Treatment of in-stent restenosis remains challenging. Drug-eluting stents have significantly reduced restenosis rates compared to bare-metal stents but treating drug-eluting stent in-stent restenosis is particularly difficult. Intracoronary imaging can provide insights into underlying causes of in-stent restenosis and guide repeated interventions. Current treatment strategies include balloon angioplasty, cutting/scoring balloons, debulking techniques, brachytherapy, and repeat stenting with drug-eluting stents. However, outcomes remain poorer for drug-eluting stent in-stent restenosis compared to bare-metal stent restenosis.
A coronary bifurcation consists of a flow divider (carina) and three vessel segments:
The proximal main vessel (PMV)
The distal main vessel (DMV) and
The side branch (SB).
A bifurcation lesion is a major epicardial coronary artery stenosis next to and/or including the ostium of a significant side branch
A significant SB is a branch whose severe narrowing or acute occlusion before or during intervention can cause considerable ischemia or a new infarction area that will worsen the clinical course of a particular patient.
Other important elements to consider that are not inherent in the bifurcation classifications include:
Extent of disease on the SB (limited to the ostium or involving the vessel beyond the ostium)
Its size (over 2.5mm in reference diameter)
Bifurcation angle, and
Disease distribution
How to deal with CALCIFIED CORONARY ARTERY LESIONS .Coronary artery calcification (CAC) is highly prevalent in patients with coronary heart disease (CHD) and is associated with major adverse cardiovascular events. There are two recognized type of CAC—intimal and medial calcification, and each of them have specific risk factors. Several theories about the mechanism of vascular calcification have been put forward, and we currently believe that vascular calcification is an active, regulated process. CAC can usually be found in patients with severe CHD, and this asymptomatic phenomenon make early diagnosis of CAC important. Coronary computed tomographic angiography is the main noninvasive tool to detect calcified lesions. Measurement of coronary artery calcification by scoring is a reasonable metric for cardiovascular risk assessment in asymptomatic adults at intermediate risk. To date, effective medical treatment of CAC has not been identified. Several strategies of percutaneous coronary intervention have been applied to CHD patients with CAC, but with unsatisfactory results. Prognosis of CAC is still a major problem of CHD patients. Thus, more details about the mechanisms of CAC need to be elucidated in order to improve the understanding and treatment of CAC.
Stratification of a given bifurcation lesion
The double kissing (DK) crush technique is better for complex coronary bifurcation
Stenting the side branch (SB)
Balloon crush
First kissing
Stenting the main vessel (MV)
2nd kissing balloon inflation
Careful rewiring from the proximal cell of the MV stent to make sure the wire is in the true lumen of the SB stent is key to acquiring optimal angiographic results
Balloon anchoring from the MV
Alternative inflation and each kissing inflation using large enough non-compliant balloons at high pressure
Proximal optimisation technique are mandatory to improve both angiographic and clinical
Speckle tracking echocardiography (STE) is an echocardiographic imaging technique that analyzes the motion of tissues in the heart by using the naturally occurring speckle pattern in the myocardium or blood when imaged by ultrasound.
Diverse and heritable lineage imprinting of early
haematopoietic progenitors
Shalin H. Naik1{, Leı¨la Perie´1,2, Erwin Swart1, Carmen Gerlach1, Nienke van Rooij1, Rob J. de Boer2 & Ton N. Schumacher1
A coronary bifurcation consists of a flow divider (carina) and three vessel segments:
The proximal main vessel (PMV)
The distal main vessel (DMV) and
The side branch (SB).
A bifurcation lesion is a major epicardial coronary artery stenosis next to and/or including the ostium of a significant side branch
A significant SB is a branch whose severe narrowing or acute occlusion before or during intervention can cause considerable ischemia or a new infarction area that will worsen the clinical course of a particular patient.
