Sirolimus-eluting stent implantation for ostial right coronary artery lesions: five-year outcomes from the j-Cypher registry

Nano-drug delivery system of natural products for disease prevention and treatment

INTRODUCTION

Natural products, derived from plants, animals, and microorganisms, offer a wide range of pharmacological activities, including anti-infective, antifungal, anti-tumor, cholesterol-lowering, and anti-inflammatory effects. However, their clinical use is often limited by challenges such as low stability, poor bioavailability, and short half-lives. Thus, developing effective drug delivery systems for these compounds is crucial.

AREAS COVERED

This review highlights the integration of natural products with nano-drug delivery systems, focusing on recent advancements that utilize the enhanced permeability and retention (EPR) effect to improve their stability, bioavailability, and targeting. By embedding natural compounds into polymeric nanoparticles or similar nanoplatforms, these formulations significantly enhance pharmacokinetic and pharmacodynamic properties, overcoming traditional limitations.

EXPERT OPINION

Combining natural products with nanoparticle technology shows great potential to expand their therapeutic applications. Although these innovations improve the pharmacological profiles of natural compounds, continued research is essential to optimize clinical use. Advances in nanoparticle design and delivery strategies will be key to maximizing the therapeutic potential of natural products, addressing existing challenges, and enhancing their efficacy in disease treatment.

Demystifying the Quandary of Ostial Stenting

Accurate stent placement is known to be hampered by the anatomical nature of percutaneous coronary intervention (PCI) of ostial lesions, such as aorta-ostial lesions and Medina 001 bifurcation lesions. The Ostial Pro device, the aorta floating wire technique, the stent pull-back technique, the Szabo (tail-wire) techniques, the marker wire technique, the T-stent and small protrusion technique, the cross-over 1-stent technique, and new dedicated ostial stents are some of the techniques used to achieve perfection in precise ostial stent placement. The current state of knowledge about ostial PCI and novel approaches for optimizing these procedures are compiled in this review.

Treatment of Ostial Right Coronary Artery Narrowings: Outcomes From the Multicenter Prospective e-ULTIMASTER Registry

Background

Treatment of right coronary artery (RCA) aorto-ostial (AO) lesions with bare-metal stents and first-generation drug-eluting stents (DES) was associated with worse outcomes. This study aimed to assess the effect of RCA-AO stenting with current-generation DES on the clinical outcome.

Methods

The large all-comer, multicontinental e-ULTIMASTER registry included 37,198 patients of whom 4775 underwent ostial and proximal RCA percutaneous coronary intervention (PCI) using the Ultimaster stent (Terumo). The primary clinical end point was 1-year target lesion failure (TLF), a composite of cardiac death; target vessel-related myocardial infarction; or clinically indicated target lesion revascularization.

Results

We compared 591 (12.4%) patients who underwent RCA-AO PCI with 4184 (87.6%) patients who underwent proximal RCA PCI. The RCA-AO group included more men and recorded significantly more comorbidities and more complex coronary anatomy. After propensity matching, the primary end point TLF occurred in 4.49% of the RCA-AO group compared with 3.00% of the proximal RCA group (P = .06). Target vessel revascularization (3.29% vs 1.90%; P = .03) and stent thrombosis (1.23% vs 0.42%, P = .01) were significantly higher among patients with RCA-AO lesions than those among patients with proximal RCA lesions. All-cause mortality was similar between the groups (2.97% vs 2.26%; P = .30).

Conclusions

The treatment of RCA-AO with DES is feasible, with similar rates of TLF but with an increased risk of target vessel revascularization and stent thrombosis.

Clinical expert consensus document on rotational atherectomy from the Japanese association of cardiovascular intervention and therapeutics: update 2023

The Task Force on Rotational Atherectomy of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) proposed the expert consensus document to summarize the techniques and evidences regarding rotational atherectomy (RA) in 2020. Because the revascularization strategy to severely calcified lesions is the hottest topic in contemporary percutaneous coronary intervention (PCI), many evidences related to RA have been published since 2020. Latest advancements have been incorporated in this updated expert consensus document.

