Intermittent spastic coronary occlusion at site of non-significant atherosclerotic lesion requiring stent implantation

A 65-year-old woman was admitted with severe but mainly atypical chest pain at rest for some weeks. Two years ago, primary percutaneous coronary intervention with stenting of the mid left anterior descending artery (LAD) had been performed in the setting of an anterior myocardial infarction. Physical examination, electrocardiogram, serum levels of troponin I, and echocardiography were normal. During maximal treadmill test, a significant depression of the ST segment was found in leads V⁴ to V⁶ while the patient remained asymptomatic. Coronary angiography demonstrated normal right (figure 1A) and circumflex (figure 1B) coronary arteries while the LAD was totally occluded just proximal to the previously implanted stent (figure 1B). However, a few minutes later, ventriculography showed – besides normal left ventricular function – anterograde filling of the LAD (figure 1C, arrows).     

Factors that affect mass transport from drug eluting stents into the artery wall

Coronary artery disease can be treated by implanting a stent into the blocked region of an artery, thus enabling blood perfusion to distal vessels. Minimally invasive procedures of this nature often result in damage to the arterial tissue culminating in the re-blocking of the vessel. In an effort to alleviate this phenomenon, known as restenosis, drug eluting stents were developed. They are similar in composition to a bare metal stent but encompass a coating with therapeutic agents designed to reduce the overly aggressive healing response that contributes to restenosis. There are many variables that can influence the effectiveness of these therapeutic drugs being transported from the stent coating to and within the artery wall, many of which have been analysed and documented by researchers. However, the physical deformation of the artery substructure due to stent expansion, and its influence on a drugs ability to diffuse evenly within the artery wall have been lacking in published work to date. The paper highlights previous approaches adopted by researchers and proposes the addition of porous artery wall deformation to increase model accuracy.     

Effects of diffusion coefficients and struts apposition using numerical simulations for drug eluting coronary stents

In the context of drug eluting stent, we present two-dimensional numerical models of mass transport of the drug in the wall and in the lumen to study the effect of the drug diffusion coefficients in the three principal media (blood, vascular wall, and polymer coating treated as a three-compartment problem) and the impact of different strut apposition configurations (fully embedded, half embedded, and not embedded). The different conditions were analyzed in terms of their consequence on the drug concentration distribution in the arterial wall. We apply the concept of the therapeutic window to the targeted vascular wall region and derive simple metrics to assess the efficiency of the various stent configurations. Although most of the drug is dispersed in the lumen, variations in the blood flow rate within the physiological range of coronary blood flow and the diffusivity of the drug molecule in the blood were shown to have a negligible effect on the amount of drug in the wall. Our results reveal that the amount of drug cumulated in the wall depends essentially on the relative values of the diffusion coefficients in the polymer coating and in the wall. Concerning the strut apposition, it is shown that the fully embedded strut configuration would provide a better concentration distribution.     

Inhibition and regression of atherosclerotic lesions

Atherosclerosis, once believed to be a result of a slow, irreversible process resulting from lipid accumulation in arterial walls, is now recognized as a dynamic process with reversibility. Liver-directed gene therapy for dyslipidemia aims to treat patients who are not responsive to currently available primary and secondary prevention. Moreover, gene therapy strategies have also proved valuable in studying the dynamics of atherosclerotic lesion formation, progression, and remodeling in experimental animals. Recent results on the long-term effect of gene therapy suggest that hepatic expression of therapeutic genes suppresses inflammation and has profound effects on the nature of the atherogenic process.     

Lipoprotein-acid mucopolysaccharide complexes of human atherosclerotic lesions.