Other important elements to consider that are not inherent in the bifurcation classifications include:
Extent of disease on the SB (limited to the ostium or involving the vessel beyond the ostium)
Its size (over 2.5mm in reference diameter)
Bifurcation angle, and
Disease distribution
How to deal with CALCIFIED CORONARY ARTERY LESIONS .Coronary artery calcification (CAC) is highly prevalent in patients with coronary heart disease (CHD) and is associated with major adverse cardiovascular events. There are two recognized type of CAC—intimal and medial calcification, and each of them have specific risk factors. Several theories about the mechanism of vascular calcification have been put forward, and we currently believe that vascular calcification is an active, regulated process. CAC can usually be found in patients with severe CHD, and this asymptomatic phenomenon make early diagnosis of CAC important. Coronary computed tomographic angiography is the main noninvasive tool to detect calcified lesions. Measurement of coronary artery calcification by scoring is a reasonable metric for cardiovascular risk assessment in asymptomatic adults at intermediate risk. To date, effective medical treatment of CAC has not been identified. Several strategies of percutaneous coronary intervention have been applied to CHD patients with CAC, but with unsatisfactory results. Prognosis of CAC is still a major problem of CHD patients. Thus, more details about the mechanisms of CAC need to be elucidated in order to improve the understanding and treatment of CAC.
Stratification of a given bifurcation lesion
The double kissing (DK) crush technique is better for complex coronary bifurcation
Stenting the side branch (SB)
Balloon crush
First kissing
Stenting the main vessel (MV)
2nd kissing balloon inflation
Careful rewiring from the proximal cell of the MV stent to make sure the wire is in the true lumen of the SB stent is key to acquiring optimal angiographic results
Balloon anchoring from the MV
Alternative inflation and each kissing inflation using large enough non-compliant balloons at high pressure
Proximal optimisation technique are mandatory to improve both angiographic and clinical
Speckle tracking echocardiography (STE) is an echocardiographic imaging technique that analyzes the motion of tissues in the heart by using the naturally occurring speckle pattern in the myocardium or blood when imaged by ultrasound.
Diverse and heritable lineage imprinting of early
haematopoietic progenitors
Shalin H. Naik1{, Leı¨la Perie´1,2, Erwin Swart1, Carmen Gerlach1, Nienke van Rooij1, Rob J. de Boer2 & Ton N. Schumacher1
Problem associated with drug eluting stentPRAVEEN GUPTA
This ppt will tell us about the problem which a cardiologist has to face after implantation of Drug eluting stent in a patient of coronary artery diseases. Although there are lots of problem but i am going to describe only three major problem.
InStent Resetenosis: An Algorithmic Approach to Diagnosis and TreatmentNAJEEB ULLAH SOFI
BMS were developed to mitigate elastic recoil and negative remodeling, but they remain prone to NIH. DES were developed to prevent NIH, and these devices (especially first-generation DES) can be accompanied by delayed reendothelialization, which has been associated with stent thrombosis.
Even in the contemporary era of percutaneous coronary intervention using drug-eluting stents, ISR remains a common problem, occurring in 5% to 20% of cases, depending on several patient and lesion characteristics.
The cumulative rates of DES failure have created a major clinical problem so that > 10% of all PCIs done in the United States are to treat ISR, and the number of ISR interventions appears to be increasing year over year
Coronary artery bypass grafting with adjunctive
endarterectomy: A mandatory procedure in complex
revascularizations. current results and postoperative
considerations
Flexible fiberoptic catheter used for light delivery
OCT enhances imaging resolution that may permit the evaluation of clinical (e.g., luminal measurements during PCI) and research (e.g., fibrous cap thickness and strut levelanalysis) parameters for the interventional cardiologist.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
2. General Overview
Management of patients with in-stent restenosis (ISR) remains an important
clinical problem.
Although drug-eluting stents (DES) have drastically reduced the incidence of
ISR, treatment of DES-ISR is particularly challenging.
ISR mainly results from aggressive neointimal proliferation, but recent data also
suggest that neoatherosclerosis may play an important pathophysiological role.
Intracoronary imaging provides unique insights to unravel the underlying
substrate of ISR and may be used to guide repeated interventions.
3. Definition
The definition of ISR
remains an
angiographic one:
recurrent diameter stenosis
>50% at the stent segment
or its edges (5-mm
segments adjacent to the
stent)
4. Role of Intravascular Imaging
play an important role in evaluation of underlying mechanical factors that contribute to
ISR
Readily detects the presence of neointimal hyperplasia obstructing the stent,
underexpansion, or edge problems
the external elastic lamina is usually well delineated behind the stent struts, and thus
provides potentially valuable insights on vessel sizing for optimization of stent expansion.
limited axial resolution (150 mm) lumen–neointimal interface may be difficult to
delineate in some areas.