Clinical Outcomes after Additional Dynamic Renal® Stent Implantation for Stent Recoil in Ostial Coronary Lesions

Background: Interventional treatment of aorto-ostial coronary stenoses is limited by stent recoil and suboptimal angiographic results, leading to restenosis and frequent re-interventions. As a potential bail-out strategy for stent recoil, implantation of an additional stent to increase radial force has been reported. Thus, we sought to investigate clinical outcomes after additional implantation of a Dynamic Renal^® stent (DRS), a non-coronary; bare-metal stent with very high radial force, in aorto-ostial coronary stenoses. Methods: Patients treated by implantation of DRSs for stent recoil in the ostial right coronary artery or the left main stem were identified from the hospital database. Baseline clinical and procedural characteristics were compared to patients who underwent re-intervention for in-stent-restenosis in similar segments by either implantation of conventional drug-eluting stents (DES) or paclitaxel-coated balloons (PCB). Clinical follow-ups were performed up to three years following re-intervention with the assessment of death, target lesion reintervention (TLR), and major adverse cardiac events (MACE) as a combination death, myocardial infarction and target vessel revascularization. Kaplan–Meier analyses were performed for event-free survival between the three groups. Results: Between 05/2013 and 07/2019, 28 patients underwent DRS implantation of aorto-ostial coronary lesions. In comparison with 49 patients with DES implantation and 29 patients undergoing PCB treatment, no relevant differences in baseline parameters were identified. Median follow-up was 714 days, with an available follow-up of >1 year after intervention in 82.1% of patients. In the entire study cohort at two years after re-intervention, the TLR rate was 16% (17 patients), the MACE rate 37% (39 patients), and all-cause mortality 9% (10 patients), with no significant differences between the three groups. Conclusions: DRS implantation for treating stent recoil of aorto-ostial coronary lesions resulted in a high rate of TLR, and was associated with similar risk for death and MACE compared to treatment of in-stent-restenosis with DES or PCB. Randomized, larger comparisons of contemporary DES in patients exclusively presenting with stent recoil are necessary to further define the efficacy and safety of this approach.

Clinical expert consensus document on rotational atherectomy from the Japanese association of cardiovascular intervention and therapeutics

Rotational atherectomy (RA) has been widely used for percutaneous coronary intervention (PCI) to severely calcified lesions. As compared to other countries, RA in Japan has uniquely developed with the aid of greater usage of intravascular imaging devices such as intravascular ultrasound (IVUS) or optical coherence tomography (OCT). IVUS has been used to understand the guidewire bias and to decide appropriate burr sizes during RA, whereas OCT can also provide the thickness of calcification. Owing to such abundant experiences, Japanese RA operators modified RA techniques and reported unique evidences regarding RA. The Task Force on Rotational Atherectomy of the J apanese Association of Cardiovascular Intervention and Therapeutics (CVIT) has now proposed the expert consensus document to summarize the contemporary techniques and evidences regarding RA.

Association of Excessive Speed Reduction with Clinical Factors During Rotational Atherectomy

BACKGROUND

Although the manufacturer recommends that excessive speed reduction (>5000 rpm) be avoided during rotational atherectomy (RA) for safety, excessive speed reduction is sometimes observed in clinical practice. The purpose of the present study was to examine the factors associated with excessive speed reduction during RA.

METHODS

Lesions (n = 300) treated by RA were divided into 3 groups: a mild speed reduction group (≤5000 rpm) (n = 182), a moderate speed reduction group (>5000-≤10,000 rpm) (n = 97), and a severe speed reduction group (>10,000 rpm) (n = 21). Two multivariate logistic regression analyses was performed to investigate the factors associated with >5000 rpm speed reduction, and factors associated with >10,000 rpm speed reduction.

