Incidence and treatment of elastic recoil occurring in the 15 minutes following successful percutaneous transluminal coronary angioplasty

Serration Angioplasty Is Associated With Less Recoil in Infrapopliteal Arteries Compared With Plain Balloon Angioplasty

PURPOSE

Recoil following balloon angioplasty of tibial arteries is a known mechanism of lumen loss and widely considered to be a contributing factor in early failure or later restenosis. The Serranator balloon has been designed to provide a controlled lumen gain while minimizing vessel injury. The objective of this study was to assess the ability to define and measure postangioplasty recoil in infrapopliteal arteries and to compare recoil after serration angioplasty and plain balloon angioplasty (POBA).

METHODS

This multi-center, sequential comparative study included patients with de novo or restenotic lesions of infrapopliteal arteries up to 22 cm in length. Patients were enrolled sequentially and underwent alternating POBA or serration angioplasty with Serranator. The study captured angiographic imaging at pre, immediately post, and 15-minute after angioplasty. Vessel recoil, final diameter stenosis, and dissection were compared using core laboratory analysis.

RESULTS

This study enrolled 36 patients who underwent treatment of 39 infrapopliteal lesions. There was no significant difference between Serranator (n=20) and POBA (n=19) with respect to baseline demographics and lesion characteristics. Arterial recoil (>10%) occurred in 25% of Serranator-treated lesions versus 64% in POBA-treated lesions (p=0.02. Clinically relevant recoil (>30%) was present after serration angioplasty in 10% of patients and after POBA in 53% (p=0.01). There was no significant difference in technical success (100% for both), dissection rate between Serranator (5%) and POBA (5.2%).

CONCLUSIONS

Arterial recoil occurs after infrapopliteal angioplasty. Serration angioplasty produces substantially less arterial recoil compared with POBA. Additional studies are needed to assess whether reduced arterial recoil translates into superior long-term clinical outcomes.

CLINICAL IMPACT

Prior studies have demonstrated over 90% recoil in patients after balloon angioplasty (POBA) of the infrapopliteal vessels, which significantly impacts the durability and impact of endovascular interventions in this clinical space. This study compared recoil after infrapopliteal angioplasty with serration angioplasty and POBA. Serration angioplasty produces substantially less arterial recoil compared with POBA. Additional studies are needed to assess whether reduced arterial recoil translates into superior long-term clinical outcomes.

Serial quantitative angiographic study of target lumen enlargement after drug-coated balloon angioplasty for native coronary artery disease

BACKGROUND

Target lumen enlargement (TLE) or "late lumen enlargement" is often encountered after percutaneous coronary intervention (PCI) with drug-coated balloons (DCB). To date, the prognosis of coronary arterial lesions with or without TLE has not been clearly elucidated.

AIMS

This study aimed to assess the long-term prognosis of coronary arterial lesions with or without TLE observed within 1 year (early TLE) after DCB angioplasty using serial quantitative angiographic follow-up.

METHODS

One hundred and ninety-three consecutive patients (de novo coronary arterial lesions, 251) who underwent follow-up angiography within 1 year after DCB angioplasty (early follow-up, median: 6 months) were retrospectively evaluated. Of these, 97 patients (125 lesions) also underwent angiography more than 1 year after DCB angioplasty (late follow-up, median: 37 months). TLE was defined as an increase in minimal lumen diameter (MLD) after PCI at each follow-up.

RESULTS

Early TLE was detected in 142 lesions (56.6%). Of these, 76 lesions were also evaluated at late follow-up. TLE persisted even at late follow-up in 67 of the 76 lesions (88.2%). An increase in MLD in early TLE (+) lesions was observed in the period between post-PCI and early follow-up (1.84 ± 0.06 vs. 2.12 ± 0.07 mm, p < 0.001) but not between early and late follow-up (2.12 ± 0.07 vs. 2.16 ± 0.07 mm, p = 0.74). In contrast, 49 of 109 lesions without early TLE were evaluated at late follow-up, of which 28 lesions (57.1%) showed TLE at late follow-up. The MLD of early TLE (-) lesions (n = 49) significantly increased from early (1.63 ± 0.061 mm) to late follow-up (1.84 ± 0.06 mm) (p < 0.001). No aneurysms were found in any of these cases.