5. In this respect, optical coherence tomography (OCT) provides a much better axial resolution (15
mm), yielding detailed images of lumen interface, the neointimal tissue, and the strut distribution.
Against this setting, residual plaque behind the stent is poorly visualized as a result of lower tissue
penetration compared with ultrasound.
ISR after DES is typically characterized by a layered or heterogeneous intrastent tissue band.
Such a tissue appearance may represent hypocellular neointima with high proteoglycan or fibrin
content or may be part of the spectrum of in-stent neoatherosclerotic changes.
Indeed, some investigators suggested that in patients with DES-ISR, OCT imaging may exhibit
presence of neoatherosclerotic tissue within the stent in up to 50% of cases.
6. Notably, OCT allows not only evaluation of the presence of
neoatherosclerotic tissue per se but also of the presence of
unstable features (e.g., plaque rupture, nonocclusive intracoronary
thrombus), which may play a strong role in prognostic assessment
and clinical decision making.• ISR caused by severe homogeneous smooth muscle cell
proliferation represents just one end of the spectrum.
• At the other extreme are patients experiencing stent thrombosis
in a widely patent stent.
• In the middle, neoatherosclerosis manifests clinically as a
multifaceted and elusive condition causing both ISR and stent
thrombosis.
8. Conventional Balloon Angioplasty
one of the earliest strategies technically straight forward satisfactory acute results and a very low
incidence of complications.
Lumen enlargement results from both tissue extrusion (axial and longitudinal) and additional stent
expansion
Results are particularly favorable in patient with “focal” patterns of ISR
However, the long-term results of patients with diffuse ISR are frequently shadowed by high
recurrent restenosis rates.
In general, a balloon-to-artery ratio o 1.1:1 is selected.
BA should target the narrowing rather than the entire stented segment
9. Conventional Balloon Angioplasty
Observed “dog bone” effects during balloon dilation should promote a
shift to aggressive dilations with a noncompliant balloon or
occasionally with a super-high-pressure noncompliant balloon
One of the limitations of BA is that sub acute tissue re-intrusion back to
the lumen tends to occur within minutes after the last balloon
inflation.
10. Cutting and Scoring Balloon Therapy
It offers protection against the problems of “watermelon seeding.”
The lateral blades of this device anchor the balloon within the target lesion,
preventing balloon slippage–related problems.
Moreover, from a mechanistic standpoint, the device deeply incises neointimal
tissue and, at least theoretically, may favor its subsequent extrusion.
Initial observational studies produce promising results, clearly superior to those
seen with conventional BA.
11. Cutting and Scoring Balloon Therapy
Results of a small randomized study (25 patients per arm) suggested that cutting balloon
therapy was superior to BA in preventing early lumen deterioration at 24 hours, and this
finding was associated with a lower rate of target lesion revascularization (12.5% vs. 40%) at
late follow-up.
In RESCUT (Restenosis Cutting Balloon Evaluation Trial), 428 patients with BMS-ISR were
randomized to receive either cutting BA or conventional BA.
At late follow-up, the angiographic restenosis rate, minimal lumen diameter, and rates of
clinical events were similar in both arms.
However, the occurrence of balloon slippage was significantly reduced (6.5% vs. 25%) in the
cutting balloon arm, and
This finding seemed to be associated with a lower requirement for unplanned stent
implantation
Montorsi P, Ital Heart J 2004;5:271–9.
J Am Coll Cardiol 2004;43:943–9.
12. Scoring balloon
Scoring balloons are based on the same principle as cutting balloons
but are especially attractive in these patients due to superior flexibility
and deliverability.
13. Debulking Techniques
The rationale for plaque Debulking was based on the hypothesis that
removing the tissue obstructing a well expanded stent was the only
action required to regain vessel lumen.
Intravascular ultrasound studies suggested that lumen gain was larger
and residual neointima smaller when ablative techniques were used in
patients with ISR compared with use of standard therapies.
Early observational studies suggested that the use of laser or
rotational atherectomy, followed by a “conservative” balloon
postdilation, was superior to conventional BA alone in these patients.
14. The value of rotational atherectomy in patients with BMS-ISR was
analyzed in 2 randomized studies
ROSTER (Randomized Trial of Rotational Atherectomy Versus Balloon
Angioplasty for Diffuse In-Stent Restenosis) was a small single-center
study in patients with diffuse ISR in whom intravascular ultrasound was
systematically used to exclude cases with severe stent underexpansion.