Lipoprotein-acid mucopolysaccharide complexes occurring in different types of human atherosclerotic lesions were isolated and partially characterized. Complexes from fatty streaks and fibrous plaques were extracted from pooled tissues with 0.15 M NaCl, purified by gel filtration, and fractionated by ultracentrifugation. Both low and very low density lipoproteins were present; low density lipoprotein was predominant. The complexes were analyzed for uronic acid, cholesterol, phospholipid, and Ca-2+ contents; there was no significant difference in the relative molar ratios between complexes from fatty streaks and fibrous plaques. Acid mucopolysaccharides were isolated from the complexes and identified by electrophoresis and enzymatic studies. Chondroitin sulfate C and hyaluronic acid were found in complexes from fatty streaks and fibrous plaques. Heparin was detected only in fibrous plaques.     

Development of atherosclerotic lesions in cholesterol-loaded rabbits.

To examine both of the target vessels and the optimal time of their endothelial denudation to study vascular restenosis after balloon injury in cholesterol-loaded rabbits, we made 36 atherosclerotic rabbits by feeding a hypercholesterol diet, and histologically examined the onset time and the development of atherosclerosis. Atheromatous changes were observed first after the 5th week in the thoracic aorta from the start of the diet, and then extended to the abdominal aorta, coronary artery with time. The atherosclerotic lesions in the thoracic aorta and the proximal portion of the coronary artery showed high-grade concentric intimal thickening with luminal stenosis. The abdominal aortic lesion mildly progressed. In the renal, carotid and femoral arteries, in contrast, slight atheroscleromatous changes developed during the diet period. These results suggest that the thoracic and abdominal aortas and the coronary artery would be suitable as target vessels to study vascular restenosis after balloon injury, and the endothelial denudation of these vessels should be performed between the 8th and 15th week in this diet protocol for an accurate analysis.     

Genetic loci for diet-induced atherosclerotic lesions and plasma lipids in mice

Genetic factors independent of those affecting plasma lipid levels are a major contributor to risk for atherosclerosis in humans, yet the basis for these is poorly understood. This study examined plasma lipids and diet-induced atherosclerosis in 16-month-old female mice of strains C56BL/6J and DBA/2J. Mice of the parental strains, from recombinant inbred strains derived from these (BXD RI), and F₂ progeny were fed an atherogenic diet for 16 weeks, beginning at 1 year of age. This induced atherosclerotic lesion formation in both parental strains, accompanied by increased plasma LDL levels. However, individual BXD RI strains and the BXD F₂ mice demonstrated a range of atherosclerotic lesion formation that was not or at best weakly correlated with plasma lipid levels. Quantitative trait locus (QTL) analysis of the BXD F₂ mice identified a locus with significant linkage (lod 4.5) for aortic lesion size on Chromosome (Chr) 10 that was independent of plasma lipids. Other loci with suggestive or significant linkage for various plasma lipid measures were identified on Chr 2, 3, 4, 5, 6, 7, 11, and 17. In this intercross, the genes primarily influencing atherosclerosis are distinct from those controlling plasma lipid levels.     

Use of drug-coated stents to treat coronary bifurcation lesions

Bifurcation stenoses are one of the most complex categories for endovascular treatment as such lesion requires that the lumen of both a great vessel and a lateral branch be recovered. Introduction of drug-coated stents into clinical practice has changed surgical approaches in this type of an atherosclerotic lesion. The use of two drug-coated endoprostheses or more within the afflicted segment to stent a great vessel or lateral branch does not increase a risk for restenosis. The considerable opportunities of endovascular technologies and the absence of a unified surgical approach in this type of lesion generate a need for systematizing the experience accumulated. The purpose of the present study is to develop an algorithm of bifurcation stenting in different types of X-ray anatomy and morphology of a coronary lesion.     

