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BACKGROUND Data on the clinical outcomes of percutaneous coronary intervention (PCI) for unprotected left main coronary artery (LMCA) in patients with acute coronary syndrome (ACS) are limited. Therefore, this study aimed to assess the clinical outcome of patients with ACS who underwent PCI for LMCA culprit lesion.Methods and Results:Of 1,809 patients enrolled in the Assessing Optimal Percutaneous Coronary Intervention for the LMCA (AOI-LMCA) registry (a retrospective 6-center registry of consecutive patients undergoing LMCA stenting in Japan), the current study population consisited of 1,500 patients with unprotected LMCA stenting for LMCA ACS (ACS with shock: 115 patients, ACS without shock: 281 patients) and stable CAD (1,104 patients). The cumulative 180-day incidence of death was markedly higher in the ACS with shock group than in the other groups (49.5%, 8.6%, and 3.3%, respectively; P

PurposeRotational atherectomy (RA) and orbital atherectomy (OA) are effective procedures for severe calcified coronary artery disease. Nonetheless, vessel perforation remains an adverse complication of these procedures. This study aimed to evaluate factors affecting elastic material damage caused by RA and OA.MethodsAn in vitro assessment was conducted in which the damage to the rubber latex, an elastic material, after RA was evaluated under various conditions, including burr rotational speed (100,000–220,000 rotations per minute), approaching curve, burr size (1.25 mm, 1.75 mm, and 2.0 mm), and fluid viscosity (water and low-molecular weight dextran). Similarly, the rubber latex damage after OA was evaluated in the same experimental system under various conditions, including crown rotational speed, approaching curve, and fluid viscosity.ResultsIn RA, the rubber latex was damaged at lower rotational speeds (p = 0.003), tighter approaching curves (p < 0.0001), and lower fluid viscosity (p = 0.03). In OA, the rubber latex was generally severely damaged.ConclusionA higher rotational speed, coaxial approach for the wall, and higher viscosity contributed to lesser elastic material damage in RA. The safety mechanism for elastic material in OA proved less effective.

Background Stent thrombosis (ST) after drug‐eluting stent (DES) implantation remains a life‐threatening complication. Recurrent ST (RST) is not a rare phenomenon, potentially contributing to high mortality after the index ST events. However, little evidence is available about the incidence, risk factors, and clinical outcomes of definite RST after DES thrombosis. Methods and Results From REAL‐ST (Retrospective Multicenter Registry of ST After First‐ and Second‐ Generation DES Implantation), this study evaluated 595 patients with definite ST (first‐generation DES thrombosis, n=314; second‐generation DES thrombosis, n=281). During a median follow‐up of 31 months, we identified 32 patients with definite RST after first‐generation DES thrombosis (n=18) and second‐generation DES thrombosis (n=15). Cumulative incidence of RST was 4.5% and 6.0% at 1 and 5 years, respectively, which did not significantly differ between first‐generation DES thrombosis and second‐generation DES thrombosis. Independent predictors of definite RST were early ST (hazard ratio [HR], 2.38; 95% CI, 1.06–5.35 [ P =0.035]) and multivessel ST (HR, 3.47; 95% CI, 1.03–11.7 [ P =0.044]). Definite RST was associated with a 2.8‐fold increased risk of mortality (adjusted HR, 2.78; 95% CI, 1.35–5.73 [ P =0.006]). Conclusions Cumulative incidence of definite RST did not significantly differ between first‐generation DES thrombosis and second‐generation DES thrombosis. Early ST and multivessel ST were risk factors of definite RST. Definite RST significantly increased mortality after DES thrombosis, highlighting the clinical importance of preventing RST to improve outcomes of patients with ST. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: UMIN000025181.