In this trial, rotational atherectomy reduced the amount of residual tissue
within the stent and the rate of target lesion revascularization at follow-
up, compared with BA alone.
Sharma SK .Am Heart J 2004;147:16–22.
15. Conversely, ARTIST (Angioplasty Versus Rotational Atherectomy for Treatment of
Diffuse In-Stent Restenosis Trial), a larger multicenter randomized study (298
patients with diffuse ISR) comparing rotational atherectomy with BA alone, failed to
show benefit with rotational atherectomy.
In fact, the restenosis rate, as well as the rates of acute complications and long-term
clinical events, were higher in the rotational atherectomy arm
Rotational atherectomy may still be required as a bailout strategy in patients with
undilatable ISR lesions as a result of severely under expanded stents or calcified
intrastent neoatherosclerosis.
Generally a step up burr approach is used ; IVUS helps inn deciding the initial and
final burr size (final artery to burr ratio = 0.6 to 0.7 )
Vom Dahl J. Circulation 2002;105:583–8.
16. Vascular Brachytherapy
Brachytherapy effectively suppressed the proliferative response and significantly
reduced clinical and angiographic restenosis rates.
Randomized clinical trials in patients with ISR demonstrated the superiority of
brachytherapy compared with conventional BA or atheroablative techniques.
both beta and gamma radiation sources were able to achieve major reductions in
the angiographic restenosis rates. Gamma emitters had profound tissue
penetration, whereas beta emitters had less tissue penetration.
But ……..
17. The issues of geographic miss and edge restenosis, as well as delayed arterial healing and
its sequelae (late stent thrombosis and late catch-up), have been well described with this
therapy.
Two large randomized clinical trials compared the efficacy of brachytherapy versus DES in
patients with BMS-ISR.
The SISR (Sirolimus- Eluting Stent vs. Brachytherapy in Patients With Bare Metal In-Stent
Restenosis) trial allocated 384 patients with BMS-ISR to undergo brachytherapy or
sirolimus-eluting stent implantation.
The TAXUS V ISR (A Prospective, Randomized Trial Evaluating Slow-Release Formulation
TAXUS Paclitaxel-Eluting Coronary Stent in the Treatment of In-Stent Restenosis) trial
randomized 396 patients with BMS-ISR to receive either brachytherapy or paclitaxel-
eluting stents.
JAMA 2006;295:1264–73.
JAMA 2006; 295:1253–63.
18. Subsequent reports from these 2 trials confirmed that the advantage of
DES over brachytherapy was maintained up to 5 years of follow-up.
In patients with DES-ISR, observational studies suggest that brachytherapy
was of clinical utility .
However, randomized trials against repeat DES or DCB therapy were never
conducted.
Overall, the inherent complexity of the technique, together with a reduced
commercial interest, led to the virtual abandonment of this strategy.
19. Repeat Stenting for Patients With ISR
Bare-metal stents.
Drug-eluting stents.
• Homo - DES
• Hetero DES
DCB Angioplasty
20. BMS STENTS
Despite increasing vessel wall injury and subsequent neointimal proliferation compared with
BA in de novo lesions, BMS reduce the risk of restenosis due in large part to higher acute gain.
The RIBS I (Restenosis Intra-stent Balloon Angioplasty Versus Elective Stenting) trial
randomized 450 patients with BMS-ISR to receive either BA or repeat BMS implantation.
Acute angiographic results were significantly better after stent implantation due to a larger
acute gain. However at 6-month follow-up, the late loss was also significantly larger in the
stent group.
As a result, final minimal lumen diameter and percent diameter stenosis were
similar in both arms. Likewise, recurrent restenosis rates were high and similar
in the 2 groups.
Alfonso J Am Coll Cardiol 2003;42:796–805.
21. BMS STENTS
There was some evidence of clinical benefit in 2 relevant pre-
specified lesion subsets.
First, patient with large vessels (>3 mm in diameter on quantitative
coronary angiography) obtained better long-term clinical and
angiographic outcomes after repeat stenting compare with BA.
Second, patients with ISR affecting the stent edge and the adjacent
vessel also exhibited better results after stenting
22. DES STENT >>>> BMS -ISR
Early observational studies suggested that first-generation DES were very effective
and safe in patients with ISR and provided excellent clinical outcomes
A thorough lesion pre-dilation with or without noncompliant balloons remains
important to treat potential underlying stent underexpansion
Adjunctive DES implantation offers durable preservation of acute gain.
