Intravascular Ultrasound–Derived Calcium Score to Predict Stent Expansion in Severely Calcified Lesions

2021 ◽  
Vol 14 (10) ◽  
Author(s):  
Mingyou Zhang ◽  
Mitsuaki Matsumura ◽  
Eisuke Usui ◽  
Masahiko Noguchi ◽  
Tatsuhiro Fujimura ◽  
...  
Keyword(s):  
Intravascular Ultrasound ◽  
Stent Implantation ◽  
Validation Cohort ◽  
De Novo ◽  
Regression Coefficient ◽  
Morphological Characteristics ◽  
Calcium Score ◽  
Coronary Calcification ◽  
Derivation Cohort ◽  
Stent Expansion

Background: Coronary calcification inhibits stent expansion. We sought to establish an intravascular ultrasound–derived calcium score to predict stent underexpansion. Methods: This is a retrospective observational study including de novo lesions that underwent intravascular ultrasound–guided stenting and had maximum superficial calcium angle >270°. Lesions with angiographic calcium not treated with atherectomy or scoring/cutting balloon before stent implantation were randomly divided into derivation and validation cohorts. The end point was stent expansion (minimum stent area/average of reference lumen area) at the maximum calcium site, and stent expansion <70% was considered underexpansion. Results: The morphological characteristics associated with stent underexpansion in derivation cohort were (1) superficial calcium angle >270° longer than 5 mm (regression coefficient, −13.0 [95% CI, −18.1 to −7.8], P <0.0001), (2) 360° of superficial calcium (regression coefficient, −14.2 [95% CI, −22.8 to −5.5], P =0.001), (3) calcified nodule (regression coefficient, −8.3 [95% CI, −14.3 to −2.2], P =0.007), and (4) vessel diameter <3.5 mm (regression coefficient, −9.4 [95% CI, −16.0 to −2.7], P =0.006). The calcium score (0-4) was significantly correlated with poor stent expansion (regression coefficient, −8.1 [95% CI, −10.5 to −5.7], P <0.0001) in the validation cohort as well as in the atherectomy cohort (regression coefficient, −4.8 [95% CI, −7.2 to −2.5], P <0.0001) with significant interaction between validation and atherectomy cohorts ( P interaction =0.02). In lesions without angiographic calcium, all calcium severity parameters were less than in the validation cohort, and stent underexpansion was observed in only 1.5% (1/67) of lesions. Conclusions: This intravascular ultrasound calcium score provides the interventionalists with a reliable tool to identify calcified stenoses at risk for stent underexpansion and requiring adjunctive calcium modification before stent implantation.

scholarly journals Clinical Risk Factors and Prognostic Model for Idiopathic Inflammatory Demyelinating Diseases after Haploidentical Hematopoietic Stem Cell Transplantation in Patients with Hematological Malignancies

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 2902-2902
Author(s):  
Rui-Xin Deng ◽  
Yun He ◽  
Xiao-Lu Zhu ◽  
Hai-Xia Fu ◽  
Xiao-Dong Mo ◽  
...  
Keyword(s):  
Risk Factors ◽  
Prognostic Model ◽  
Validation Cohort ◽  
Regression Coefficient ◽  
Risk Group ◽  
Area Under The Curve ◽  
Demyelinating Diseases ◽  
Decision Curve Analysis ◽  
Derivation Cohort ◽  
Risk Of Death

