Quantitative and qualitative assessment of X-ray morphology of coronary restenosis after balloon angioplasty and stenting

The study was undertaken to compare the data of quantitative angiographic analysis of early and late outcomes of intracoronary stenting (ICS) and balloon coronary angioplasty (BCA) with the X-Ray morphology of restenosis. The prospective study enrolled 67 patients undergone repeated coronary angiography 2-10 months after successful BCA. Group I included 34 patients with coronary restenosis. Group II comprised 33 patients without restenosis signs. Each group was divided into 2 subgroups: A--patients undergone BCA; B--patients undergone ICS. Subgroups IA and IB included 22 and 12 patients, respectively, and subgroups IIA and IIB consisted of 24 and 19. The X-ray morphology of the underlying versus restenosis lesions in the subgroups was quantitatively and qualitatively assessed. The findings have led to the following conclusions that ICS yields more optimal early and late angiographic results than does BCA; according to the site of restenosis against the underlying lesion, the following types of restenosis following BCA and ICS are identified: diffuse, localized, marginal, and mixed; restenosis after ICS is characterized by for concentric morphology while that following BCA preserves the morphology of a primary lesion.     

Comparison of the results of stenting ans balloon angioplasty of coronary arteries in relation to the type of stenosis

Based on the comparison of the immediate and late results of stenting and balloon angioplasty (BA), the authors consider whether it is expedient to perform stenting of coronary arteries (CA) in all cases of BA in patients with coronary heart disease (CHD) and different types of CA stenosis. The study included 410 patients: a group of stenting (n = 197) and a group of traditional BA (n = 213). All the patients in both groups were divided into four subgroups in relation to the type of detected stenosis according to the classification of the American Association of Cardiologists (ACC/AHA). The positive angiographic and clinical results were observed in all 197 patients after stenting. This was associated neither with the type of dilated stenosis nor with the design of an implanted stent. In dilation of types A and B1 stenoses, a stent-like result was significantly more frequently observed than in dilation of types B2 and C stenoses. There was no significant difference in the development of restenosis in patients after routine BA and stenting of types A and B1 stenoses. At the same time, after BA of types B2 and C stenoses, restenosis developed significantly more frequently than in stenting. Thus, on the basis of this study, it may be stated that the traditional BA yields the so-called stent-like result significantly more frequently in patients with uncomplicated forms of CA stenoses than in those with complicated ones. Once the stent-like result is achieved in patients with type A stenoses, stenting should not be performed since the latter fails to improve the immediate and late results of angioplasty. Despite that the stent-like result is achieved in patients with complicated forms of CA stenoses, it is expedient to make stenting. Our findings indicate that the obtained good immediate result reduces the incidence of restenosis.     

Efficiency of endovascular re-interventions for evolving restenosis of different types of stents

The paper compares the results of different treatment options (balloon angioplasty and restenting) for in-stent restenosis in case of evolving restenosis of drug- and nondrug eluting stents. The investigation enrolled 496 coronary heart disease patients with clinical presentation of angina pectoris and/or signs of myocardial ischemia, as well as hemodynamic restenosis of a previously implanted stent. Of them, 216 and 280 patients had restenosis of previously implanted drug- and nondrug-eluting stents, respectively. In the patients with non-drug-eluting stent restenosis, recurrent angina pectoris and the frequency of repeated restenosis were significantly more frequently observed after balloon dilatation than after drug-eluting stent implantation (28.4 and 10.2%; p < 0.05; 19.9 and 8.7%; p < 0.05). In those with drug-eluting stent restenosis, recurrent angina pectoris and the frequency of repeated restenosis did not differ significantly between balloon dilatation of restenosis and implantation of a second drug-eluting stent.     

Plasma endothelin levels as a function of coronary artery manipulation during balloon angioplasty and high-speed rotational atherectomy

This study was conducted to test the hypothesis that endothelin levels may be related to the coronary artery manipulation during balloon angioplasty (BA) or rotational atherectomy (RA). Blood endothelin levels were measured in 35 patients who underwent BA and in 11 patients who underwent RA followed by adjunctive balloon angioplasty. Arterial and venous levels were measured before, immediately after, and 24 h after the procedure. The levels were then related to the number of balloon inflations, the total inflation time and the maximal pressure in the balloon during inflation. There were no significant differences between groups or time periods. However, 24 h after BA the endothelin plasma levels in venous blood were directly related to the number of balloon inflations (r 3 0.49; P 3 0.03), to the total inflation time (r 3 0.67; P 3 0.005) and to the maximal inflation pressure (r 3 0.71; P 3 0.001). No such correlation was found in venous blood immediately after BA, either in arterial blood or in the RA group. It can be concluded that plasma endothelin levels do not change significantly after balloon angioplasty; however, venous endothelin levels 24 h after BA are related to procedural parameters, reflecting endothelial damage, which may determine the post-angioplasty late results.     