CONCLUSION

Early TLE was observed in more than half of the lesions, with the majority remaining at late follow-up. Alternatively, half of the lesions without early TLE showed late TLE, occurring biphasically after DCB angioplasty.

Efficacy of Low-Pressure Inflation of Oversized Drug-Coated Balloon for Coronary Artery Disease

Objectives

This study sought to assess the efficacy of oversized drug-coated balloon (DCB) inflation at low pressure for the prevention of acute dissections and late restenosis.

Background

The major limitation of DCB coronary angioplasty is the occurrence of severe dissection after inflation of DCB.

Methods

Between 2014 and 2018, 273 consecutive patients were retrospectively studied. 191 lesions (154 patients) treated by oversized DCB inflation at low pressure (<4 atm, 2.4 ± 1.2 atm, DCB/artery ratio 1.14 ± 0.22; LP group) were compared with 135 lesions (119 patients) treated by the standard DCB technique (7.1 ± 2.2 atm, DCB/artery ratio 1.03 ± 0.16; SP group).

Results

Although the lesions in the LP group were more complex than those in the SP group (smaller reference diameter (2.38 mm vs. 2.57 mm, P=0.011), longer lesions (11.7 mm vs. 10.5 mm, P=0.10), and more frequent use of rotational atherectomy (45.0% vs. 28.1%, P=0.003), there was no significant difference in the NHLBI type of dissections between the two groups (11.5%, 12.0%, 5.2% vs. 12.6%, 12.6%, 2.2% in type A, B, and C, P=0.61), and no bailout stenting was required. In 125 well-matched lesion pairs after propensity score analysis, the cumulative incidence of target lesion revascularization at 3 years was 4.5% vs. 7.0%, respectively (P=0.60). Late lumen loss (−0.00 mm vs. −0.01 mm, P=0.94) and restenosis rates (7.4% vs. 7.1%, P=1.0) were similar in both of the groups.

Conclusion

The application of oversized DCB at low pressure is effective and feasible for preventing late restenosis comparative to the standard technique of DCB.

Early Recoil After Balloon Angioplasty of Erection-Related Arteries in Patients With Arteriogenic Erectile Dysfunction

Purpose: To evaluate the incidence of elastic recoil in patients presenting with erectile dysfunction (ED) undergoing endovascular revascularization of the pudendal or penile arteries. Methods: A consecutive series of 21 ED patients (mean age 58.3±9.3 years) undergoing minimally invasive revascularization of 31 arteries was analyzed. ED lesions included the pudendal arteries (n=27) and the penile artery (n=4). Mean lesion length was 20.6±13.9 mm. Minimal lumen diameter (MLD) measurements were assessed at baseline, immediately after balloon angioplasty, and 10 minutes thereafter. Early recoil was defined as an MLD reduction >10%. Elastic recoil with >10% lumen compromise was treated with drug-coated balloons, while severe elastic recoil (>30%) required drug-eluting stents (DES). The International Index of Erectile Function (IIEF-15) score was obtained prior to and 3 months after the procedure to obtain information on functional outcomes subsequent to angioplasty. Results: Mean MLD at baseline was 0.9±0.6 mm, which improved to 2.0±0.9 mm immediately after balloon dilation. At 10 minutes after dilation, the MLD was 1.7±1.0 mm. Elastic recoil was observed in all 31 lesions and resulted in a mean lumen compromise of 21.2%. Severe (>30%) recoil was observed in 14 arteries, which underwent DES therapy. The IIEF-15 score improved from 31.3±11.2 at baseline to 49.8±16.8 (p<0.001) at the 3-month follow-up. Conclusion: Endovascular revascularization constitutes a safe and feasible treatment modality to restore erectile function in patients with arteriogenic ED and ineffective conservative management. Early elastic recoil is very frequent subsequent to balloon dilation of small-caliber erection-related arteries. Thus, mechanical scaffolding with DES is required in a high subset of ED patients to provide favorable early angiographic and clinical results.