We evaluated the factors that increase the maximum static friction force between the anchoring balloon and the vessel wall. The anchor technique in percutaneous coronary intervention (PCI) may be better supported by a guiding catheter. However, in some cases, the anchor balloon does not perform optimally due to slippage within the anchoring vessel. Furthermore, the optimal procedure for balloon anchoring remains unknown. We evaluated the maximum static friction force of the anchor balloon via in vitro assessments using a simulated vessel model and coronary balloons. The simulated vessel model was composed of polytetrafluoroethylene, and its inner diameter was 1.5 mm. The various-sized balloons (diameter: 1.5 mm, 1.75 mm, and 2.0 mm; length: 10 mm and 15 mm) were inflated within the simulated vessel at various atmospheres. The maximum static friction force was measured by pulling on the balloon catheter shaft using 10-g weights. We performed the same experiment with a jailing 0.014″ wire under the anchoring balloon. Evaluated wires included a silicon coating coil wire, hydrophilic coating coil wire, polymer-coated non-tapering wire, and polymer-coated tapered wire. The maximum static friction force between the anchoring balloon and the simulated vessel increased with an increase in inflation pressure and balloon length. However, increasing the balloon diameter was not effective. The jailing 0.014″ wire, particularly coil wire, was effective in increasing the maximum static friction force of the anchor balloon. A longer balloon, higher inflation pressure, and jailing coil wire could reinforce the anchor balloon system.

It is still uncertain whether the final kissing balloon technique (FKBT) is mandatory after crossover stenting for the left main coronary artery (LMCA). Assessing Optimal Percutaneous Coronary Intervention for LMCA (AOI-LMCA) registry, a 6-center retrospective registry, enrolled 1809 consecutive patients for LMCA stenting in Japan. In the present analysis, 5-year clinical outcomes were compared between non-FKBT (n = 160) and FKBT (n = 578) groups in patients treated with crossover stenting with drug-eluting stents from the LMCA to the left anterior descending artery. Propensity score-matched analysis was also performed in 160 patient pairs. In the entire study population as well as in the propensity-matched population, the cumulative 5-year incidence of the primary outcome measure (target lesion revascularization: TLR) was not significantly different between the FKBT and non-FKBT groups (10.7 versus 14.3%, P = 0.49, and 11.8 versus 14.3%, P = 0.53, respectively). In the sensitivity analysis by the multivariable Cox proportional hazard model, the effect of FKBT relative to non-FKBT for TLR remained insignificant (adjusted HR 0.89, 95% CI 0.47–1.69, P = 0.72). Regarding the TLR location, there were no significant differences in the cumulative incidences of TLR for LMCA-only, for the main branch, and for the side branch between the 2 groups (2.2 versus 1.3%, P = 0.93, 11.8 versus 9.1%, P = 0.71, and 8.2 versus 7.6%, P = 0.82, respectively). FKBT after a 1-stent strategy for LMCA crossover stenting did not affect TLR and other clinical outcomes during 5-year follow-up.Clinical Trial Registration: Assessing Optimal Percutaneous Coronary Intervention for Left Main Coronary Artery Stenting Registry (AOI LMCA Stenting Registry). http://www.umin.ac.jp/ctr/index/htm/. Unique Identifier: UMIN000014706.

Objectives Although conventional open repair is our preference for patients with aortic arch aneurysms, we have often chosen thoracic endovascular aneurysm repair (TEVAR) with a handmade branched stent graft (bTEVAR) in high-risk patients. The aim of this study was to compare the midterm clinical outcomes of our bTEVAR technique to those of the open repair. Methods Between January 2007 and December 2014, we treated 129 patients with aortic arch aneurysm by means of either conventional open repair (OPEN, n = 61) or bTEVAR (n = 68) at our institution. Results The mean ages were 70.5 ± 12.7 years in the OPEN group and 72.7 ± 12.5 years in the bTEVAR group (P = 0.32). The aetiologies included true aneurysm in 101 patients (78.3%) and chronic dissection in 26 (20.1%). There were 2 (3.3%) in-hospital deaths in the OPEN group and 3 (4.4%) in the bTEVAR group. The mean follow-up duration was 3.0 ± 2.1 years (2.4 ± 1.9 years in the OPEN group and 3.6 ± 2.3 years in the bTEVAR group). There was no difference in 5-year aneurysm-related mortality between groups (10.7% in OPEN vs 12.8% in bTEVAR, P = 0.50). In terms of late additional procedures, however, none were required in the OPEN group, whereas 10 (15.4%) additional endovascular repairs and 4 (6.2%) open repairs were required in the bTEVAR group. Conclusions Our bTEVAR could be performed with low early mortality, and it yielded similar midterm aneurysm-related mortality to that of conventional open repair. However, these patients undergoing this technique required more late additional procedures than those undergoing conventional open repair.