Inhibition of endothelin-converting enzyme for protection against neointimal proliferation following balloon angioplasty of the rat carotid artery

Clinical success of percutaneous transluminal coronary angioplasty is limited by restenosis within months of the initial intervention. A number of vasoactive mediators and growth factors have been reported to participate in this process. The aim of the present experiments was to examine the effects of nonselective neutral endopeptidase (NEPi)/endothelin-converting enzyme (ECEi) inhibitors against neointimal proliferation (NIP) following balloon angioplasty of the left carotid artery of Sprague-Dawley rats with the right vessel serving as the uninjured control. The rats were divided in several groups: group 1, nontreated (vehicle); group 2, treated with a selective NEPi i.p.; groups 3-7, treated with nonselective NEPi/ECEi either i.p., s.c., i.v., or p.o. at various doses. After 2 weeks, cross-sectional histopathological and morphometrical examination of the left carotids revealed a severe NIP in vehicle-treated angioplastic rats compared with the control uninjured right carotid of the same rats. The selective NEPi CGS 24592 had no significant effect on restenosis, nor did the dual NEPi/ECEi CGS 26303 at 5 mg x kg(-1) x day(-1) i.p. Both s.c and i.v. NEPi/ECEi treatment (10 mg x kg(-1) x day(-1) b.i.d. s.c. or 10 mg x kg(-1) x day(-1) i.v.) reduced NIP by up to 35%. The prodrug CGS 26393 (p.o.) also attenuated NIP by 23%. Plasma concentrations of these compounds correlated with the degree of inhibition. These data support the participation of the endothelin system in the rat model of balloon angioplasty and suggest that selective ECEi may be effective.     

Cardiac autonomic control during balloon carotid angioplasty and stenting

Hemodynamic alterations during balloon carotid angioplasty (BCA) and stenting have been ascribed to the consequences of direct carotid baroreceptor stimulation during balloon inflation. BCA with stenting in patients with carotid atheromatous stenoses offers a unique opportunity for elucidating the cardiovascular autonomic response to direct transient intravascular stimulation of the baroreceptors. We analysed the consequences of BCA on the autonomic control of heart rate and on breathing components in nine patients with atheromatous stenoses involving the bifurcation and the internal carotid. A time-frequency domain method, the smoothed pseudo-Wigner-Ville transform (SPWVT), was used to evaluate the spectral parameters (i.e., the instantaneous amplitude and centre frequency (ICF) of the cardiovascular and respiratory oscillations). Those parameters and their dynamics (8 and 24 h later) were evaluated during and after the procedure. BCA stimulates baroreceptors in all patients, which markedly reduces heart rate and blood pressure. Vagal baroreflex activation altered the respiratory sinus arrhythmia in terms of amplitude and frequency (ICF HF RR shifted from 0.27 +/- 0.03 to 0.23 +/- 0.04 Hz pre-BCA vs. BCA, respectively; p < 0.01). Both the high- and low-frequency amplitudes of heart rate oscillations were altered during carotid baroreceptor stimulation, strongly supporting a contribution of the baroreflex to the generation of both oscillations of heart rate. Carotid baroreceptors stimulation increased the inspiratory time (Ti) (1.5 +/- 0.5 to 2.3 +/- 0.6 s pre-BCA vs. BCA, respectively; p < 0.01). In awake patients, BCA with stenting of atheromatous stenosis involving the bifurcation and internal carotid causes marked changes in the cardiac autonomic and respiratory control systems.     