Outcomes after drug-coated balloon treatment for patients with calcified coronary lesions

OBJECTIVES

To investigate the efficacy of drug-coated balloon (DCB) for calcified coronary lesions.

BACKGROUND

Calcified coronary lesions is associated with poor clinical outcomes after revascularization. Recently, DCB is emerging as an alternative strategy for de novo coronary lesions. However, reports describing the efficacy of DCB for calcified coronary lesions are limited.

METHODS

A total of 81 patients (96 lesions) who electively underwent DCB treatment for de novo coronary lesions were enrolled: 46 patients (55 lesions) in the calcified group and 35 patients (41 lesions) in the non-calcified group. Angiographic follow-up data and clinical outcomes after the procedure were evaluated.

RESULTS

The diameter of the DCB used was 2.5 ± 0.5 mm. No bail-out stenting was observed after DCB treatment. Rotational atherectomy was used in 82% of lesions in the calcified group. Follow-up angiography (median, 6.5 months after intervention) was performed for 59 patients (30 in the calcified group and 29 in the non-calcified group). Late lumen loss and rates of restenosis were comparable between the groups (0.03 mm in the calcified group vs -0.18 mm in the non-calcified group, P = 0.093 and 13.9% vs 3.03%, P = 0.095, respectively). The survival rates for target lesion revascularization free survival and major adverse cardiac events at 2 years were comparable between the groups (85.3% vs 93.4%, P = 0.64 and 81.4% vs 88.5%, P = 0.57, respectively).

CONCLUSION

Calcified coronary lesions might dilute the effect of DCB. However, clinical outcomes in the calcified group were similar to those in the non-calcified group.

Does patency matter in patients with critical limb ischemia undergoing endovascular revascularization?

Restenosis is the major drawback in patients undergoing tibial angioplasty. In contrast to earlier observations, tibial patency was shown to impact on clinical outcomes in current randomized trials and is thus attributed more importance. Accordingly, intentions to reduce tibial restenosis have been intensified. Both drug-eluting balloons (DEB) and drug-eluting stents (DES) were shown to reduce tibial restenosis when compared with its plain counterparts. However, both endovascular technologies have its limitations for tibial arterial application. While DEB technology may not address elastic recoil, a pathophysiological mechanism frequently observed in tibial arteries and a significant contributor to restenosis, currently available DES do not fully address tibial arterial lesion morphology. Purpose of the present manuscript is to outline the problem and the incidence of tibial arterial restenosis, its importance on clinical outcomes and to provide an overview on technical developments aimed at its prevention.

Decrease of fractional flow reserve shortly after percutaneous coronary intervention

BACKGROUND

The aim of the present study was to quantitatively assess the physiological acute recoil after percutaneous coronary intervention (PCI), and to determine the relation between it and target lesion revascularization (TLR) in the chronic phase.

METHODS AND RESULTS

This study evaluated 76 patients who underwent elective PCI between May 1997 and December 2001: plain old balloon angioplasty (POBA) in 50 patients and bare metal stent implantation in 26 patients. Fractional flow reserve (FFR) was measured immediately (FFR0m) and 15 min (FFR15m) after the final dilation, and the difference (dif-FFR) was calculated. In POBA patients with TLR, FFR15m was significantly low (0.79+/-0.05 vs 0.87 +/-0.08, p<0.001) and dif-FFR was significantly high (0.06+/-0.04 vs -0.01+/-0.04, p<0.001) compared with the patients without TLR. The patients with a larger dif-FFR value (> or =0.05) had a higher rate of TLR (92%). Dif-FFR was the strongest independent predictor of TLR.

CONCLUSIONS

The changes in FFR during the time course shortly after coronary intervention can be detected and a decrease in the first 15 min after PCI is associated with a higher rate of TLR.

Effect of estrogen on coronary vasoconstriction in patients undergoing coronary angioplasty

BACKGROUND

Estrogen has an antioxidant potential which may contribute to its cardioprotective effect. We sought to determine whether estrogen administration can affect coronary vasomotor tone in patients after angioplasty by reducing 8-iso-prostaglandin (PG) F(2alpha) concentrations, a bioactive product of lipid peroxidation.