Background Data are scarce on the role of aortic valve area (AVA) to identify those patients with asymptomatic severe aortic stenosis (AS) who are at high risk of adverse events. We sought to explore the prognostic impact of AVA in asymptomatic patients with severe AS in a large observational database. Methods and Results Among 3815 consecutive patients with severe AS enrolled in the CURRENT AS (Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis) registry, the present study included 1309 conservatively managed asymptomatic patients with left ventricular ejection fraction ≥50%. The study patients were subdivided into 3 groups based on AVA (group 1: AVA >0.80 cm2, N=645; group 2: 0.8 cm2 ≥AVA >0.6 cm2, N=465; and group 3: AVA ≤0.6 cm2, N=199). The prevalence of very severe AS patients (peak aortic jet velocity ≥5 m/s or mean aortic pressure gradient ≥60 mm Hg) was 2.0%, 5.8%, and 26.1% in groups 1, 2, and 3, respectively. The cumulative 5‐year incidence of AVR was not different across the 3 groups (39.7%, 43.7%, and 39.9%; P=0.43). The cumulative 5‐year incidence of the primary outcome measure (a composite of aortic valve–related death or heart failure hospitalization) was incrementally higher with decreasing AVA (24.1%, 29.1%, and 48.1%; P, See Editorial by Tribouilloy et al

The clinical outcomes of drug-eluting stent (DES) implantation after rotational atherectomy (RA) for complex left main coronary artery (LMCA) bifurcation lesions remain unclear. Among 1,809 patients retrospectively enrolled in the Assessing Optimal percutaneous coronary Intervention for LMCA Registry, we identified 1,199 patients with LMCA bifurcation lesions treated by crossover stenting with DES for the main vessel. The study population was divided according to the use of RA. The patients in the RA group were further subdivided into the 2 subgroups on the basis of the stenting approach. The rates of periprocedural myocardial infarction and in-hospital death in the RA group were comparable to those in the non-RA group. The cumulative 5-year incidences of all-cause death and target lesion revascularization (TLR) were significantly higher in the RA group than those in the non-RA group. However, after adjusting confounders, the excess risks of the RA group relative to the non-RA group for all-cause death and TLR were no longer significant (hazard ratio 0.95, 95% confidence intervals 0.59 to 1.52, p = 0.83, and hazard ratio 1.46, 95% confidence intervals 0.82 to 2.60, p = 0.20, respectively). In the RA group, the cumulative 5-year incidences of all-cause death and TLR were markedly higher in the 2-stent subgroup than in the 1-stent subgroup (58.1% vs 26.0%, p = 0.001, and 43.0% vs 16.3%, p = 0.001, respectively). In conclusion, DES implantation after RA was a safe and feasible strategy in treating those patients with complex LMCA bifurcation lesions. In this strategy, the 2-stent approach was associated with markedly worse 5-year clinical outcomes than the 1-stent approach.

Data on the clinical outcomes of percutaneous coronary intervention (PCI) for unprotected left main coronary artery (LMCA) in patients with acute coronary syndrome (ACS) are limited. Therefore, this study aimed to assess the clinical outcome of patients with ACS who underwent PCI for LMCA culprit lesion.Methods and Results:Of 1,809 patients enrolled in the Assessing Optimal Percutaneous Coronary Intervention for the LMCA (AOI-LMCA) registry (a retrospective 6-center registry of consecutive patients undergoing LMCA stenting in Japan), the current study population consisited of 1,500 patients with unprotected LMCA stenting for LMCA ACS (ACS with shock: 115 patients, ACS without shock: 281 patients) and stable CAD (1,104 patients). The cumulative 180-day incidence of death was markedly higher in the ACS with shock group than in the other groups (49.5%, 8.6%, and 3.3%, respectively; P0.0001), but mortality beyond 180-day was not significantly different among the 3 groups (30.2%, 20.4%, and 19.5%, respectively; P=0.65). In the ACS with shock group, the initial TIMI flow grade did not affect 5-year mortality (57.1% and 62.2%, P=0.99), but in the ACS without shock group, 5-year mortality was significantly higher in patients with initial TIMI flow grade ≤1 than in patients with TIMI flow grade ≥2 (44.4% and 23.7%, respectively; P=0.008).In patients with LMCA ACS, survival correlates with baseline hemodynamic and coronary flow status.