23. DES STENT >>>> BMS -ISR
The ISAR-DESIRE (Intracoronary Stenting or Angioplasty for Restenosis Reduction–Drug-Eluting
Stents for In-Stent Restenosis) trial was the first randomized study assessing the value of DES in
patients with BMS-ISR.
300 patients were randomly allocated to treatment with sirolimus-DES, paclitaxel-DES, or BA.
The rate of recurrent restenosis was significantly reduced with sirolimus-DES (14.3%) and
paclitaxel-DES (21.7%) compared with BA (44.6%).
Patients treated with sirolimus-DES tended to have lower rates of angiographic restenosis and
target vessel revascularization compared with those receiving paclitaxel-DES
JAMA 2005;293:165–71.
24. DES STENT >>>> BMS -ISR
The RIBS II (Restenosis Intrastent: Balloon Angioplasty Versus Elective
Sirolimus-Eluting Stenting) trial was a multicenter Spanish study that
compared sirolimus-DES versus BA in patients with BMS-ISR.
Compared with the BA arm, patients treated with sirolimus-DES had a
significantly lower restenosis rate (11%) and superior long-term clinical
outcome, mainly as a result of a reduced need for interventions.
The long-term (4-year) follow-up of this study was reassuring, because
a sustained clinical benefit was demonstrated
Alfonso F, J Am Coll Cardiol 2006;47: 2152–60.
25. DES-ISR
Overall, treatment of DES-ISR is associated with poorer late outcomes than those
obtained after treatment for BMS-ISR.
Repeat stenting with DES rapidly became established as the treatment of choice in
DES-ISR.
However, the issue of whether a DES eluting the same or a similar type of drug
(homo-DES approach) versus a switch to a different type of drug (hetero-DES
approach) should be selected has continued to attract considerable debate.
The benefits of a switch strategy are based on the hypothesis that it might overcome
drug resistance or specific polymer-related problems.
Overall, results remain inconclusive, and the evidence favoring a switch strategy is
weak.
26. DES-ISR
The ISAR-DESIRE 2 (Intracoronary Stenting and Angiographic Results:
Drug Eluting Stents for In-Stent Restenosis 2) trial randomly allocated
450 patients with sirolimus-DES-ISR to undergo repeat stenting with
sirolimus-DES versus switching to stenting with paclitaxel- DES.
Regarding antirestenotic efficacy, there were no differences between
the 2 arms in late loss (0.40 vs. 0.38 mm), binary restenosis (19.6% vs.
20.6%), or target lesion revascularization (16.6% vs. 14.6%). Safety was
also comparable.
These observations argue against a clear benefit from a switch DES
strategy
Mehilli J, J Am Coll Cardiol 2010;55:2710–6.
27. In the RIBS III (Restenosis Intra-Stent: Balloon Angioplasty Versus Drug-Eluting Stent)
trial, a prospective multicenter registry including 363 patients with DES-ISR.
The main finding was that the hetero-DES approach (or switch DES strategy) was
associated with better clinical outcomes.
In RIBS III, there was a suggestion that the use of second-generation DES was
superior to first generation DES and
also that guidance with intracoronary imaging was associated with better long-term
results
Alfonso FJ Am Coll Cardiol Intv 2012; 5:728–37.
28. summary
Finally, the best approach to patients presenting with “recurrent” DES-ISR remains unsettled.
Many of these patients had resistant under expandable stents despite the use of high
pressures.
When severe resistant underexpansion is confirmed (which may require intracoronary
imaging),
some investigators support the use of highly aggressive strategies, including rotational
atherectomy, to correct this underlying problem (stent ablation)
However, the risk/benefit of this approach remains unknown, and the problem of publication
bias (selective reporting of successful cases) seems likely
29. SUMMARY
In patients with recurrent ISR, implantation of
new DES would result in a vessel with multiple
metal layers.
This patient cohort seems to be at a high risk for
additional recurrences, and coronary surgery
should always be contemplated for these
“frequent flyer” patients.
30. Bioresorbable vascular scaffolds
Bioresorbable vascular scaffolds have also been proposed as treatment for
patients with ISR
The chief advantage is that the device should eventually disappear from the
vessel wall, avoiding the presence of multiple stent layers (“onion-skin”
phenomena).
