Crystalline sirolimus-coated balloon (cSCB) angioplasty in an all-comers, patient population with stable and unstable coronary artery disease including chronic total occlusions: rationale, methodology and design of the SCORE trial

BACKGROUND

A decade ago, the iopromide-paclitaxel coated balloon (iPCB) was added to the cardiologist's toolbox to initially treat in-stent restenosis followed by the treatment of de novo coronary lesions. In the meantime, DES technologies have been substantially improved to address in-stent restenosis and thrombosis, and shortened anti-platelet therapy. Recently, sirolimus-coated balloon catheters (SCB) have emerged to provide an alternative drug to combat restenosis.

METHODS

The objective of this study is to determine the safety and efficacy of a novel crystalline sirolimus-coated balloon (cSCB) technology in an unselective, international, large-scale patient population. Percutaneous coronary interventions of native stenosis, in-stent stenosis, and chronic total occlusions with the SCB in patients with stable coronary artery disease or acute coronary syndrome were included. The primary outcome variable is the target lesion failure (TLF) rate at 12 months, defined as the composite rate of target vessel myocardial infarction (TV-MI), cardiac death or ischemia-driven target lesion revascularization (TLR). The secondary outcome variables include TLF at 24 months, ischemia driven TLR at 12 and 24 months and all-cause death, cardiac death at 12 and 24 months.

DISCUSSION

Since there is a wealth of patient-based all-comers data for iPCB available for this study, a propensity-score matched analysis is planned to compare cSCB and iPCB for the treatment of de novo and different types of ISR. In addition, pre-specified analyses in challenging lesion subsets such as chronic total occlusions will provide evidence whether the two balloon coating technologies differ in their clinical benefit for the patient.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT04470934.

Surgical treatment of choanal atresia with transnasal endoscopic approach with stentless single side-hinged flap technique: 5 year retrospective analysis

INTRODUCTION

Choanal atresia is a rare congenital malformation of the nasal cavity characterized by the complete obliteration of the posterior choanae. In 67% of cases choanal atresia is unilateral, affecting mainly (71%) the right nasal cavity. In contrast to the unilateral form, bilateral choanal atresia is a life-threatening condition often associated with respiratory distress with feeding and intermittent cyanosis exacerbated by crying. Surgical treatment remains the only therapeutic option.

OBJECTIVE

To report our experience in the use of a transnasal endoscopic approach with stentless single side-hinged flap technique for the surgical management of choanal atresia.

METHODS

A 5 year retrospective analysis of surgical outcomes of 18 patients treated for choanal atresia with a transnasal technique employing a single side-hinged flap without stent placement. All subjects were assessed preoperatively with a nasal endoscopy and a Maxillofacial computed tomography scan.

RESULTS

Ten males and eight females with a mean age at the time of surgery of 20.05±11.32 years, underwent surgery for choanal atresia. Fifteen subjects (83.33%) had a bony while 3 (26.77%) a mixed bony-membranous atretic plate. Two and sixteen cases suffered from bilateral and unilateral choanal atresia respectively. No intra- and/or early postoperative complications were observed. Between 2 and 3 months after surgery two cases (11.11%) of partial restenosis were found. Only one of these presented a relapse of the nasal obstruction and was subsequently successfully repaired with a second endoscopic procedure.

CONCLUSION

The surgical technique described follows the basic requirements of corrective surgery and allows good visualization, evaluation and treatment of the atretic plate and the posterior third of the septum, in order to create the new choanal opening. We believe that the use of a stent is not necessary, as recommended in case of other surgical techniques involving the use of more mucosal flaps.

Incidence and Predictors of In-stent Re-Stenosis in the Superficial Femoral Artery: Evaluation of Long-Term Outcomes by Color Duplex Ultrasound

This study aimed to investigate the incidence and predictors of in-stent re-stenosis (ISR) for nitinol stents in the superficial femoral artery (SFA) by color duplex ultrasound (CDU). In total, 235 patients undergoing SFA stenting were included in the present study. The cumulative ISR rates at 3, 6, 12, 24 and 36 mo post-procedure were 5.4%, 24.0%, 49.0%, 61.5% and 71.5%, respectively. The markedly low peak systolic velocity of the popliteal artery (PSV2) post-operation was inversely correlated with the ISR. The threshold for ≥50% re-stenosis was PSV2 ≤ 63 cm/s with 86.6% sensitivity and 90.5% specificity. With regard to re-occlusion, the PSV2 was ≤40 cm/s with 98.1% sensitivity and 93.4% specificity. Cox regression analysis indicated that the cumulative stent length, diabetes, and pre-stent stenosis level were independent risk factors of ISR. In conclusion, the ISR incidence after SFA stenting is relatively high and CDU follow-up is a feasible method for evaluating ISR.

Improving arteriovenous fistula patency: Transdermal delivery of diclofenac reduces cannulation-dependent neointimal hyperplasia via AMPK activation

Creation of an autologous arteriovenous fistula (AVF) for vascular access in haemodialysis is the modality of choice. However neointimal hyperplasia and loss of the luminal compartment result in AVF patency rates of ~ 60% at 12 months. The exact cause of neointimal hyperplasia in the AVF is poorly understood. Vascular trauma has long been associated with hyperplasia. With this in mind in our rabbit model of AVF we simulated cannulation autologous to that undertaken in vascular access procedures and observed significant neointimal hyperplasia as a direct consequence of cannulation. The neointimal hyperplasia was completely inhibited by topical transdermal delivery of the non-steroidal anti-inflammatory (NSAID) diclofenac. In addition to the well documented anti-inflammatory properties we have identified novel anti-proliferative mechanisms demonstrating diclofenac increases AMPK-dependent signalling and reduced expression of the cell cycle protein cyclin D1. In summary prophylactic transdermal delivery of diclofenac to the sight of AVF cannulation prevents adverse neointimal hyperplasic remodelling and potentially offers a novel treatment option that may help prolong AVF patency and flow rates.

Intracoronary Radiation

With in-stent restenosis remaining major limitation of coronary stenting and adjunctive pharmacologic therapy and re-stenting having failed to reduce the rates of in-stent restenosis, a new treatment alternative is warranted. Vascular brachytherapy - the intracoronary delivery of radiation has been proposed as one such therapy. Thus far it is an important break-through in combating re-stenosis. Todate, 5 years of clinical data has been generated and further studies are underway to perfect the technology.