Patient Initials or Identifier Number B.Y ### Relevant Clinical History and Physical Exam A 76-year-old man had been introduced from the clinic due to intermittent claudication since 2 months ago. The index of Rutherford classification was class 3. His vital signs were normal. He had

Background Donor artery fractional flow reserve (FFR) often improves after treatment of recipient artery stenosis, but the physiological mechanism underlying this phenomenon has not been elucidated. This study aimed to assess two novel equations that explain the donor–recipient artery interaction. Method Eq. (A) predicts the donor artery FFR after complete release of recipient artery stenosis, while Eq. (B) predicts the donor artery FFR after partial release of recipient artery stenosis. Eq. (B) is a general form of Eq. (A). (A) F F R ′ 1 − pred = F F R 1 − C F I 1 F F R 2 − C F I 2 − C F I 1 C F I 2 1 − F F R 1 1 − F F R 2 + C F I 1 1 − F F R 1 1 − C F I 2 / 1 − C F I 1 F F R 2 − C F I 2 (B) F F R ′ ′ 1 − pred = F F R 1 − C F I 1 F F R 2 − C F I 2 − C F I 1 C F I 2 1 − F F R 1 1 − F F R 2 + C F I 1 1 − F F R 1 1 − C F I 2 F F R ′ 2 / 1 − C F I 1 F F R 2 − C F I 2 Eqs. (A) and (B) were assessed using an in vitro model of coronary circulation with a collateral channel connecting the donor and recipient arteries. Results The donor artery FFR always improved after releasing the recipient artery stenosis. A good linear correlation was found between the predicted FFR of Eq. (A) and the actual FFR (n=40, r=0.95, p Conclusions Eqs. (A) and (B) accurately predicted the true FFR value of the donor artery in a coronary circulation model and explain the donor–recipient artery interaction observed in clinical practice.

Background Multifunction cardiogram (MCG) is a computer-enhanced, resting electrocardiogram analysis developed to detect hemodynamically relevant coronary artery disease (CAD). Based on data from previous studies suggesting excellent diagnostic accuracy in detecting CAD, MCG (approved by the Food and Drugs Administration) received a Current Procedure Terminology (CPT) code in 2010 in United States. However, there is no previous study validating MCG by using fractional flow reserve (FFR) as the reference standard. Methods Multifunction cardiogram Evaluation in Diagnosis of Functional coronary Ischemia sTudy (MED-FIT) was designed as a single-center, prospective study enrolling 100 stable patients with suspected CAD scheduled for coronary angiography. The primary and secondary analyses evaluated the diagnostic performance of the MCG severity score to detect functional myocardial ischemia by FFR ≤0.80, and angiographically significant coronary stenosis (percent diameter stenosis ≥50%) by quantitative coronary angiography. Results The current analysis set consisted of 91 patients in whom MCG data with adequate quality was obtained. The prevalence of positive functional myocardial ischemia and angiographically significant stenosis in the current study was 42.7% and 41.8%, respectively. Area under the receiver operating characteristics curve (AUC) of the MCG severity score for functional myocardial ischemia and angiographically significant stenosis was low (AUC 0.51, 95% confidence interval [CI] 0.38–0.63, and AUC 0.58, 95%CI 0.46–0.70, respectively). Sensitivity, and specificity of the MCG severity score for functional myocardial ischemia and angiographically significant stenosis was also low (32%/67%, and 37%/72%) using a cutoff value of 4.0. Conclusions Diagnostic performance of the MCG severity score was poor for both functional myocardial ischemia, and angiographically significant stenosis.

Coronary collateral circulation is an alternative source of blood supply to the myocardium when the original blood flow is not sufficient. The pressure derived collateral flow index (CFI) calculated with (P w - P v)/(P a - P v) can be measured during angioplasty and predicts the outcome of the patients with ischemic heart disease. However, the necessity of occluding the coronary artery at maximum hyperemia hampers the wide spread use. We mathematically derived a new equation which calculates CFI in sequential stenoses. The present study aimed to validate the equation in an in vitro model of coronary circulation. The predicted CFI is calculated from the following equation: CFI = (FFRpre - FFRpost(1 - ∆FFR))/(FFRpre + ∆FFR - FFRpost). FFRpre/post is the FFR before and after the angioplasty. ∆FFR is the FFR gradient across the target stenosis. The experimental system consisted of a pump, systemic circulation, coronary circulation, and 5 constrictors placed in the coronary artery. A total of 30 different sequential coronary stenoses were randomly created and 30 different pressure data were obtained. The predicted CFI was compared with the true CFI. A close positive correlation (r = 0.90, p 0.0001) was found between the predicted CFI and the true CFI. The accuracy of the equation was demonstrated in an in vitro model of coronary circulation.