Artery balloon angioplasty and depression symptoms

Peripheral arterial occlusive disease (PAOD) as a chronic disease is associated with physical, psychological and social distress for elderly patients and their families. The study has three main aims: 1. to evaluate the occurrence and the relevance of depression symptoms in patients with PAOD, 2. to evaluate the effect of age and Fontaine stage of PAOD on relevance of depression in patients with PAOD, and 3. to evaluate the effect of artery balloon angioplasty (ABA) on occurence and relevance of depression symptoms. The study was prospective and longitudinal. Dates were obtained during year 2006. The total number of subjects with PAOD was 42 (28 males, 14 females). Thirty subjects with PAOD (20 male, 10 female) treated by ABA filled in Zung's scale 3-6 months after ABA (61%). The mean age of all subjects was 65.4 years (aged 45-79). The evaluation of occurrence and relevance of depression was performed with Czech version of Zung self-rating depression scale (ZSRS). The mean Zung self-rating depression score (ZSRDS) certifies the presence of signs of minimum or mildly depression in patients with PAOD. The results proved statistically significant dependence of depression on age and on Fontaine stage of PAOD. Also, the results proved that artery balloon angioplasty has a highly positive effect on occurrence and relevance of depression symptoms. The results had shown the existence of the association between PAOD, depression and ABA.     

Long period of balloon inflation and the implantation of stents potentiate smooth muscle cell death. Possible role of chronic vascular injury in restenosis

BACKGROUND: It has been suggested that the severity of acute vascular injury immediately after percutaneous transluminal coronary angioplasty (PTCA) or stent implantation correlates with the extent of neointimal hyperplasia and restenosis. However, the influence of prolonged or chronic vessel injury on the pathogenesis of restenosis is unclear. METHODS: Rabbit iliac arteries were balloon dilated for a short (1 min) or prolonged (10 min) period of time, or were chronically dilated and received a Palmaz-Schatz stent (balloon inflation for 1 min). All arteries were overexpanded to a balloon:artery ratio of 1.2:1 as determined by angiography. The arteries were removed 30 min and 4 weeks after the angioplasty procedures. The sites of injury were evaluated by gross histology and transmission electron microscopy (TEM). Cell death of medial smooth muscle cells (SMCs) was specified by TEM images 30 min after the procedures. Computer-assisted quantification of the neointimal cross-sectional areas was performed after 4 weeks using a light microscope connected to a digital image analyser. RESULTS: The results show that prolonged balloon dilatation and stent implantation increased necrotic SMC death compared with balloon dilatation for 1 min. After 30 min, increased staining of SMC nuclei, enlarged intercellular spaces and changes in SMC shape in the media indicated cell death induced by prolonged balloon dilatation or chronic stent injury. Stent implantation markedly augmented vessel damage by persistent compression of the media, compared with a balloon dilatation for 1 or 10 min. Both prolonged balloon dilatation and stent implantation increased neointimal hyperplasia at 4 weeks compared with balloon dilatation for 1 min (0.6 3 0.2 and 1.0 3 0.2 mm(2) versus 0.2 3 0.1 mm(2), P < 0.001 versus dilatation for 1 min). CONCLUSION: Prolonged or chronic vascular expansion due to long balloon-inflation periods or the implantation of stents increases medial SMC death, which subsequently stimulates neointimal growth in this restenosis model. Chronic vascular injury may be an important stimulus for restenosis after angioplasty procedures.     

Adenovirus-mediated transfer of the herpes simplex virus thymidine kinase gene inhibits vascular smooth muscle cell proliferation and neointima formation following balloon angioplasty of the rat carotid artery.