RESULTS

Multivariate logistic regression analysis revealed that an ostial right coronary artery (RCA) lesion (OR 6.13, 95% CI 1.82-20.70, P = 0.004) and total ablation time (every 10 s increase: OR 1.09, 95% CI 1.05-1.14, P < 0.001) were significantly associated with >5000 rpm speed reduction. An ostial RCA lesion (OR 14.17, 95% CI 3.85-52.23, P < 0.001), use of intra-aortic balloon pump support (OR 4.19, 95% CI 1.18-14.87, P = 0.03), and systolic blood pressure just before RA (every 10 mmHg increase: OR 1.25, 95% CI 1.02-1.52, P = 0.03) were significantly associated with >10,000 rpm speed reduction.

CONCLUSIONS

RA of ostial RCA lesions was significantly associated with excessive speed reduction during RA, which implies that RA of ostial RCA lesions is technically more difficult than RA of non-ostial RCA lesions.

Efficacy of biolimus A9-eluting stent for treatment of right coronary ostial lesion with intravascular ultrasound guidance: a multi-center registry

The aim of this study was to assess the efficacy of a biolimus A9-eluting stent in patients with a right coronary artery (RCA) ostial lesion. Ostial lesions of the RCA have been a limitation of percutaneous coronary intervention even in the drug-eluting stent (DES) era. However, clinical outcomes after the deployment of a second generation DES to an RCA ostial lesion with intravascular ultrasound (IVUS) guidance have not been fully elucidated. From September 2011 to March 2013, 74 patients were enrolled in 17 centers from Japan. RCA ostial lesion was defined as de novo significant stenotic lesion located within 15 mm from ostium. IVUS was used for all cases to confirm the location of ostium and evaluate stent coverage of ostium. Patients with hemodialysis were excluded. The primary endpoint is a major adverse cardiac event (MACE) at 1 year. Forty two percent of patients had multi-vessel disease. Angiographically severe calcification was observed in 26% of the lesions. The mean stent diameter was 3.3 ± 0.3 mm (3.5 mm, 72%, 3.0 mm, 25%, and 2.75 and 2.5 mm, 3%), stent length was 17.5 ± 5.8 mm, and dilatation pressure of stenting was 15.6 ± 4.1 atm. RCA ostium was covered by stent in all lesions in IVUS findings. Post dilatation was performed for 64% of lesions (balloon size 3.7 ± 0.6 mm). MACE rate at 1 year was 5.4% (target lesion revascularization 5.4%, myocardial infarction 1.2%, and no cardiac death). The biolimus A9-eluting stent for RCA ostial lesions with IVUS guidance showed favorable results at 1-year follow-up.

Outcomes of First- Versus Second-Generation Drug-Eluting Stent Implanted for Right Coronary Artery Ostial Narrowing

Clinical outcome is generally poor when stents are implanted at right coronary artery ostial lesion (RCAos). We compared the clinical outcome between the first-generation drug-eluting stent (first DES) and second-generation drug-eluting stent (second DES) used for RCAos. Consecutive 88 patients who underwent percutaneous coronary interventions of de novo RCAos using the first DES (33 patients) or second DES (55 patients) were analyzed. The incidence of major adverse cardiac events (MACE) defined as the composite of cardiac death, myocardial infarction attributed to right coronary artery, and target lesion revascularization within 2.5 years was compared. The incidence of MACE was significantly lower in second DES (11% vs 36%, p = 0.010) than that in the first DES. Multivariate analysis revealed use of second DES (odds ratio 0.24, 95% CI 0.11 to 0.93, p = 0.008) alone was significantly associated with MACE. In conclusion, second DES revealed better clinical outcome than the first DES when used in de novo RCAos.

Late Restenosis After Both First-Generation and Second-Generation Drug-Eluting Stent Implantations Occurs in Patients With Drug-Eluting Stent Restenosis

Background—

There are currently inadequate data about whether late restenosis occurs after drug-eluting stent (DES) implantation in patients with DES restenosis.

