Critical limb ischemia (CLI) represents the most severe form of peripheral arterial disease. Manifestations of CLI include rest pain, ischemic ulcers, and/or gangrene. The presence of CLI frequently leads to amputation, and furthermore, patients with CLI are at an increased risk of cardiovascular events including death. Treatment options for CLI when revascularization is not possible are extremely limited. Therapeutic angiogenesis is a promising new tool in the management of CLI. There is a growing body of evidence demonstrating the safety and efficacy of therapeutic angiogenesis with gene and cell therapy. Many factors must be considered in formulating clinically efficacious gene and/or cell therapies. The dosing regimen, route of delivery, and choice of growth factor or cell population must be decided. Although the optimal regimen of therapeutic angiogenesis has yet to be identified, building on the knowledge gained from the early pioneering studies may help to identify the best combination.
The optimal treatment of coronary artery disease (CAD) involves reducing the ischemic burden, lowering the risk of future adverse cardiac events, and relieving symptoms of angina pectoris. Medical and mechanical therapies have played a major role in reducing the morbidity and mortality associated with ischemic heart disease. Despite the success of these conventional therapies, there are patients with CAD who continue to experience angina despite maximal medical and revascularization therapy. Therapeutic angiogenesis represents a novel treatment option for these “no‐option” patients with refractory ischemic coronary disease. A growing body of evidence has demonstrated the therapeutic potential of therapeutic angiogenesis with gene, protein, or cell‐based therapies. The goal of therapeutic angiogenesis is to induce the formation of new vessels that can enhance blood flow to areas that no longer have adequate blood supply. While the existing data are not definitive, there is reason to be optimistic, as several studies have suggested a clinical benefit. This review focuses on the current state of therapeutic angiogenesis in the management of the “no‐option” patient with refractory angina.
Prior studies of premature coronary artery disease (CAD) in young adults did not address the association of race/ethnicity and risk factors. Therefore, the authors conducted a study of 400 patients 40 years and older undergoing coronary angiography at a large, urban public hospital that serves predominately minority, uninsured populations. The prevalence of risk factors and their association with premature CAD varied markedly by ethnic group. Among blacks, dyslipidemia, diabetes, and smoking were independently associated with premature CAD. Among Hispanics, dyslipidemia, male sex, and family history of CAD were independently associated with premature CAD. Smoking was the only risk factor in whites, and no independent risk factor was identified in Asian Indians. Whites and Asian Indians had a higher prevalence of disease than blacks or Hispanics—before and after adjusting for risk factor imbalances across ethnic groups. In this ethnically diverse population, the authors’ findings underscore the importance of identifying distinctive risk factors in various ethnic groups.
Background Bifurcation lesions account for 20% of all percutaneous coronary interventions and represent a complex subset which are associated with lower procedural success and higher rates of restenosis. The ideal bifurcation technique, however, remains elusive. Methods and Results Extensive search of the literature was performed to pull data from randomized clinical trials that met predetermined inclusion criteria. Conventional meta‐analysis produced pooled relative risk (RR) and 95% CI of 2‐stent technique versus provisional stent on prespecified outcomes. Both frequentist and Bayesian network meta‐analyses were performed to compare bifurcation techniques. A total of 8318 patients were included from 29 randomized clinical trials. Conventional meta‐analysis showed no significant differences in all‐cause mortality, cardiac death, major adverse cardiac events, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization between 2‐stent techniques and provisional stenting. Frequentist network meta‐analysis revealed that double kissing crush was associated with lower cardiac death (RR, 0.57; 95% CI, 0.38–0.84), major adverse cardiac events (RR, 0.50; 95% CI, 0.39–0.64), myocardial infarction (RR, 0.60; 95% CI, 0.39–0.90), stent thrombosis (RR, 0.50; 95% CI, 0.28–0.88), target lesion revascularization, and target vessel revascularization when compared with provisional stenting. Double kissing crush was also superior to other 2‐stent techniques, including T‐stent or T and protrusion, dedicated bifurcation stent, and culotte. Conclusions Double kissing crush was associated with lower risk of cardiac death, major adverse cardiac events, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization compared with provisional stenting and was superior to other 2‐stent techniques. Superiority of 2‐stent strategy over provisional stenting was observed in subgroup meta‐analysis stratified to side branch lesion length ≥10 mm.
BackgroundIntracoronary imaging modalities, including intravascular ultrasound (IVUS) and optical coherence tomography (OCT), provide valuable supplemental data unavailable on coronary angiography (CA) and have shown to improve clinical outcomes. We sought to compare the clinical efficacy of IVUS, OCT, and conventional CA‐guided percutaneous coronary interventions (PCI).MethodsFrequentist and Bayesian network meta‐analyses of randomized clinical trials were performed to compare clinical outcomes of PCI performed with IVUS, OCT, or CA alone.ResultsA total of 28 trials comprising 12,895 patients were included. IVUS when compared with CA alone was associated with a significantly reduced risk of major adverse cardiovascular events (MACE) (risk ratio: [RR] 0.74, 95% confidence interval: [CI] 0.63–0.88), cardiac death (RR: 0.64, 95% CI: 0.43–0.94), target lesion revascularization (RR: 0.68, 95% CI: 0.57–0.80), and target vessel revascularization (RR: 0.64, 95% CI: 0.50–0.81). No differences in comparative clinical efficacy were found between IVUS and OCT. Rank probability analysis bestowed the highest probability to IVUS in ranking as the best imaging modality for all studied outcomes except for all‐cause mortality.ConclusionCompared with CA, the use of IVUS in PCI guidance provides significant benefit in reducing MACE, cardiac death, and revascularization. OCT had similar outcomes to IVUS, but more dedicated studies are needed to confirm the superiority of OCT over CA.
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