BACKGROUND: Vascular smooth muscle cell (VSMC) proliferation following arterial injury plays a critical role in a variety of vascular proliferative disorders, including atherosclerosis and restenosis after balloon angioplasty. In this study, we tested the hypothesis that localized arterial infection at the time of balloon angioplasty with an adenovirus (ADV-tk) encoding the herpes simplex virus thymidine kinase gene (HSV-tk), followed by systemic ganciclovir administration, can inhibit VSMC proliferation and neointima formation in a well-characterized model of arterial injury and restenosis. MATERIALS AND METHODS: The left carotid arteries of 31 male Sprague-Dawley rats were subjected to balloon angioplasty and immediately infected with 2 x 10(9) pfu of either ADV-tk or a control adenovirus that does not encode a recombinant protein (ADV-delta E1). Twenty-four hours after injury, animals from each experimental group were randomized to receive a course of systemic ganciclovir (ADV-tk/+GC, ADV delta E1/+GC) or saline (ADV-tk/-GC, ADV-delta E1/-GC). VSMC DNA synthesis was measured by 5'-bromodeoxuridine (BrdU) incorporation 2-4 days after balloon injury. The extent of restenosis, expressed as the neointima to media (I/M) area ratio was determined by digital planimetry 20 days after balloon injury in each of the four treatment groups. Immunohistochemistry using a mAb to von Willebrand factor (vWF) was used to determine the effects of ADV-tk infection and ganciclovir treatment on re-endothelialization of the carotid arteries 20 days following balloon angioplasty. RESULTS: Forty-one percent of the medial VSMCs in the ADV-tk/-GC arteries were labeled with BrdU 4 days after balloon injury. In contrast, ADV-tk infected animals that were treated with systemic ganciclovir (ADV-tk/+GC) displayed a 40% reduction in BrdU-staining medial VSMCs (p < 0.03). I/M area ratios of the three control groups were 1.17 +/- 0.18 (ADV-tk/-GC, n = 5), 1.15 +/- 0.10 (ADV-delta E1/+GC, n = 6), and 0.91 +/- 0.08 (ADV-delta E1/-GC, n = 6). These differences were not statistically significant (p > 0.05). In contrast, the ADV-tk/+GC animals (n = 6) displayed an I/M area ratio of 0.49 +/- 0.13 which was significantly lower than that seen in each of the three control groups (p < 0.02). None of the treated animals showed evidence of significant organ toxicity at autopsy. A regenerated endothelium was observed in the ADV-tk/+GC animals 20 days after balloon injury. CONCLUSIONS: Localized arterial infection with ADV-tk at the time of balloon angioplasty followed by systemic ganciclovir therapy reduces VSMC proliferation and neointimal expansion in the rat carotid artery injury model. Moreover, combined treatment with ADV-tk and systemic ganciclovir does not result in systemic toxicity and appears to selectively eliminate proliferating VSMCs, while preserving the capacity of the injured arterial segments to re-endothelialize within 3 weeks of injury. Taken together, these results support the feasibility of using this gene therapy approach for the treatment of human vascular proliferative disorders.     

Brachytherapy with gamma radiation of a coronary artery for in-stent restenosis may induce the regression of in-stent restenosis of an adjacent coronary artery without angioplasty. First case report and review of the literature

Here, we present a case of a 63-year-old male who presented with in-stent restenosis of two coronary arteries simultaneously (mid circumflex and proximal ramus). After the brachytherapy of the circumflex artery for in-stent restenosis, the patient refused the staged procedure for the ramus in-stent restenosis. After approximately 2 years, the patient underwent coronary angiography for recurrent chest pain. Surprisingly, the proximal ramus stent showed marked regression of in-stent restenosis. We hypothesized that the gamma brachytherapy of the circumflex artery could have induced the regression of in-stent restenosis of the adjacent ramus artery due to the deep tissue penetration of gamma radiation. Based on our observation, we believe that in the treatment of in-stent restenosis of a coronary artery, the initial balloon angioplasty may not be as important as the radiation itself. This observation warrants further study to evaluate the effect of external or internal radiation on in-stent restenosis without balloon angioplasty. If our hypothesis is confirmed, the treatment of in-stent restenosis with external radiation could substantially simplify the treatment of this disease. This case report follows a brief review of the literature.     

Intramural delivery of Sirolimus prevents vascular remodeling following balloon injury

OBJECTIVE: Several studies have demonstrated that Sirolimus-eluting stents reduce restenosis in patients with coronary artery disease. Here, we tested whether direct delivery of Sirolimus into the vessel wall during balloon angioplasty can modify vascular remodeling over several weeks. METHODS AND RESULTS: During angioplasty of the rabbit iliac artery we administered an intramural infusion of Sirolimus or its vehicle directly through a balloon catheter into the vessel wall. After 3 weeks neointimal formation was decreased (0.71+/-0.1 vs. 1.4+/-0.12 intima/media ratio), and this process was attributed to the inhibitory properties of Sirolimus on ECM deposition and smooth muscle cell proliferation. Sirolimus also significantly reduced the deposition of elastin, collagen III and fibronectin within the vascular wall. In parallel, proteomic profiles of arterial wall segments were obtained and 485 protein spots were consistently matched between non-dilated and dilated vessels. Differential expression of 12 proteins were observed between the groups and direct sequencing of digested peptides was performed. Local delivery of sirolimus during angioplasty attenuated the expression of structural proteins that included lamin A, vimentin, alpha-1-antitrypsin, and alpha-actin. CONCLUSIONS: Local administration of Sirolimus during angioplasty prevents smooth muscle cell proliferation associated with vascular remodeling as well as the expression of extracellular matrix and structural proteins. Therefore, local injection of Sirolimus during balloon inflation may be an alternative therapeutic approach for preventing restenosis in small stenotic vessels (i.e., <2.5 mm).     