METHODS

The study was designed to prospectively investigate 30 consecutive patients scheduled for elective coronary angioplasty. Patients were randomized into two groups according to whether they did not (group 1, n = 15) or did have (group 2, n = 15) intracoronary (i.c.) treatment with estrogen prior to coronary angioplasty.

RESULTS

There were no significant differences of collateral circulation assessed by intracoronary Doppler flow velocity during balloon inflations between the study groups. The diameters of the coronary artery at the dilated and distal segments were significantly reduced 15 min after dilation compared with those immediately after dilation in group 1 (both P < 0.0001). The vasoconstriction was significantly blunted in group 2. The 8-iso-PGF(2alpha) levels in plasma from the coronary sinus rose significantly from 194 +/- 45 to 390 +/- 97 pg/ml (P < 0.0001, 95% confidence intervals = 142-249 pg/ml) 15 min after angioplasty in group 1, which was attenuated after administering estrogen. Significant correlation was found between the changes of coronary vasomotion of the dilated segment and 8-iso-PGF(2alpha) levels in group 1 (r = 0.73, P = 0.002).

CONCLUSIONS

8-iso-PGF(2alpha) is released into the coronary circulation during angioplasty, and this vasoactive substance may contribute to the occurrence of vasoconstriction. Estrogen administration attenuated vasoconstriction by reducing the 8-iso-PGF(2alpha) levels. This finding may provide a new strategy to treat coronary vasoconstriction after angioplasty.

Differential role of K(ATP) channels activated by conjugated estrogens in the regulation of myocardial and coronary protective effects

BACKGROUND

We have demonstrated that estrogen can reduce myocardial injury in ischemia-reperfusion via activation of ATP-sensitive potassium (K(ATP)) channels. We sought to determine whether the protective effect of estrogen extends to epicardial coronary artery with attenuated vasoconstriction in patients after angioplasty by activation of such channels.

METHODS AND RESULTS

The study was designed to prospectively investigate 41 consecutive patients scheduled for elective coronary angioplasty. Pretreatment with estrogen limited myocardial ischemia during coronary occlusion and attenuated postangioplasty coronary vasoconstriction at the dilated and distal segments. An inhibitor of K(ATP) channels, glibenclamide, did not affect coronary vasomotor response, although it abolished the beneficial effect of estrogen on myocardial ischemia. Patients to whom estrogen was administered after the second balloon deflation experienced a similar magnitude of myocardial ischemia as controls but showed significantly attenuated vasoconstriction compared with controls (P=0.0001). Endothelin-1 levels from the great cardiac vein rose significantly from 1.9+/-0.4 to 3.1+/-0.6 pg/mL (P=0.001) 15 minutes after angioplasty in the control group; this was attenuated after estrogen was administered. Significant correlation was found between the changes in coronary vasomotion of the dilated segment and endothelin-1 levels (r=0.65, P<0.0001).

CONCLUSIONS

These results demonstrate that estrogen is protective against both myocardial ischemia and coronary vasoconstriction through different mechanisms. The myocardial effect of estrogen was abolished by glibenclamide, which suggests that the cardioprotective effect of estrogen may result from activation of K(ATP) channels. In contrast, estrogen-induced attenuated vasoconstriction is associated with an attenuated release of endothelin-1, independent of K(ATP) activation.

The effects of vasodilators on the relaxation of guinea-pig aorta during acute recoil

BACKGROUND

We have investigated the effects of various vasodilators on smooth muscle relaxation during acute recoil with guinea-pig aorta to find effective therapies to prevent acute recoil at percutaneous transluminal coronary angioplasty (PTCA).

METHODS

Muscle strips from guinea-pig aorta without endothelium were placed in a bath filled with modified Krebs solution. The strip was isotonically stretched with a tension of 9 mN for 1 min, and then isometric tension was measured until the tension reached a steady state. Various vasodilators were applied during isometric tension measurement.

