坂倉 建一

Percutaneous coronary intervention (PCI) for severely calcified coronary lesions remains challenging, as extensive calcification frequently hampers adequate lesion preparation and optimal stent expansion, thereby increasing the risk of procedural complications and adverse clinical outcomes. The management of these complex lesions continues to require careful procedural planning. Intravascular imaging (IVI), including intravascular ultrasound and optical coherence tomography/optical frequency domain imaging, provides detailed insights into coronary calcium morphology. IVI has become an important tool in contemporary PCI. IVI allows comprehensive evaluation of calcium characteristics such as arc, longitudinal length, thickness, depth, and surface morphology. These findings are closely related to lesion compliance and subsequent stent expansion. The information from IVI facilitates appropriate selection and optimization of calcium modification strategies, including conventional balloons, atherectomy devices, and intravascular lithotripsy. Furthermore, IVI enables assessment of procedural effectiveness by confirming plaque modification, calcium fracture, and stent expansion, while also identifying imaging features associated with an increased risk of vessel injury, dissection, or slow flow. However, each imaging modality has inherent limitations, and careful interpretation of imaging findings is essential, particularly in severely calcified lesions. In this review, we summarize current concepts of IVI-based assessment of coronary calcification and discuss practical considerations for device selection and lesion preparation in severely calcified lesions. Integrating intravascular imaging into PCI may contribute to more tailored treatment strategies and improved clinical outcomes in patients with severely calcified coronary artery disease.

The clinical outcomes of acute myocardial infarction (AMI) in dialysis patients are poor, and the outcomes may be worse in the long-term dialysis patients due to diabetic nephropathy (DMN). However, there are limited reports on the in-hospital outcomes of dialysis patients with AMI considering the underlying disease and duration of dialysis. This retrospective study aimed to compare the in-hospital outcomes in dialysis patients who underwent percutaneous coronary intervention (PCI) for AMI between with and without long-term dialysis due to DMN. We included 239 dialysis patients with AMI and divided them into the long-DMN group (n = 101) and the other group (n = 138) according to the presence or absence of the combination of DMN and ≥ 3 years duration of dialysis. The long-DMN group had significantly advanced Killip class and the higher prevalence of cardiac arrest at prehospital, lower left ventricular ejection fraction, and more frequent multivessel disease and severe calcification. The incidence of in-hospital death was significantly higher in the long-DMN group (14.9%) than in the other group (5.8%) (p = 0.026). In multivariate analysis, long-DMN was significantly associated with in-hospital death (OR 2.601, 95% CI 1.047-6.464, p = 0.040) after controlling for age and sex. AMI patients with long-term dialysis due to DMN had the higher in-hospital death rate than those with other dialysis status. Long-term dialysis due to DMN may be associated with in-hospital outcomes in dialysis patients with AMI.

Different vascular beds show different tissue characteristics. The mechanism of progression at the culprit site in femoropopliteal arteries remains unclear. This study aims to assess the causes of significant stenosis at culprit lesions in femoropopliteal arteries using optical frequency domain imaging. Femoropopliteal arteries were evaluated in 54 legs from 44 patients with lower extremity artery disease undergoing optical frequency domain imaging-guided endovascular therapy. The causes of stenosis at the culprit sites were evaluated, and the types of acute thrombus were assessed. Multivariate logistic regression analysis was used to find the factors significantly associated with acute thrombus and healed plaque at the culprit sites. Acute thrombus (48%) and healed plaque (46%) were 2 major causes at the culprit sites. Among the types of acute thrombus at the culprit sites, eruptive calcified nodule was the most frequent (66%), erosion (24%) was second, and rupture (10%) was third. Dual antiplatelet therapy before admission to endovascular therapy and low run-off number (0, 1, and 2) were significantly related to acute thrombus, whereas the factors significantly associated with healed plaque were run-off number 0, lipidic plaque, and longer lesions. In conclusion, regardless of acute thrombus or healed plaque, the mechanisms of lower extremity artery disease at culprit sites were associated with thrombus. The prevalence of types of acute thrombus in femoropopliteal arteries was in order of eruptive calcified nodule, erosion, and rupture.

BACKGROUND: Acute myocardial infarction (AMI) is a fatal cardiovascular disease with varying prognosis. Recent studies suggest a close relationship between cardiovascular disease and metabolic dysfunction-associated fatty liver disease (MAFLD), but because the prognostic value of MAFLD in patients with AMI remains unclear, we investigated the relationship between MAFLD and clinical outcomes in patients with AMI. METHODS AND RESULTS: This retrospective study included 1,142 patients with AMI who underwent percutaneous coronary intervention (PCI) to the culprit lesion of AMI and were classified as MAFLD (n=231) and non-MAFLD (n=911). Hepatic steatosis was diagnosed by a liver-to-spleen attenuation (L/S) ratio <1 on computed tomography. The primary outcome was major adverse cardiovascular events (MACE), which were defined as a composite of all-cause death, non-fatal MI, and readmission for heart failure. Over a median follow-up of 609 days, MACE was less frequently observed in the MAFLD group than in the non-MAFLD group (P=0.015). However, the multivariate Cox hazard analysis showed that MAFLD was not associated with MACE (hazard ratio 0.80, 95% confidence interval 0.564-1.140, P=0.219) after controlling for confounding factors. CONCLUSIONS: We could not show a significant association between MAFLD and MACE in patients with AMI, suggesting the absence of strong association between MAFLD and long-term clinical outcomes in these patients.