Numerical simulation of arterial dissection during balloon angioplasty of atherosclerotic coronary arteries

Balloon angioplasty is a standard clinical treatment for symptomatic coronary artery disease. In this procedure, controlled damage is applied intraluminally to the wall of a stenotic artery. Dissection of the coronary artery is a commonly observed clinical complication of angioplasty; however, not all dissections can be detected angioscopically. This work focuses on studying the dissection mechanisms triggered during the early stages of angioplasty in an atherosclerotic coronary artery, addressing the problem by means of a parametric study based on a simplified finite element model and cohesive interface modeling. Our results emphasize the presence of several damage mechanisms, at different locations, that are triggered near the very beginning of the process and evolve competitively, depending on both geometry and material properties of the atherosclerotic vessel. Small-scale damage was evidenced, which would not be detectable by angiography or intravascular ultrasound, but could potentially be sufficient to stimulate smooth muscle cell activation, promoting late-onset complications such as restenosis.     

冠状动脉内放射抑制球囊扩张术后ERK1/2活性及c-fos基因表达

本文旨在观察血管内放射对冠状动脉球囊扩张术后细胞外信号调节激酶１／２（ＥＲＫ１／２）及ｃ－ｆｏｓ基因表达的影响。实验对猪的左冠状动脉前降支或回旋支行球囊行过度扩张术,术后即刻能过血管内放射治疗系统对猪冠状动脉损伤局部给予２０Ｇｙ的放射剂量,分别是在术后３ｄ和３０ｄ处死动物,留取目标血管组织。通过反转录－聚合酶链反应定量检测血管内入射对球囊扩张术后血管组织ｃ－ｆｏｓ ｍＲＮＡ的表达,采用生化方法测定     

Clinical trends in stent treatment of simple and complex coronary disease

This is a retrospective analysis of a consecutive group of patients from a single medical center who underwent stent implantation. It describes 316 patients who constituted 53% of the angioplasty procedures carried out in a single year. The authors describe the complications and their 1-year follow-up. We aimed to study the short and long-term results of stenting in our centre in relation to multiple clinical and angiographic variables. During 1996, 316 consecutive patients were treated with stent implantation for a total of 381 coronary lesions. The pharmacological protocol methods of stent implantation and patient characteristics were used. Clinical variables were: age 59.1 3 10.7 years, diabetes mellitus 25.3%, hypertension 33.0% and angina pectoris 88.7% (unstable in 44.1%). Previous coronary surgery had been undergone by 9.2%. Multivessel disease was present in 56% of the patients. The indications for stenting were: primary 58.5%, suboptimal results 33.0% and threatened or acute occlusion 8.5%. Angiographic success was 98.9% and clinical success 96.8%. The major in-hospital complications were acute myocardial infarction (2.2%), acute revascularization (0.3%) and major bleeding (0.6%). All occurred within 24 h of revascularization. Repeated angiography was performed in 115 cases (30.2%) at 160.3 3 109.4 days after stent procedure for unstable angina (38.7%), stable angina (26.1%) and other causes (35.2%). The restenosis rate in those catheterized was 38.1%, with an overall clinical restenosis rate of 11.3% during the follow-up period. Restenosis was more prevalent among diabetic patients (17.9 vs 9.15%, P 3 0.02) and patients with prior balloon angioplasty (18.6 vs 9.75%, P 3 0.046). Clinical follow-up was available in 90.8% of the patients for 291 3 112 days. The actuarial survival at the end of the follow-up period was 93.8%. Death/myocardial infarction was associated with unstable angina pectoris (P 3 0.006), hypertension (P 3 0.001), smoking (P 3 0.046) and threatened or acute occlusion (P < 0.001). In the first year of extensive stent use, stenting is associated with high technical and clinical success rates. Long-term results after stent implantation are associated with the occurrence of acute or threatened occlusion, and the in-hospital complications diabetes mellitus and hypertension.     

Telomeric restriction analysis of vascular smooth muscle cells following balloon angioplasty in rabbits

Intimal hyperplasia due to smooth muscle cell proliferation and migration has been reported to be responsible for the pathogenesis of atherosclerosis and restenosis, manifested following balloon angioplasty. In this study, we employed the balloon angioplasty model to study telomere length regulation in proliferating vascular smooth muscle cells. Our results showed that balloon angioplasty in iliac arteries resulted in intimal hyperplasia due to proliferation of the smooth muscle cells and small size telomeric restrictional fragments were evident in injured arteries.     