Potential limitations of Bioresorbable vascular scaffolds in this setting include
• Lumen crowding due to strut thickness (particularly in small vessels),
• Device flexibility that may affect access to restenotic lesions, and
• Questions regarding radial strength and recoil, which may be particularly important in treating cases of
ISR.
31. the RIBS V Clinical Trial. J Am Coll
Cardiol 2014;63:1378–86.
32. The study suggested that second-generation DES exhibit some evidence of
superiority in terms of angiographic endpoints but without a clear signal of
clinical benefit.
Therefore, additional studies with a larger number of patients and a longer
follow-up are required to address this important question.
The value of DCB in patients with DES-ISR has also been well tested
Recently, the larger ISAR-DESIRE 3 (Intracoronary Stenting and Angiographic
Results: Drug Eluting Stents for In-Stent Restenosis) multicenter randomized
trial investigated the efficacy of DCB versus paclitaxel-DES versus conventional
BA in patients with limus DES-ISR.
This study demonstrated that DCB were noninferior to paclitaxel- DES and
that both DCB and paclitaxel-DES were superior to BA alone
Lancet 2013;381:461–7.
PEPCAD- DES
33. It was suggested that by obviating the need of an additional stent layer, DCB might
emerge as the treatment strategy of choice for patients with DES-ISR.
In summary, data from the available randomized clinical trials suggest that
DCB are superior to BA and similar to first-generation DES in patients with
BMS-ISR or DES-ISR
Although largely speculative, currently DCB may be preferred over DES in
patients with ISR and multiple metal layers, in those with large side branches,
and in those at high bleeding risk undergoing prolonged dual antiplatelet
therapy.
Alternatively, DES may be preferred over DCB in patients with stent fracture
or restenosis extending outside the stent edge and also in patients with
suboptimal results after lesion predilation.
34. Although the advent of DES has reduced the incidence of ISR, treatment of this clinical
entity remains a prevailing clinical problem.
The substrate of ISR encompasses a pathological spectrum ranging from smooth muscle
cell proliferation to neoatherosclerosis.
Intracoronary imaging provides unique insights into the underlying etiology of ISR, but its
role in optimizing the clinical results of these reinterventions still remains unsettled.
Evidence from controlled clinical studies suggests that among currently available
therapeutic modalities, DES and DCB provide the best clinical and angiographic results in
patients with ISR.
However, the field is rapidly evolving. Further studies are required to identify clinical and
anatomic characteristics that may help to refine selection and tailor available therapeutic
strategies to improve clinical outcomes.
Editor's Notes
IVUS OCT
Edge-related complications should be carefully avoided
during aggressive balloon dilations.
Special care should be
paid to prevent balloon slippage outside the stent (“watermelon
seeding” phenomenon) (74).
This problem, typical of ISR lesions, occurs more often in severe and diffuse narrowing,
especially when balloons are oversized.
This is not just a time-consuming nuisance resulting in more cumbersome
procedures, but it is also associated with suboptimal
acute results and adverse clinical and angiographic outcomes
that might be related to geographic miss.
Occasionally, despite dedicated maneuvers, anchoring the balloon at the
target site during inflation may be challenging. Some investigators
propose the use of a buddy-wire technique to
stabilize the balloon.
Montorsi P, Galli S, Fabbiocchi F, Trabattoni D, Ravagnani PM,
Bartorelli AL. Randomized trial of conventional balloon angioplasty
versus cutting balloon for in-stent restenosis. Acute and 24-hour
angiographic and intravascular ultrasound changes and long-term
follow-up. Ital Heart J 2004;5:271–9.
Sharma SK, Kini A, Mehran R, et al. Randomized trial of Rotational
Atherectomy Versus Balloon Angioplasty for Diffuse In-stent
Restenosis (ROSTER). Am Heart J 2004;147:16–22.
vom Dahl J, Dietz U, Haager PK, et al. Rotational atherectomy does
not reduce recurrent in-stent restenosis: results of the Angioplasty
Versus Rotational Atherectomy for Treatment of Diffuse In-stent
Restenosis Trial (ARTIST). Circulation 2002;105:583–8.
the RIBS V Clinical Trial. J Am Coll Cardiol 2014;63:1378–86.