Cardiovascular Intervention and Therapeutics最新文献

Approximately 60% of patients with angina symptoms do not have obstructive coronary lesions, a condition known as ischemia with non-obstructive coronary arteries (INOCA). Among these patients, coronary microvascular dysfunction (CMD) is found in nearly half. The epicardial coronary arteries represent only a small portion of the heart's vascular bed, with CMD increasingly recognized as a significant mechanism of myocardial ischemia in INOCA. Recent revisions in the Japanese and European guidelines emphasize the importance of a comprehensive functional evaluation through interventional diagnostic procedure (IDP) for diagnosing CMD and coronary vasospastic angina, two primary causes of ischemia in INOCA patients. IDP allows clinicians to identify the underlying endotype and implement tailored therapeutic strategies, moving beyond empirical therapy. Despite its clinical relevance, INOCA remains under-recognized due to a lack of awareness among healthcare providers as well as the general public, leading to diagnostic delays and undertreatment. Public education campaigns and clinician training are crucial for improving disease recognition and reducing diagnostic delay. Future directions for INOCA management include standardizing and simplifying IDP protocols, incorporating artificial intelligence for diagnostic support, and developing non-invasive alternatives for coronary functional testing. These efforts will enhance the accuracy and accessibility of IDP, facilitating its integration into routine clinical practice. Ultimately, the continued evolution of IDP will play a key role in advancing precision cardiovascular medicine, bridging the gap between symptoms, diagnosis, and meaningful care, and improving outcomes for INOCA patients.

While numerous endovascular technologies exist for lower extremity arterial disease (LEAD), evidence guiding device selection based on lesion length is limited. We therefore conducted a network meta-analysis to compare the efficacy of contemporary endovascular therapy (EVT) strategies, stratified by clinical presentation and lesion length. Following PRISMA guidelines (PROSPERO: CRD420251031338), we searched major databases for randomized controlled trials (RCTs) comparing nine contemporary endovascular therapy (EVT) modalities for femoropopliteal intermittent claudication (IC) or infrapopliteal chronic limb-threatening ischemia (CLTI). Analyses were stratified by lesion length (short vs. long) for each clinical subgroup. Primary outcomes were primary patency, target lesion revascularization (TLR), major amputation and all-cause mortality at multiple follow-up intervals. Seventy seven RCTs involving 11,788 patients were included. For short femoropopliteal IC lesions (≤ 73.0 mm), drug-coated balloon (DCB) and covered stent were most effective for maintaining patency. For long femoropopliteal lesions (> 73.0 mm), atherectomy with DCB (AT-DCB) and drug-eluting stent (DES) demonstrated superior patency. In short infrapopliteal CLTI lesions (≤ 44.1 mm), DES provided the most consistent benefits in both patency and freedom from TLR. For long infrapopliteal lesions (> 44.1 mm), AT-DCB was the most effective strategy for improving primary patency. Importantly, no significant differences in major amputation or mortality were detected among strategies in most subgroups. The optimal endovascular strategy for LEAD appears to be highly dependent on lesion length, supporting a shift towards a more individualized treatment strategy.

In-stent protrusion is sometimes observed after the stent implantation to the culprit lesion of ST-segment elevation myocardial infarction (STEMI). However, it remains unclear whether additional interventions are necessary for non-obstructive in-stent protrusions. The purpose of this retrospective study was to compare clinical outcomes of patients with STEMI between with and without angiographically visible in-stent protrusions, and to evaluate the association between angiographically visible in-stent protrusions and long-term clinical outcomes in patients with STEMI. We included 639 patients with STEMI who underwent stent implantation and divided them into the protrusion group (n = 59) and the clear stent group (n = 580). In-stent protrusion was defined as an angiographically visible in-stent contrast filling defect at final angiography. The primary endpoint was major adverse cardiovascular events (MACE), which were defined as the composite of all cause death, non-fatal myocardial infarction, and ischemia-driven target vessel revascularization. During the median follow-up duration of 620 (213-1379) days, MACE were more frequently observed in the protrusion group than in the clear stent group (p = 0.002). The multivariate Cox hazard analysis revealed that in-stent protrusion was significantly associated with MACE after controlling for multiple confounding factors (HR 2.373, 95% CI 1.311-4.294, p = 0.004). In conclusion, angiographically visible in-stent contrast filling defect at final angiography is a marker for worse clinical outcomes in primary PCI. When interventional cardiologists recognize visible irregular protrusion after stent implantation for STEMI, additional intervention or careful clinical follow up may be needed.

Drug-coated balloons (DCB) are increasingly utilized for treating in-stent restenosis (ISR), yet the comparative efficacy of limus-coated balloons (LCBs) versus paclitaxel-coated balloons (PCBs) remains uncertain. The aim of this study is to compare the clinical and angiographic outcomes of LCB versus PCBs in treating ISR. We searched PubMed, Embase, and ClinicalTrials.gov through July 2025 for RCTs comparing LCBs versus PCBs in patients with ISR. The primary outcome was late lumen loss (LLL). Secondary outcomes included percentage diameter stenosis (%DS), minimal lumen diameter (MLD), and binary restenosis at 6-12 months and target lesion revascularization (TLR), target lesion failure (TLF), target vessel myocardial infarction, cardiac death, and stent thrombosis at 12 months. Mean differences (MDs) were calculated for continuous outcomes and relative risks (RRs) for binary outcomes. Six RCTs with 968 patients (512 LCB, 456 PCB) showed statistical non-inferiority for LLL with an MD of 0.06 mm (-0.07 to 0.18, P for non-inferiority < 0.001, I² = 65%) based on the prespecified 0.20 mm margin. No significant differences were found in other angiographic outcomes: MD of 3.13 (-1.07 to 7.33, p = 0.14) for %DS, - 0.07 (-0.17 to 0.03, p = 0.15) for MLD, and RR of 1.32 (0.86 to 2.03, p = 0.21) for binary restenosis. Clinical outcomes were comparable with a non-significant trend toward higher TLR (RR: 1.23 [0.87 to 1.75], P = 0.24) and TLF (1.19 [0.88 to 1.63], P = 0.26) in LCB arm. LCBs are statistically non-inferior to PCBs for ISR treatment regarding late lumen loss, with considerable heterogeneity. Given the inconclusiveness of angiographic outcomes and marginally better clinical outcomes in PCBs, the conduct of larger trials seems necessary.

Measurement of absolute coronary blood flow and myocardial resistance by continuous intracoronary thermodilution was recently introduced and facilitates assessment of the coronary microcirculation. In addition, Microvascular Resistance Reserve (MRR) is a new index that further permits the characterization of coronary microcirculatory function. It can be calculated from resting and hyperemic absolute coronary flow and resistance, measured during continuous thermodilution. By being independent of both epicardial disease and myocardial mass, MRR is highly specific for the microvascular compartment. Measurement of absolute flow, resistance, and MRR by continuous thermodilution has been shown to be accurate and reproducible, with minimal operator interference. In conjunction with the measurement of absolute flow and resistance, MRR could become the index of reference for the diagnosis of coronary microvascular disease and the evaluation of new therapies. In this paper, the basis and practicalities of these measurements are shortly reviewed and its characteristics, its advantages over existing indices, its limitations, and future perspectives are discussed. Word count abstract: 158. Word count text: 7954 (including references and legends).