients (85.0%), but thallium with reinjection correctly identified tissue viability in 6 of 7 segments with discordance between 2 studies. These data suggest that most cases of reversible asynergy (hibernating myocardium) respond to ISDN and dobutamine, suggesting the possibility of predicting improvement by revascularization, although some underestimation of tissue viability remained to be resolved. Thallium with reinjection is superior to low-dose dobutamine + ISDN GBPS for the assessment of myocardial viability.

A new 6 French (F) guiding catheter with a large, teflon-coated internal lumen (4.2F) was developed, permitting use of the standard ultralow profile (less than 3F) over-the-wire system. This small coronary angioplasty system (6F-PTCA) was evaluated in 48 lesions in 45 of 137 patients (33%) who underwent coronary angioplasty between September 1990 and January 1991. The mean age was 64 years (range 49 to 82); 37 (82%) were male. The procedure was via the brachial artery in 28 patients (62%). The overall primary success rate was 96%. It was 100% via the brachial artery and 90% via the femoral artery. There were no major complications. The puncture compression time with the 6F-PTCA via the brachial artery and via the femoral and with 8F-PTCA via the femoral was 3.8, 9.6, and 16.9 hr, respectively (P less than 0.001), although the procedure time of the 6F-PTCA via brachial and via femoral and of the 8F-PTCA was not significantly different. The mean hospital stay was 3.1, 4.5, and 5.5 days, respectively (P less than 0.01). A small hematoma occurred in 2 patients (4.4%) after the 6F-PTCA and in 3 (3.3%) after 8F-PTCA, and a large hematoma (greater than 5 cm) was noted in 7 patients (7.6%) after 8F-PTCA. These results indicate that coronary angioplasty using the over-the-wire system through the new 6F guiding catheter is technically feasible. Moreover, this approach, especially when advanced via the brachial artery, could shorten the hemostasis time and facilitate early ambulation.

慢性血液透析 (HD) 患者の脂質代謝異常が動脈硬化症の進展に関与していることが報告されているが, 持続性自己管理腹膜透析 (CAPD) 患老ではHD患者の脂質代謝異常の特徴である高中性脂肪 (TG) 血症, 低HDL-コレステロール (HDL-C) 血症に透析膜によるブドウ糖の負荷と透析膜としての腹膜の特性が加味された病態が予想される.本研究ではIgA腎症, HD患者を対照にCAPD患者の脂質代謝異常について検討した. また高脂血症, 血栓症, 動脈硬化症との関係から注目されているLp(a) についても検討し, 以下の結論が得られた.CAPD患者では, IgA腎症, HD患者に比較して総コレステロール (TC), TG, LDL-コレステロール (LDL-C), 動脈硬化指数, アポリポタンパクB (Apo B), Apo B/A-Iが高く, HDL-CはHD患者と同様に低値を示した. またCAPD患者のLp(a) は高値を示し, 血清アルブミンと逆相関を認めたことから, 肝での合成亢進による可能性が考慮されるが, その機序の詳細は不明である. なおペルサンチン負荷心筋タリウムシンチグラムで心筋虚血が認められたCAPD患者のLp(a) は認められなかった患者に比較して高値を示さなかった.以上よりCAPD患者はIgA腎症, HD患者に比較して脂質代謝の面より動脈硬化促進的であることが示唆された.

The aim of this study was to evaluate the safety and feasibility of a new concept for chronic total occlusion (CTO) recanalization-using a bilateral approach that utilizes a Controlled Antegrade and Retrograde subintimal Tracking (CART) technique.Successful percutaneous recanalization of coronary CTOs results in improved long-term outcomes. The recanalization of CTOs in native coronary arteries no doubt represents one of the most technically challenging of interventional procedures.A total of 224 consecutive patients (mean age 61 +/- 9 years; 86.2% men) were enrolled in this prospective multicenter registry. This technique combines the simultaneous use of antegrade and retrograde approaches. A subintimal dissection is created in both antegrade and retrograde fashion, thereby limiting the extension of the subintimal dissection within the CTO portion.Of 224 CTO lesions (3 months in duration) undergoing attempted recanalization using the CART technique, 145 cases (64.7%) had undergone previous CTO recanalization attempts. The success rates of crossing in a retrograde fashion with a wire and a balloon were 87.9% and 79.9%, respectively. The overall technical and procedural success rates achieved in this registry were 92.4% and 90.6%, respectively.A bilateral approach for CTO lesions using the CART technique is feasible, safe, and has a higher success rate than previous approaches. These results indicate that a bilateral technique can solve a major dilemma that commonly affects CTO procedures.

We sought to report the results of both bench-testing and our first clinical experience with this novel technique.The optimal stenting technique for bifurcation lesions has yet to be defined.This technique works by flaring the proximal side of the stent in side branch out like a flower petal. We tested it in vitro and the resultant stent structure and stent polymer damage was observed in both main branch and side branch with an optical microscopy, multislice computer tomography, intravascular ultrasound, endoscopy, and by electron microscopy. We also applied this technique in 33 patients and assessed patient outcomes up to 9 months prospectively. Drug-eluting stents were used for the bench tests and for all patients.Bench-testing showed complete coverage of the bifurcation with minimal stent-layer overlapping. There was little polymer damage by electron microscopy. Procedural success was achieved in all cases and restenosis occurred in 2 cases. In both restenosis cases, "petal" stenting technique was done reluctantly after another stent had already been deployed in the main branch before any stenting of the side branch. There were no incidences of restenosis when this technique was used electively.In terms of damage to the polymer and ostial strut coverage, this new "flower petal stenting" technique is effective for treatment of bifurcation lesion and it may well be superior to other available techniques.