Abstract Introduction As a neurological complication following haploidentical haematopoietic stem cell transplantation (haplo-HSCT), immune-mediated demyelinating diseases (IIDDs) of the central nervous system (CNS) are rare, but they seriously affect a patient's quality of life (J Neurooncol, 2012). Although several reports have demonstrated that IIDDs have a high mortality rate and a poor prognosis (J Neurooncol, 2012; Neurology 2013), a method to predict the outcome of CNS IIDDs after haplo-HSCT is not currently available. Here, we reported the largest research on CNS IIDDs post haplo-HSCT, and we developed and validated a prognostic model for predicting the outcome of CNS IIDDs after haplo-HSCT. Methods We retrospectively evaluated 184 consecutive CNS IIDD patients who had undergone haplo-HSCT at a single center between 2008 and 2019. The derivation cohort included 124 patients receiving haplo-HSCT from 2014 to 2019, and the validation cohort included 60 patients receiving haplo-HSCT from 2008 to 2013. The diagnosis of CNS IIDDs was based on the clinical manifestations and exclusion of other aetiologies, including infection, neurotoxicity, metabolic encephalopathy, ischaemic demyelinating disorders, and tumor infiltration. The final prognostic model selection was performed by backward stepwise logistic regression using the Akaike information criterion. The final model was internally and externally validated using the bootstrap method with 1000 repetitions. We assessed the prognostic model performance by evaluating the discrimination [area under the curve (AUC)], calibration (calibration plot), and net benefit [decision curve analysis (DCA)]. Results In total, 184 of 4532 patients (4.1%) were diagnosed with CNS IIDDs after transplantation. Among them, 120 patients had MS, 53 patients had NMO, 7 patients had ADEM, 3 patients had Schilder's disease, and 1 patient had Marburg disease. Grades II to IV acute graft-versus-host disease (aGVHD) (p&lt;0.001) and chronic GVHD (cGVHD) (p&lt;0.001) were identified as risk factors for developing IIDDs after haplo-HSCT. We also tested immune reconstitution by measuring the following parameters 30, 60, and 90 days after haplo-HSCT: proportions of CD19+ B cells, CD3+ T cells and CD4+ T cells; counts of lymphocytes and monocytes; and levels of immunoglobulins A, G, and M. These parameters showed no significant differences between patients with and without IIDD. CNS IIDDs were significantly associated with higher mortality and a poor prognosis (p＜0.001). In a/the multivariate logistic analysis of the derivation cohort, four candidate predictors were entered into the final prognostic model: cytomegalovirus (CMV) infection, Epstein-Barr virus (EBV) infection, the cerebrospinal fluid (CSF) IgG synthesis index (IgG-Syn), and spinal cord lesions. The value assignment was completed according to the regression coefficient of each identified independent prognostic factor for CNS IIDDs in the derivation cohort to establish the CELS risk score model. According to the regression coefficient, point values were given to each factor based on the log scale, and 1 point was awarded for each variable. These 4 factors determined the total risk score, ranging from 0 to 4. There was a higher risk of death in IIDD patients with higher CELS scores and we, therefore, defined three levels of risk of death in IIDD patients: a low-risk group for patients with a score of 0, a medium-risk group for patients with a total score of 1 or 2, and a high-risk group for patients with a total score of 3 or 4. The prognostic model had an area under the curve of 0.864 (95% CI: 0.803-0.925) in the internal validation cohort and 0.871 (95% CI: 0.806-0.931) in the external validation cohort. The calibration plots showed a high agreement between the predicted and observed outcomes. Decision curve analysis indicated that IIDD patients could benefit from the clinical application of the prognostic model. Conclusion s We identified the risk factors for IIDD onset after haplo-HSCT, and we also developed and validated a reliable prediction model, namely, the CELS, to accurately assess the outcome of IIDD patients after haplo-HSCT. Identifying IIDD patients who are at a high risk of death can help physicians treat them in advance, which will improve patient survival and prognosis. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Abstract 2566: Intravascular Ultrasound Guidance may Modify Neointimal Coverage Following Sirolimus-Eluting Stent Implantation

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Fusako Sera ◽  
Masaaki Uematsu ◽  
Jun-ichi Kotani ◽  
Masaki Awata ◽  
Takakazu Morozumi ◽  
...  
Keyword(s):  
Intravascular Ultrasound ◽  
Stent Implantation ◽  
Plaque Burden ◽  
Elastic Membrane ◽  
Stent Expansion ◽  
Group I ◽  
Group A ◽  
Neointimal Coverage ◽  
Sirolimus Eluting Stent