Treatment of calcified ostial disease by rotational atherectomy and adjunctive cutting balloon angioplasty prior to stent implantation

Both heavily calcified and ostial lesions are difficult to deal with by percutaneous transluminal coronary angioplasty (PTCA) alone. Acute results are often sub-optimal, complications are more frequent, and long-term results are disappointing. Optimal stent deployment may not be possible unless satisfactory lesion dilatation is achieved and the lesion made more compliant. The use of rotational atherectomy and cutting balloon angioplasty to a calcified ostial lesion in the left circumflex coronary artery prior to stent implantation is reported.     

Management of acute coronary occlusion during percutaneous transluminal coronary angioplasty: experience of complications in a hospital without on site facilities for cardiac surgery.

OBJECTIVE--To determine whether percutaneous transluminal coronary angioplasty may be safely performed in cardiology centres in the United Kingdom without immediate on site cardiac surgical cover for complications arising at angioplasty. DESIGN--Retrospective review of coronary angioplasties and complications in a hospital without on site cardiac surgical cover. SETTING--All angioplasties were performed in the catheterisation laboratory of the Belfast City Hospital. Revascularisation surgery for complicated coronary angioplasty was performed in the cardiac surgical unit of the Royal Victoria Hospital, 2.4 km away from the catheterisation laboratory. PATIENTS--540 Coronary angioplasties were performed on 512 patients between late 1982 and November 1988. Indications included stable angina, unstable rest angina, and suitable coronary disease at coronary arteriography after myocardial infarction. MAIN OUTCOME MEASURES--In hospital mortality after complicated coronary angioplasty and delay to surgical revascularisation after acute coronary occlusion at angioplasty. RESULTS--Coronary angioplasty was successful in 444 cases (82%). Acute coronary occlusion occurred in 35 cases (6.5%). Twelve patients required urgent revascularisation surgery and were transferred safely to the surgical unit; none of these patients died. A mean delay of 268 minutes (range 180-390 minutes) occurred before revascularisation compared with 273 minutes (range 108-420 minutes) in the Royal Victoria Hospital, where on site surgical cover was available. The principal cause of delay was the wait for a cardiac operating theatre to become available and not the transfer time between hospitals. Five deaths occurred after coronary angioplasty, a mortality of 0.9%. Three deaths were related to acute coronary occlusion. The absence of immediate surgical help did not influence the outcome in any patient. CONCLUSION--With careful selection of patients coronary angioplasty may be safely performed in a hospital without on site cardiac surgical facilities, provided that these are available at a nearby centre.     

Coronary pressure and FFR predict long-term outcome after PTCA

Although coronary stents have been the most important improvement in percutaneous coronary interventions in the last 10 years, it is well known to interventionalists that many patients after percutaneous transluminal coronary angioplasty (PTCA) have a favourable outcome without stenting. Coronary angiography, however, is not sensitive enough to identify those particular patients and it has been suggested that a combination of angiographic and functional criteria would be more suitable to distinguish patients with a low restenosis chance after plain balloon angioplasty. In the present study, the authors investigated the value of coronary pressure measurement for conditional stenting in 85 patients. It was demonstrated that in patients in whom a high fractional flow reserve (FFR) was present (> 0.90), the incidence of coronary events at two-year follow-up was almost three times lower than in those patients with an FFR below 0.90. Such high FFRs could be obtained in approximately 45% of all patients. In an additional group of patients, it was demonstrated by intravascular ultrasound (IVUS) studies that the mechanism of a high FFR after plain balloon angioplasty is most likely the result of a larger lumen compared with patients with a suboptimal FFR. This means that, in patients in whom both the angiographic and the functional result after PTCA is optimal, a restenosis rate is achieved similar to that achieved by stenting. Obviously, in such patients, additional stenting and a number of problems in the long-term possibly related to stenting can be avoided. Therefore, coronary angiography and coronary pressure measurement have a complementary value in the evaluation of PTCA results and such information can be easily obtained by using a pressure wire instead of a regular guidewire.     

Severe acute coronary spasm following intracoronary radiation for in-stent restenosis: A case report

Intracoronary radiation therapy is currently the only available treatment for the prevention of recurrence of in-stent restenosis. We report a case of severe coronary spasm after excimer laser angioplasty, balloon angioplasty, and intracoronary gamma radiation in the right coronary artery (RCA) that resulted in an acute myocardial infarction. Treatment with 600 μg of intracoronary nitroglycerin resulted in minimal improvement; therefore, diltiazem 400 μg was administered intracoronary with total resolution of the spasm, restoring normal coronary blood flow without trace of acute dissection or thrombus inside the artery.