Autophagy of vascular smooth muscle cells in atherosclerotic lesions

Autophagy genes were first identified in the yeast system and some of their mammalian orthologues have also been characterized. Increasing lines of evidence indicate that various intracellular proteins, including G proteins, mammalian target of rapamycin (mTor) and Pl3K/Akt/PKB, of transmembrane signaling pathways are involved in the regulation of autophagy genes. We have recently discovered autophagy as a mechanism of cell death in atherosclerotic vascular smooth muscle cells (VSMCs). Tumor necrosis factor-alpha (TNF-alpha), insulin-like growth factor-1 (IGF-1), and 7-ketocholesterol can regulate the expression of autophagic genes, including microtubule-associated protein 1 light chain-3 (MAP1LC3) and Beclin 1, through Akt/PKB and c-jun N-terminal signal pathways in VSMCs. However, the balance between cell death and survival of VSMCs in the fibrous cap of atherosclerotic plaques appears to best correlate with plaque instability. Understanding the underlying cellular and molecular mechanisms of autophagy can provide key insights into the cell death machinery of atherosclerotic diseases.     

The release kinetics of drug eluting stents containing sirolimus as coated drug: Role of release media

Prior understanding on the in vitro release profile of the drug from drug eluting devices such as stent (DES) is crucial in designing and optimizing the drug embedded coating or matrices. In fact, assessing in vitro release profile is a mandatory requirement prior to the clinical evaluation of DES. The in vitro release is also employed to estimate parameters such as T1/2. The release profile largely depends on the release medium selected for the studies. Normally PBS with a pH of 7.4 is used for assessing the release kinetics of the drug. Often drug undergoes irreversible changes such as hydrolysis in PBS leading to erroneous assessment of the release profile. This is particularly true in the case of sirolimus, one of the widely used drugs in various applications. We studied the influence of various media on the release profile of sirolimus from DES. The data generated suggested that a release medium consisting of 9:1 (v/v) of normal saline and isopropanol is a most suitable one for assessing in vitro the release kinetics of sirolimus from DES.     

Effect of a taurine treatment on the regression of existing atherosclerotic lesions in rabbits fed on a high-cholesterol diet

We studied whether taurine has any regressive effect on existing atherosclerotic lesions and lipid peroxidation in rabbits fed on a high-cholesterol (HC) diet. The cholesterol, triglyceride, malondialdehyde (MDA) and diene conjugate (DC) levels, as well as the aortic histopathological findings were examined in rabbits that had been fed on a cholesterol-containing diet for 8 months [0.5% cholesterol (w/w) for 3 months and subsequently 0.25% cholesterol (w/w) for 5 months], and then for a further 4 months on a normal diet with or without taurine treatment [1% (w/v) in the drinking water]. High levels of lipid and lipid peroxide induced by the HC diet were observed to decline in the plasma, liver and aorta of atherosclerotic rabbits, as well as a slight retardation in aortic atherosclerotic lesions during the regression period. Although no significant differences in the lipid and lipid peroxide levels in the plasma and aorta were found between the regressed groups with or without the taurine treatment, the extent of atherosclerotic lesions in the aorta was less in the taurine-treated regressed group than in the non-treated regressed group. However, the liver MDA and DC levels were lower in the regressed rabbits with the taurine treatment in the non-treated group. These results indicate that the taurine treatment may accelerate the regression of cholesterol-induced atherosclerotic lesions in rabbits without having any effect on the plasma and aorta lipid and lipid peroxide levels.     

Paclitaxel C-10 carbamates: potential candidates for the treatment of neurodegenerative tauopathies

A series of paclitaxel C-10 carbamates was synthesized and evaluated in a bi-directional permeability assay in comparison with paclitaxel and the blood-brain barrier-permeable C-10 ester derivative, TX-67. A number of the carbamates were found not to be substrates for Pgp. Moreover, when tested for Pgp-inhibitory potential, representative compounds proved to be devoid of Pgp interactions. Side-by-side comparison between TX-67 and the corresponding C-10 carbamate, CNDR-3, revealed a significantly longer half-life for CNDR-3 in both mouse and human plasma, suggesting that this class of derivatives is appropriate for further in vivo evaluation.     