Methods and Results—

We collected data for 608 patients who received revascularization for DES restenosis between 2004 and 2012 and analyzed 688 lesions: 359 lesions treated with a first-generation DES (first DES) and 329 lesions treated with a second-generation DES (second DES). Two serial angiographic follow-ups were routinely planned for the patients (at 8 and 20 months after the procedure). Early follow-up angiography was performed for 620 lesions (90.1%), and recurrent restenosis occurred in 84 lesions (25.8%) in the first DES group and in 72 lesions (24.5%) in the second DES group ( P =0.78). Target lesion revascularization was performed for 69 lesions (21.2%) in the first DES group and for 48 lesions (16.3%) in the second DES group ( P =0.15). Late follow-up angiography was performed for 438 (87.1%) of the remaining 503 lesions (excluding target lesion revascularization lesions), and late restenosis was found in 35 lesions (15.8%) in the first DES group and in 28 lesions (14.7%) in the second DES group ( P =0.79). Nonfocal-type restenosis, percentage diameter stenosis after the procedure, previous stent size ≤2.5 mm, and right coronary artery ostial lesion were independent predictors of early restenosis. Nonfocal-type restenosis, percentage diameter stenosis at early follow-up, and stent fracture were independent predictors of late restenosis.

Conclusions—

Late restenosis occurs after both first DES implantation and second DES implantation for DES restenosis.

Incidence, predictive factors, and clinical impact of stent recoil in stent fracture lesion after drug-eluting stent implantation

BACKGROUND

Stent fracture (SF) after drug-eluting stent (DES) implantation was reported to be associated with target lesion revascularization (TLR). We have noted abnormal late acquired stent axial deformation in lesions after DES implantation, especially in SF lesions, and defined it as stent recoil (SR). We evaluated the incidence, predictive factors, and clinical impact of SR in SF lesions.

METHODS

Between 2003 and 2012, 5456 patients (11,712 lesions) underwent DES implantations and follow-up angiography within one year after the index procedure. SR was defined as an axial recoil deformation less than 80% of the stent diameter and SF was defined as the separation of stent segments or stent struts. SF and SR were confirmed by follow-up angiography. The primary endpoint was defined as clinically driven TLR.

RESULTS

SF was observed in 494 lesions (4.2%) and SR in 138 of SF lesions (27.9%). According to multinomial logistic regression analyses, severe calcification and ostial lesion in the right coronary artery were stronger predictive factors of SF with SR lesions. The cumulative incidences of any and clinically driven TLR at 5years were both significantly higher in the SF with SR group than in the SF without SR group (51.7% versus 35.0%, P<0.001; 22.2% versus 12.8%, P=0.019; respectively).

CONCLUSIONS

SR in SF lesions after DES implantation could be related to the lesion characteristics. SF with SR was highly associated with subsequent TLR compared with SF without SR.

Comparison of floating wire and single wire techniques in right coronary ostial lesions in terms of procedural features and one-year clinical follow-up results

Objective:

The floating wire technique is a special technique for solving interventional problems in aortaostial lesions. There are no long-term data in the literature for the floating wire technique in right aorto-ostial lesions.

Methods:

One hundred twenty six patients were retrospectively analyzed in this study. All of these patients had a critical right coronary aortoostial lesion. The floating wire technique was performed on 64 patients, and the single wire technique was performed on 62 patients. The two groups were compared with each other in terms of lesional and procedural properties. Additionally, 1-year clinical follow-up results were compared between the two groups.

Results:

There was no significant difference in terms of lesion properties between the groups. In the floating wire group, mean stent length, number of stents, mean procedure time, mean contrast volume, and mean fluoroscopy time were significantly lower than in the single wire group. At 1 year, 1 patient from each group had myocardial infarction, and no mortality was observed. In the floating wire group, the number of patients who experienced angina and the target lesion revascularization rate were both significantly lower than in the single wire group.

Conclusion:

The floating wire technique in right coronary ostial lesions provides a significant advantage over the single wire technique according to procedural and clinical follow-up results.