心房性Na利尿ペプチド (α-hANP) の慢性血液透析 (HD) 患者と持続性自己管理腹膜透析 (CAPD) 患者の臨床的意義, とくにドライウエイトとの関係について検討した.健常者10例 (男性5例, 女性5例, 平均年齢45.6歳), CAPD患者11例 (男性7例, 女性4例, 平均透析歴20.9か月), HD患者10例 (男性5例, 女性5例, 平均透析歴25.4か月) を対象とした. GAPDならびにHD患者の基礎疾患は全例, 慢性糸球体腎炎である. CAPD患者では心臓超音波検査施行日にα-hANPと限外濾過指数 (UFI) を測定した. HD患者ではHD前後に心臓超音波検査を, またHD前後ならびに次回HD前にα-hANPを測定した. また心エコー図法により左房径, 左室心筋重量を求めた.以下の結論が得られた. 1. HD患者のα-hANPは健常者, CAPD患者に比較して上昇していた. 2. 左室心筋重量はCAPDとHD患者で増大していた. CAPD患者に比較してHD患者でその増大傾向は顕著であった. 3. 左房径とα-hANPとの間に有意の正相関が認められた. 4. HDによりα-hANPは減少した. α-hANPの減少率と体重減少率との間に有意の相関が認められた. 5. HD後と次回HD前のα-hANP増加率と体重増加率との間に有意な正相関が認められた. 6. UFIの低下しているCAPD患者のα-hANPは高値を示した.以上よりα-hANPは慢性維持透析患者のドライウエイトの指標になり得るものと思われた. 具体的には, HD後ならびにCAPD中のα-hANP値が50ng/ml以下であればドライウエイトに到達している可能性が高いものと思われる.

Background: The aim of this study is to asses the effect of 12 month treatment with Fluvastatin (60 mg daily) on progression of fibroatheroma in a non-culprit vessel. Methods: This prospective study was performed at 2 centers and designed to enroll 80 patients. Patients were randomized to receive lipid-lowering therapy by Fluvastatin or a lipid lowering diet. All patients with high low-density lipoprotein-cholesterol level (> 140 mg/dl) were included in the Fluvastatin group. Non-culprit vessels were imaged with a 20 MHz phased-array intravascular ultrasound (IVUS) catheter with motorized pull-back system at 0.5 mm/s. Virtual Histology-derived fibroatheroma (VHD-FA) was defined as 1) percent necrotic core area >20%; 2) percent plaque plus media cross-sectional area >40%. For each image, the area of vessel and each plaque component were calculated. At 12-month followup repeat IVUS measurements were performed. Results: A total of 44 VHD-FAs in the Fluvastatin group and 47 VHD-FAs in the control group were detected at baseline. In the Fluvastatin group, fibrous and fibro-fatty areas are significantly decreased, necrotic core did not increase, and there was a significant reduction in atherogenic lipoproteins. In the control group, fibrous, necrotic core and dense calcium areas significantly increased (table ). Conclusion: Lipid-lowering therapy with Fluvastatin prevented progression of coronary fibroatheroma. Laboratory data and IVUS measurements

Virtual Histology (VH) intravascular ultrasound (IVUS) allows differentiation between 4 different tissue phenotypes. However, the current classification tree for analysis cannot differentiate the presence of intramural thrombus. The aim of this study was to evaluate the impact of intramural thrombus for correlative accuracy between in vitro histopathology of coronary atherosclerotic plaque obtained by directional coronary atherectomy and corresponding in vivo tissue characterization obtained by VH IVUS. Coronary IVUS imaging of 30 coronary artery lesions was obtained using a 20-MHz phased-array IVUS catheter with a motorized pull-back system at set 0.5 mm/s. The debulking region of the in vivo histologic image was predicted from comparison between pre- and post–first debulking VH IVUS images. Cross-sectional histologic slices were cut every 0.5 mm starting from the most proximal part of the formalin-fixed debulking tissue. Histologic slices were divided into 2 groups by the presence or absence of pathologic thrombus. A total of 259 in vitro histologic slices were obtained, and pathologic thrombus was detected in 81 slices. Correlation was favorable, with high sensitivity for all plaque components, but specificities for fibrous (thrombus slices vs nonthrombus slices 36% vs 94%) and fibrofatty (9% vs 60%) tissue were lower in thrombus slices. Therefore, predictive accuracies for the 2 plaque components were lower in thrombus slices (fibrous tissue 78% vs 99%, fibrofatty tissue 68% vs 83%, respectively). In conclusion, intramural thrombus was colored as fibrous or fibrofatty by VH IVUS, reducing VH accuracy in these kinds of lesions.