Background: Although sirolimus-eluting stent (SES) has significantly reduced in-stent restenosis, insufficient neointimal coverage may result in adverse outcomes. Intravascular ultrasound (IVUS) guided percutaneous coronary intervention improves the patency of bare-metal stents at follow-up. IVUS guidance at the time of SES implantation may also optimize neointimal coverage following stenting. Methods: We evaluated 55 SES implanted lesions using both angioscopy and IVUS at follow-up (12±7 months). The lesions were divided into two groups: IVUS guided implantation (group I, n=40); angiography alone (group A, n=15). Neointimal coverage was classified into 4 grades by angioscopy: no coverage ( G0 ); struts bulged into the lumen, but were covered and still translucently visible ( G1 ); struts were visible, but not clear ( G2 ); and struts were embedded and invisible ( G3 ). Minimal stent area (MSA), external elastic membrane (EEM), lumen cross-sectional area (CSA) and plaque burden were measured by IVUS at follow up. Both proximal and distal references were used. Stent expansion was assessed by stent expansion index (SEI) = MSA/reference EEM CSA. Results: Lesion and procedural characteristics were similar between the groups both at stent implantation and at follow-up. Although the post-procedural quantitative angiographic data were not different between the groups, distribution of the angioscopic grades of neointimal coverage at follow-up were significantly different (group A = 1.0±0.5 grades versus group I = 1.5±0.6 grades, p=0.01). IVUS measurements at follow up showed larger plaque burden at the proximal reference sites (54±12% versus 46±9%, p=0.02) and smaller SEI (0.35±0.09 versus 0.46±0.10, p=0.001) in group A than in group I. Conclusions: IVUS guidance at the time of SES implantation may modify angioscopic grades of the neointimal coverage, possibly optimizing neointimal coverage and preventing thrombosis.

Impact of Intravascular Ultrasound–Guided Optimal Stent Expansion on 3-Year Hard Clinical Outcomes

2021 ◽  
Vol 14 (10) ◽  
Author(s):  
Yong-Joon Lee ◽  
Jun-Jie Zhang ◽  
Gary S. Mintz ◽  
Sung-Jin Hong ◽  
Chul-Min Ahn ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Intravascular Ultrasound ◽  
Stent Implantation ◽  
Hazard Ratio ◽  
Drug Eluting Stent ◽  
Lumen Area ◽  
Ultrasound Guided ◽  
Stent Expansion ◽  
Drug Eluting

Background: Although stent underexpansion on intravascular ultrasound (IVUS) has been a major predictor for adverse outcomes in previous studies, these studies have primarily focused on angiographic restenosis or repeat revascularization with short-term follow-up. This study sought to evaluate the long-term benefit of different criteria for IVUS-defined optimal stent expansion on hard clinical outcomes. Methods: From the pooled data of 2 randomized trials, IVUS-XPL (Impact of Intravascular Ultrasound Guidance on the Outcomes of Xience Prime Stents in Long Lesions) and ULTIMATE (Intravascular Ultrasound Guided Drug Eluting Stents Implantation in All-Comers Coronary Lesions) that compared IVUS- versus angiography-guided drug-eluting stent implantation, a total of 1254 patients with IVUS-guided drug-eluting stent implantation into 1484 long lesions (implanted stent length, ≥28 mm) were included. Different criteria for IVUS-defined optimal stent expansion based on minimum stent area (MSA) as an absolute measure or MSA relative to reference lumen area were applied and validated. The primary end point was composite of cardiac death, target lesion–related myocardial infarction, or stent thrombosis at 3 years. Results: The rate of the primary end point was lower in patients with optimal stent expansion versus those without optimal stent expansion according to 3 IVUS-defined optimal stent expansion criteria: MSA >5.5 mm 2 (0.5% versus 2.2%; hazard ratio, 0.21 [95% CI, 0.06–0.75]; P =0.008), MSA >5.0 mm 2 (0.6% versus 2.6%; hazard ratio, 0.24 [95% CI, 0.09–0.68]; P =0.003), and MSA/distal reference lumen area >90% (0.5% versus 2.4%; hazard ratio, 0.32 [95% CI, 0.12–0.88]; P =0.019). Achieving other relative expansion criteria, MSA/distal reference lumen area >100% or 80% or MSA/average reference lumen area >90% or 80%, was not associated with a reduction in hard clinical events. Conclusions: In patients undergoing IVUS-guided drug-eluting stent implantation for long lesions, achieving optimal stent expansion of MSA >5.5 mm 2 , >5.0 mm 2 , or MSA/distal reference lumen area >90% was associated with improved long-term hard clinical outcomes.