RESULTS

When no drug was applied (control), isometric tension reached a steady state within 20 min. The steady state was approximately 10% lower (more relaxed) than the stretched level. When isosorbide dinitrate (ISDN, 1 mM) was applied during isometric measurement, 18.7+/-5.3% greater relaxation occurred than in control relaxation (P<0.05, n=5). When nicorandil (1 mM) was applied, the following relaxation was 18.6+/-5.7% greater than control (P<0.05, n=8). The simultaneous application of glibenclamide (1 mM) completely inhibited such additional relaxation by nicorandil. Application of nifedipine (10 microM) caused a 12.9+/-2.5% greater relaxation than control (P=0.066, n=4). The first metabolite of sarpogrelate (BP984, 10 microM) caused much greater relaxation than control (23.7+/-7.9%, P<0.05, n=6). Amlodipine (10 microM), phentolamine (10 microM), and sarpogrelate (10 microM) had no influence on the relaxation of the strip.

CONCLUSIONS

ISDN, nicorandil and BP984 significantly increase relaxation of the muscle strips after stretching compared to the control. These vasodilators may reduce acute recoil of the smooth muscle after PTCA.

Failure of prolonged dilation to improve long-term patency of femoropopliteal artery angioplasty: results of a prospective trial

PURPOSE

To determine long-term patency of femoropopliteal artery percutaneous transluminal angioplasty (PTA) in a prospective trial during which prolonged balloon inflation was used for optimization of initial results.

MATERIALS AND METHODS

Femoropopliteal PTA was performed in 112 limbs of 97 patients. The mean total length of the treated segments was 7.2 cm (95% CI: 5.99-8.46; median: 5.5 cm). In cases of unsatisfactory primary results after standard dilation for 1-3 minutes, the procedure was continued with prolonged dilation (93 limbs; mean balloon inflation time: 31 min; 95% CI: 24.2-37.7; median: 15 min) with use of the same balloon catheter (77 limbs) or a perfusion balloon catheter (35 limbs). Thirty-four proximal infrapopliteal artery stenoses were treated to improve peripheral runoff and 12 short stents were placed because of flow-limiting dissections.

RESULTS

Primary hemodynamic success established by Doppler ultrasound (US) criteria was achieved in 92.9% (104 of 112) of the limbs. Three major complications were encountered; none were related to prolonged balloon inflation. The primary patency rate according to Kaplan-Meier analysis was 42% (+/-5% SE) at 1 year and 39% (+/-5%) at 2 and 3 years. The corresponding secondary patency rates were 51% (+/-5%) and 47% (+/-5%). Large numbers of diseased vessels in the treated limb (four to 10 instead of one to three), eccentric lesions (as opposed to concentric morphology), and additional treated segments (instead of only femoropopliteal lesions) were associated with poorer long-term patency. The duration of balloon dilation was not a determinant of long-term patency.

CONCLUSION

Although prolonged dilation is safe and feasible in femoropopliteal artery PTA, its routine use is not warranted because it does not result in superior long-term patency rates.

Oestrogen attenuates coronary vasoconstriction after angioplasty: role of endothelin-1

BACKGROUND AND AIMS

There were controversies as to whether endothelin-1 is released after coronary angioplasty. We sought to determine whether endothelin-1 is released after coronary angioplasty and whether oestrogen administration can affect coronary vasomotor tone by reducing endothelin-1 concentrations.

METHODS

The study was designed to prospectively investigate 24 consecutive patients scheduled for elective coronary angioplasty. Patients were randomized into two groups according to whether they did not (group 1, n = 12) or did (group 2, n = 12) have intracoronary treatment with oestrogen. Quantitative coronary angiography was monitored at baseline, immediately after successful angioplasty, and 15 min after the last deflation. Blood samples for measuring the levels of endothelin-1 were drawn from the ascending aorta and the coronary sinus simultaneously before angioplasty and 15 min after balloon dilatation.

RESULTS

The diameters of the coronary artery at the dilated segments were significantly reduced 15 min after dilation compared with those immediately after dilation in group 1 from 3.20 +/- 0.22 to 2.30 +/- 0.23 mm (P < 0.001), respectively. The vasoconstriction was significantly blunted in group 2. The endothelin-1 levels from the coronary sinus rose significantly, by 29%, 15 min after angioplasty in group 1, which was attenuated after administering oestrogen. Significant correlation was found between the changes of coronary vasomotion of the dilated segment and endothelin-1 levels (r = 0.70, P = 0.01).