The aim of this study was to evaluate the prognostic impact of left ventricular ejection fraction (LVEF) in patients with severe aortic stenosis (AS).The prognostic impact of LVEF in severe AS remains controversial.Among 3,815 consecutive patients with severe AS enrolled in the CURRENT AS (Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis) registry, the present study population consisted of 3,794 patients after excluding 21 patients without LVEF data. Patients were divided into 4 groups according to LVEF at index echocardiography (50%, 50% to 59%, 60% to 69%, and ≥70%; conservative strategy: n = 388, n = 390, n = 1,025, and n = 800; initial aortic valve replacement strategy: n = 206, n = 170, n = 375, and n = 440). Echocardiographic data were site reported, and there was no echocardiography core laboratory.In the conservative group, the cumulative 5-year incidence of the primary outcome measure (a composite of aortic valve-related death or heart failure hospitalization) was significantly higher in patients with LVEFs 50% and 50% to 59% than in those with LVEFs 60% to 69% and ≥70% (72.3%, 58.4%, 38.7%, and 35.0%, respectively, p 0.001), whereas in the initial aortic valve replacement group, the negative effect of low LVEF was markedly attenuated (20.2%, 20.3%, 17.7%, and 12.4%, respectively, p = 0.03). After adjusting for confounders, LVEF 50% (hazard ratio: 1.82; 95% confidence interval: 1.44 to 2.28; p 0.001) and 50% to 59% (hazard ratio: 1.77; 95% confidence interval: 1.42 to 2.20; p 0.001) but not 60% to 69% (hazard ratio: 1.14; 95% confidence interval: 0.94 to 1.39; p = 0.17) were independently associated with poorer outcomes compared with LVEF ≥70% (reference) in the conservative group. In the initial aortic valve replacement group, the adjusted risk for the primary outcome measure was not significantly different across the 4 LVEF groups.This study demonstrates that survival in patients with severe AS is impaired when LVEF is 60%, and these findings have implications for decision making with regard to the timing of surgical intervention.

We hypothesized that patients who had previous target-lesion revascularization (TLR) for DES restenosis in non-left main coronary artery (LMCA) lesions might have a higher risk for restenosis after subsequent DES implantation for a de novo unprotected LMCA lesion. Among 1809 patients enrolled in the Assessing Optimal Percutaneous Coronary Intervention for LMCA (AOI-LMCA) registry, which is a retrospective 6-centre registry of consecutive patients undergoing LMCA stenting in Japan, 251 patients with previous DES implantation for non-LMCA lesions were subdivided into the 2 groups with (N = 56) or without (N = 195) previous TLR in non-LMCA lesions. The risk for TLR for LMCA was neutral between the prior TLR for DES restenosis group and the no prior TLR for DES restenosis group [hazard ratio (HR) 0.99, 95% confidence interval (CI) 0.44–2.02, P = 0.98]. The risks for both TLR caused by restenosis of the LMCA main branch, and second TLR for restenosis after first TLR for LMCA were also neutral between the 2 groups (HR 0.42, 95% CI 0.10–1.25, P = 0.13, and HR 0.59, 95% CI 0.03–3.63, P = 0.60, respectively). In conclusion, prior TLR for DES restenosis in non-LMCA lesions was not associated with worse long-term clinical outcomes after DES implantation for de novo unprotected LMCA lesions. Clinical Trial Registration: Assessing Optimal Percutaneous Coronary Intervention for Left Main Coronary Artery Stenting Registry (AOI LMCA Stenting Registry). http://www.umin.ac.jp/ctr/index/htm/ . Unique Identifier: UMIN000014706.