Abstract 2777: Optimal Expansion of the Stent is a Major Contributor to the Neointimal Coverage Following Sirolimus-eluting Stent Implantation: A Combined Study of Angioscopy and Intravascular Ultrasound

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Fusako Sera ◽  
Jun-ichi Kotani ◽  
Masaki Awata ◽  
Shinsuke Nanto ◽  
Masaaki Uematsu ◽  
...  
Keyword(s):  
Intravascular Ultrasound ◽  
Stent Implantation ◽  
Neointimal Hyperplasia ◽  
Multivariate Logistic Regression Analysis ◽  
Plaque Burden ◽  
Elastic Membrane ◽  
Major Contributor ◽  
Stent Expansion ◽  
Neointimal Coverage ◽  
Sirolimus Eluting Stent

Background: Although sirolimus-eluting stent (SES) has significantly reduced in-stent restenosis by inhibiting neointimal hyperplasia, insufficient neointimal coverage after stenting may result in adverse outcomes. Determinants of neointimal coverage following SES, however, are poorly understood. Methods: We evaluated 28 SES lesions using both angioscopy and intravascular ultrasound (IVUS). Degree of neointimal coverage was judged by angioscopy at follow-up (11 ± 6 months): complete/incomplete coverage, based on whether the stent struts were embedded by the neointima. Minimal stent area (MSA), external elastic membrane (EEM), lumen cross-sectional area (CSA) and plaque burden (EEM minus lumen/EEM CSA) were measured by IVUS at stent implantation. Both proximal and distal references were used. Stent expansion was assessed by stent expansion index (SEI) as MSA/reference EEM CSA. Under-expansion was defined as SEI < 0.4. Incomplete apposition was defined as the lack of contact between any strut and the underlying vessel wall. Results: Complete coverage was identified in 10 (36%), and incomplete coverage in 18 (64%). Time from the stenting to angioscopy (10 ± 5 versus 11 ± 7 months, p=0.8) as well as the lesion and procedural characteristics was similar between the complete/incomplete coverage groups. IVUS parameters were also similar, except for the final MSA (7.0±1.8mm 2 in complete versus 5.3±1.9mm 2 in incomplete , p=0.02) and lumen CSA at the distal reference site (6.1±1.4mm 2 in complete versus 4.9 ±1.2mm 2 in incomplete , p= 0.02). The frequency of incomplete apposition was similar between the groups (20% in complete versus 39% in incomplete , P= 0.4); however, SEI was significantly larger in the complete coverage than in the incomplete coverage group (0.52 ± 0.11 versus 0.39 ± 0.09, p=0.002). Stent under-expansion was identified only in 2 (20%) of the complete coverage, as compared to 67% of the incomplete coverage group (P=0.046). By multivariate logistic regression analysis, large SEI was strongly associated with complete neointimal coverage (P=0.04). Conclusion: Optimal expansion of the stent is a major contributor to the complete neointimal coverage following sirolimus-eluting stent implantation.

scholarly journals Impact of Optimal Stent Expansion on Late Outcomes after Sirolimus-Eluting Stent Implantation: An Intravascular Ultrasound Study

2007 ◽  
Vol 37 (6) ◽  
pp. 244 ◽  
Author(s):  
Chang-Wook Nam ◽  
Kwon-Bae Kim ◽  
Seung-Ho Hur ◽  
Yun-Kyeong Cho ◽  
Hyung Seop Kim ◽  
...  
Keyword(s):  
Intravascular Ultrasound ◽  
Stent Implantation ◽  
Stent Expansion ◽  
Ultrasound Study ◽  
Sirolimus Eluting Stent
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