CONCLUSION

Endothelin-1 is released into the coronary circulation after angioplasty, and this vasoactive substance may contribute to the occurrence of vasoconstriction. The vasoconstriction is attenuated by oestrogen by reducing the endothelin-1 levels. This finding provided a new strategy to treat coronary vasoconstriction after angioplasty.

In vivo assessment of stent recoil in normal porcine arteries: evaluation of contemporary stent designs

Acute stent recoil has been observed following balloon deflation in normal and diseased coronary arteries, and the magnitude varies by stent design. We sought to evaluate acute stent recoil in five new stents. Twenty-five stents (four Crown, five Nir Conformer Royale, five Crossflex, five SupraG, and six GFX) were implanted in six Yorkshire pigs. All stents were expanded using a noncompliant balloon (balloon:artery ratio 1.2:1.0). Continuous ultrasound imaging was performed during stepwise balloon inflation and deflation using a 0.018" imaging core. Maximum cross-section areas (CSA) and minimal luminal diameter (MLD) were measured at 12 atm and immediately following balloon deflation. Maximum stent CSA matched expected balloon CSA. Area and diameter recoil were calculated as 1 - (CSAdeflation/CSAmax) and 1 - (MLDdeflation/MLDmax), respectively. Upon deflation, all stents showed recoil from maximal CSA. Area recoil was significantly lower for slotted-tube stents than modular stents (12.6% +/- 1.6% vs. 23.2 +/- 3.5%; P < 0.05). In compliant, nonatherosclerotic porcine coronary arteries, acute stent recoil for the four slotted-tube designs ranged from 8.4% to 18.0% by area. The modular stent tested was associated with significantly greater acute recoil than the slotted-tube stents.

Exaggerated luminal loss a few minutes after successful percutaneous transluminal coronary angioplasty in patients with recent myocardial infarction compared with stable angina: an intracoronary ultrasound study

This study investigates the mechanisms of exaggerated acute luminal loss after successful coronary angioplasty in patients with recent myocardial infarction compared with stable angina by angiography and intracoronary ultrasound (ICUS). We studied 15 consecutive patients (group 1) who, after a successful thrombolysis for myocardial infarction, underwent delayed (8 +/- 2 days after the myocardial infarction) successful balloon coronary angioplasty. Group 1 patients were individually matched with 15 stable angina patients (group 2). The percentage of stenosis and acute luminal loss were measured by quantitative coronary analysis. The ultrasound characteristics of lumen pathology were described as soft, hard, calcified, eccentric, concentric, thrombotic, and dissection lesions. Matching by stenosis location, reference diameter, sex, and age resulted in 2 comparable groups of 15 lesions with identical baseline characteristics. Immediately after percutaneous transluminal coronary angioplasty (PTCA), the minimal luminal diameter increased from 0.5 +/- 0.3 mm to 2.4 +/- 0.3 mm and from 0.5 +/- 0.2 mm to 2.4 +/- 0.3 mm in groups 1 and 2, respectively. Similar balloon sizes were used in both groups. The acute luminal loss (the difference between the maximal dilated balloon diameter and the minimal luminal diameter) immediately after PTCA was 0.4 +/- 0.2 mm and 0.3 +/- 0.3 mm (14 +/- 8% and 10 +/- 11% of balloon size) (P = not significant [NS]) in groups 1 and 2, respectively. After ICUS (mean 24 min after the last balloon deflation), the acute luminal loss was 0.9 +/- 0.3 mm and 0.5 +/- 0.4 mm (29 +/- 11% and 17 +/- 8% of balloon size) (P = 0.01) in groups 1 and 2, respectively. There was a significantly higher prevalence of intracoronary thrombus formation as detected by ICUS in group 1 compared with group 2 (80% vs. 20%; P < 0.001). In matched groups of successfully treated coronary angioplasty, patients with recent myocardial infarction had a similar magnitude of acute gained luminal loss immediately after the procedure. However, an exaggerated luminal loss a few minutes after the last balloon deflation in patients with recent myocardial infarction was noted because of mural thrombus formation compared with patients with stable angina.