Background There are limited data regarding the risk stratification based on peak aortic jet velocity (Vmax) in patients with severe aortic stenosis ( AS ). Methods and Results Among 3815 consecutive patients with severe AS enrolled in the CURRENT AS (Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis) registry, the study population consisted of 1075 conservatively managed patients with Vmax ≥4.0 m/s and left ventricular ejection fraction ≥50%. The study patients were subdivided into 3 groups based on Vmax (group 1, 4.0 ≤ Vmax AS ‐related events (aortic valve–related death or heart failure hospitalization) was incrementally higher with increasing Vmax (entire population; 38.0%, 49.4%, and 62.8%, P P =0.008; and asymptomatic patients; 29.4%, 38.9%, and 47.7%, P =0.005). After adjusting for confounders, the excess risk of group 2 and group 3 relative to group 1 for AS ‐related events remained significant (hazard ratio, 1.39; 95% CI , 1.07–1.81; P =0.02, and hazard ratio, 1.53; 95% CI , 1.17–2.00; P =0.002, respectively). The effect size of group 3 relative to group 1 for AS ‐related events in asymptomatic patients (N=479) was similar to that in symptomatic patients (N=596; hazard ratio, 1.59; 95% CI , 1.01–2.52; P =0.047, and hazard ratio, 1.67; 95% CI , 1.16–2.40, P =0.008, respectively), and there was no significant overall interaction between the symptomatic status and the effect of the Vmax categories on AS ‐related events (interaction, P =0.88). Conclusions In conservatively managed severe AS patients with preserved left ventricular ejection fraction, increasing Vmax was associated with incrementally higher risk for AS ‐related events. However, the cumulative 5‐year incidence of the AS ‐related events remained very high even in asymptomatic patients with less greater Vmax.

We assessed long-term outcomes after left main coronary artery (LMCA) stenting based on lesion types and stenting strategies. In the Assessing Optimal percutaneous coronary Intervention for Left Main Coronary Artery stenting registry, we evaluated 1,607 consecutive patients undergoing stent implantation for unprotected LMCA lesions (bifurcation lesions: n = 1318 and nonbifurcation lesions: n = 289). Among the bifurcation lesions, 1,281 lesions were treated with stenting across the bifurcation (bifurcation 1-stent strategy: n = 999 or bifurcation 2-stent strategy: n = 282). Among the nonbifurcation lesions, 219 lesions were treated with nonbifurcation stenting. The median follow-up duration was 4.6 (95% CI 4.5 to 4.8) years. The 5-year risk of bifurcation lesions relative to nonbifurcation lesions was neutral for target lesion revascularization (TLR) (adjusted hazard ratio [HR] 0.82, 95% CI 0.55 to 1.23, p = 0.34) and all-cause death (adjusted HR 1.22, 95% CI 0.87 to 1.71, p = 0.26). The risk of the bifurcation 1-stent strategy relative to nonbifurcation stenting in nonbifurcation lesions was also neutral for TLR (adjusted HR 1.19, 95% CI 0.74 to 1.90, p = 0.47) and all-cause death (adjusted HR 0.81, 95% CI 0.56 to 1.18, p = 0.27). However, the bifurcation 2-stent strategy was associated with worse clinical outcomes than the bifurcation 1-stent strategy in TLR (adjusted HR 1.76, 95% CI 1.23 to 2.52, p = 0.002) and definite or probable stent thrombosis (crude HR 3.50, 95% CI 1.32 to 9.33, p = 0.01), despite neutral risk for all-cause death (adjusted HR 1.00, 95% CI 0.74 to 1.36, p = 0.99). There was no definite or probable very late stent thrombosis up to 5 years. In conclusion, long-term outcomes after stent implantation for unprotected LMCA lesions were not dependent on the bifurcation lesion types but related to the bifurcation stenting strategies with worse outcomes for the bifurcation 2-stent strategy.