Numerical simulation on the effects of drug eluting stents at different Reynolds numbers on hemodynamic and drug concentration distribution

Background

The changes of hemodynamics and drug concentration distribution caused by the implantation of drug eluting stents (DESs) in curved vessels have significant effects on In-Stent Restenosis.

Methods

A 3D virtual stent with 90°curvature was modelled and the distribution of wall shear stress (WSS) and drug concentration in this model were numerically studied at Reynolds numbers of 200, 400, 600, 800.

Results

The results showed that (1) the intensity of secondary flow at the 45° cross-section was stronger than that at the 90° cross-section; (2) As the Reynolds number increases, the WSS decreases. When the Reynolds number reaches 600, the low-WSS region only accounts for 3% of the total area. (3) The effects of Reynolds number on drug concentration in the vascular wall decreases in proportionally and then the blood velocity increased 4 times, the drug concentration in the vascular wall decreased by about 30%. (4) The size of the high drug concentration region is inversely proportional to the Reynolds number. As the blood velocity increases, the drug concentration in the DES decreases, especially at the outer bend.

Conclusions

It is beneficial for the patient to decrease vigorous activities and keep calm at the beginning of the stent implantation, because a substantial amount of the drug is released in the first two months of stent implantation, thus a calm status is conducive to drug release and absorption; Subsequently, appropriate exercise which increases the blood velocity is helpful in decreasing regions of low-WSS.

     

A comparison of clinical outcomes of Chinese sirolimus-eluting stents versus foreign sirolimus-eluting stents for the treatment of coronary artery disease

Background

Chinese sirolimus-eluting stents (SES) have been widely used in recent years. However, the comparison of clinical outcomes between Chinese and foreign SES remains unknown.

Objectives

To compare the outcomes of Chinese SES (Firebird) with foreign SES (Cypher Select) in the treatment of patients undergoing percutaneous coronary intervention (PCI).

Methods

4000 consecutive patients treated with SESs from January 2008 to December 2009 were included in this study. Based on the differences of the stents, the patients were divided into a Chinese SES group (Firebird; n = 2008) and a foreign SES group (Cypher Select; n = 1992). Outcomes were monitored for 1 year. The primary clinical endpoint was major adverse cardiac events (MACE): a composite of death, non-fatal myocardial infarction (MI) and target-vessel revascularisation (TVR).

Results

No differences were observed in the incidence of MACE (17.8% vs. 18.6%, p = 0.514) and TVR rate (9.0% vs. 8.6%, p = 0.632) during 1-year follow-up.

Conclusions

Chinese SES and foreign SES have similar effects on 1-year clinical outcomes and safety.     

Macroscopic distribution of coronary atherosclerotic lesions in cholesterol-fed rabbits.

In the present study we macroscopically examined a change in the distribution of coronary atherosclerosis in cholesterol-fed rabbits. Rabbits were fed a cholesterol-enriched diet for 15 weeks, then replaced by a normal diet, and were sacrificed at 15, 24, 32 and 42 weeks after the start of the experiment. The coronary atherosclerosis in the cholesterol-fed rabbits was distributed more densely in the proximal portion than in the middle and distal portions, and the lesions were severe at 24 and 32 weeks after the start of the experiment. comparison of lesions in the three portions at these time points showed that the percentages of lesion areas in the proximal portion, the middle portion and the distal portion were approximately 51%, 21 to 25% and 0.2 to 3.7%, respectively. Macroscopic observation of the coronary atherosclerotic lesions showed that the lesions formed over the vessel lumen in the proximal portion within the range of approximately 5 mm from the orifice of the left coronary artery. In the middle portion, the lesions formed predominantly around the orifices of branches as small patchy lesions from 1 to 3 mm in diameter. These findings support previous histopathological reports that suggested that the incidence of stenosis in the proximal portion was high, and the incidence of lesion occurrence in the middle and the distal portions varied. The method, macroscopical investigation of the coronary artery, is useful for analyzing coronary atherosclerosis in the rabbit.