Background— Many of the previous randomized trials comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with multivessel coronary artery disease reported equivalent or better survival with CABG as compared with PCI at 5-year follow-up. However, 5-year follow-up might be too short to evaluate the true differences in long-term clinical outcomes between PCI and CABG. Methods and Results— Among 8934 patients enrolled in the extended 10- to 14-year follow-up study of the CREDO-Kyoto registry cohort-1 (Coronary Revascularization Demonstrating Outcome study in Kyoto) conducted in the bare-metal stent era, 5152 (PCI: n=3490 and CABG: n=1662) patients had multivessel coronary artery disease without left main disease. Median follow-up duration was 11.2 (interquartile range: 10.2–12.2) years. The cumulative 10-year incidence of all-cause death was not significantly different between PCI and CABG (32.2% versus 31.7%; log-rank P =0.93). After adjusting for confounders, however, the mortality risk of PCI was significantly higher than that of CABG (hazard ratio, 1.19 [95% confidence interval, 1.02–1.39]; P =0.03). Within 5 years after the index procedure, the risk for all-cause death was significantly higher after PCI than after CABG (hazard ratio, 1.41; 95% CI, 1.12–1.79; P =0.004). By a landmark analysis at 5 years, however, the cumulative 10-year incidence of and adjusted risk for all-cause death beyond 5 years were not significantly different between PCI and CABG (19.3% versus 20.0%; log-rank P =0.22 and hazard ratio, 1.02, 95% confidence interval, 0.83–1.26; P =0.82). Conclusions— CABG as compared with PCI was associated with better 10-year survival in patients with multivessel coronary artery disease. However, the benefit of CABG compared with PCI on late mortality beyond 5 years was not observed in this study.

Aims The functional impact of downstream coronary stenoses on left main coronary artery (LMCA) stenosis has not been fully elucidated. This study therefore aimed to use in vitro and in vivo experiments to assess two novel equations that predict the true fractional flow reserve (FFR) of a left main coronary artery (LMCA) stenosis with concomitant downstream stenoses. Methods and results Two novel equations were derived. One equation predicts the true fractional flow reserve (FFR) of an LMCA stenosis with a downstream stenosis (Equation A), and the other predicts the true FFR of an LMCA stenosis with downstream stenoses in both the left anterior descending and left circumflex arteries (Equation B). The equations were validated in both in vitro and in vivo models of the coronary circulation. The agreements between the apparent FFR (FFRapp), the predicted FFR (FFRpred) and the true FFR (FFRtrue) were assessed by Passing-Bablok regression analysis. Passing-Bablok regression analysis revealed that there were fixed proportional errors between FFRapp-m and FFRtrue-m, though a very small fixed error and no proportional errors between FFRpred-m and FFRtrue-m. The absolute differences between FFRpred and FFRtrue were significantly lower as compared to those between FFRapp and FFRtrue in all experiments. Conclusions Two novel equations which predict the true FFR of LMCA stenosis were demonstrated to be correct. The study also revealed that the functional impact of downstream stenoses on the LMCA stenosis became stronger when the downstream stenoses became more severe.

Recently, stent implantation for left main coronary artery (LMCA) lesions has become a common clinical practice; however, the effects of bifurcation lesion and stenting strategies on long-term clinical outcomes remain to be investigated. We assessed 1809 consecutive patients undergoing stent

Patient initials or identifier number M . O ### Relevant clinical history and physical exam An 83-year-old woman who had chronic atrial fibrillation admitted to our hospital. Her chief complain was intermittent claudication which occurred suddenly two weeks ago. The left common femoral artery

Background Thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysms (TAAs) is in rapid expansion due to its minimal invasiveness. However, TEVAR for an arch aneurysm with a straight stent graft needs surgical reconstruction for supra-aortic vessels. A branched stent graft pioneered by Inoue (branched Inoue Stent Graft [ISG]) has been expected to resolve this problem, but its utility remains to be established in the real clinical setting. This study evaluated the long-term clinical outcome of branched ISGs for TAAs. Methods Among 217 consecutive patients who underwent TEVAR with ISGs between March 2003 and September 2013, 89 patients with TAAs were treated with implantation of the branched ISG (single branch: n = 64; double branch: n = 18; triple branch: n = 7). The primary end point was freedom from aneurysm-related death. Secondary end points included periprocedural adverse events, freedom from all-cause death and major adverse events (composite of aneurysm-related death, surgical conversion, aneurysm rapture, persistent type I or III endoleak, graft infection, graft occlusion, graft migration, and aneurysm expansion), changes of aneurysm diameter, stroke, and any endovascular reintervention during follow-up. Results All deployments of branched ISGs were successful. The 30-day mortality was 4.5% (single branch, 3.1%; double branch, 0%; triple branch, 29%), and periprocedural stroke was 16% (single branch, 7.8%; double branch, 33%; triple branch, 42%). At 1 and 5 years, freedom from aneurysm-related death was 93% and 93%, respectively, and freedom from all-cause death was 85% and 59%, respectively. Survival free of major adverse events was 76% at 5 years. The cumulative incidence of stroke was 11% at 5 years. Three patients underwent surgical conversion because of persistent type I endoleak. One branch graft occlusion was observed at the left subclavian artery in a patient who received a double-branched graft. Conclusions Periprocedural outcome of the single-branched ISG was acceptable, and long-term safety and efficacy were demonstrated. However, the procedural complications of the multibranched ISG leave room for improvement.

Whether the final kissing balloon technique (FKBT) is mandatory after crossover stenting of the left main coronary artery (LMCA) in patients with or without true bifurcation remains unclear. The Assessing Optimal Percutaneous Coronary Intervention for LMCA (AOI-LMCA) registry is a retrospective

We aimed to investigate the effectiveness of a scoring balloon catheter in expanding a circumferentially calcified lesion compared to a conventional balloon catheter using an in vitro experiment setting and elucidate the underlying mechanisms of this ability using a finite element analysis. True efficacy of the scoring device and the underlying mechanisms for heavily calcified coronary lesions are unclear. We employed a Scoreflex scoring balloon catheter (OrbusNeich, Hong Kong, China). The ability of Scoreflex to dilate a calcified lesion was compared with a conventional balloon catheter using 3 different sized calcium tubes. The thickness of the calcium tubes were 2.0, 2.25, and 2.5 mm. The primary endpoints were the successful induction of cracks in the calcium tubes and the inflation pressures required for inducing cracks. The inflation pressure required for cracking the calcium tubes were consistently lower with Scoreflex (p < 0.05, Student t test). The finite element analysis revealed that the first principal stress applied to the calcified plaque was higher by at least threefold when applying the balloon catheter with scoring elements. A scoring balloon catheter can expand a calcified lesion with lower pressure than that of a conventional balloon. The finite element analysis revealed that the concentration of the stress observed in the outside of the calcified plaque just opposite to the scoring element is the underlying mechanism of the increased ability of Scoreflex to dilate the calcified lesion.

Several studies suggested that prolonged dual antiplatelet therapy (DAPT) reduced the risks of ischemic events, but increased the risk of bleeding. Optimal duration of DAPT after left main coronary artery (LMCA) stenting remains unclear. From Nov. 2004 to Dec. 2012, we enrolled consecutive 1809

Background: The clinical guideline for unprotected left main (LM) disease has been updated and percutaneous coronary intervention (PCI) for LM disease has become a common procedure in daily clinical practice. Long-term clinical outcome, however, has not been adequately addressed yet, especially late adverse events beyond 1 year after stent implantation for LM disease. Methods and results: We evaluated long-term clinical outcome including late adverse events beyond 1-year after LM-PCI in consecutive 134 patients who received unprotected LM stenting with sirolimus eluting stents (SES) at Kyoto university hospital between September, 2004 and December, 2009. The mean clinical follow-up period of this study was 4.0±1.8 years. Late Adverse events were defined as sudden cardiac death, target-vessel myocardial infarction (MI), emergent revascularization for LM disease, and acute congestive heart failure (ACHF), which occurred beyond 1 year after stent implantation. The cumulative incidence of all-cause death, cardiac death, and target-lesion revascularization (TLR) for LM disease was 26.5%, 8.1%, and 12.9%, at 5 years after LM-PCI, respectively. The cumulative incidence of cardiac death was significantly higher in patients with 2 stenting technique compared to those with single stenting. Late adverse events were occurred in 6 patients. There are no late adverse events in patients with non-bifurcation LM disease at initial procedure. View this table: Table 1. Late adverse events Conclusions: Five-year clinical outcome of SES implantation for unprotected LM disease was relatively favorable and the risk of late adverse events seemed to be an acceptable range. However, the high risk patient for late adverse events, such as those with true bifurcation lesion and receiving complex stenting, seems to require close observation.

Aneurysm expansion due to type 2 endoleak is one of the major troubles after endovascular aneurysm repair (EVAR). Long-term outcome about persistent type 2 endoleak is still unclear. The aim of this study is to evaluate the clinical significance of persistent type II Endoleak and feasibility of