The additive effect of essential hypertension on coronary artery plaques in type 2 diabetes mellitus patients: a coronary computed tomography angiography study

Background The effect of comorbid hypertension and type 2 diabetes mellitus (T2DM) on coronary artery plaques examined by coronary computed tomography angiography (CCTA) is not fully understood. We aimed to comprehensively assess whether comorbid hypertension and T2DM influence coronary artery plaques using CCTA. Materials and methods A total of 1100 T2DM patients, namely, 277 normotensive [T2DM(HTN−)] and 823 hypertensive [T2DM(HTN +)] individuals, and 1048 normotensive patients without T2DM (control group) who had coronary plaques detected on CCTA were retrospectively enrolled. Plaque type, coronary stenosis, diseased vessels, the segment involvement score (SIS) and the segment stenosis score (SSS) based on CCTA data were evaluated and compared among the groups. Results Compared with patients in the control group, the patients in the T2DM(HTN−) and T2DM(HTN +) groups had more partially calcified plaques, noncalcified plaques, segments with obstructive stenosis, and diseased vessels, and a higher SIS and SSS (all P values < 0.001). Compared with the control group, T2DM(HTN +) patients had increased odds of having any calcified and any noncalcified plaque [odds ratio (OR) = 1.669 and 1.278, respectively; both P values < 0.001]; both the T2DM(HTN-) and T2DM(HTN +) groups had increased odds of having any partially calcified plaque (OR = 1.514 and 2.323; P = 0.005 and P < 0.001, respectively), obstructive coronary artery disease (CAD) (OR = 1.629 and 1.992; P = 0.001 and P < 0.001, respectively), multivessel disease (OR = 1.892 and 3.372; both P-values < 0.001), an SIS > 3 (OR = 2.233 and 3.769; both P values < 0.001) and an SSS > 5 (OR = 2.057 and 3.580; both P values < 0.001). Compared to T2DM(HTN−) patients, T2DM(HTN +) patients had an increased risk of any partially calcified plaque (OR = 1.561; P = 0.005), multivessel disease (OR = 1.867; P < 0.001), an SIS > 3 (OR = 1.647; P = 0.001) and an SSS > 5 (OR = 1.625; P = 0.001). Conclusion T2DM is related to the presence of partially calcified plaques, obstructive CAD, and more extensive coronary artery plaques. Comorbid hypertension and diabetes further increase the risk of partially calcified plaques, and more extensive coronary artery plaques.

Dark crescent sign: high-risk calcified coronary plaque detected by electrocardiogram-gated non-contrast computed tomography

Electrocardiogram-gated non-contrast computed tomography can discriminate a dark crescent-shaped calcified plaque characterised as a low-intensity area surrounded by high-intensity signals. Careful attention should be paid to performing a percutaneous coronary intervention for a plaque with the dark crescent sign because of its potential high risk of no-flow phenomenon.

Testosterone Therapy for Men With Age-Related Low Testosterone: Tempest in a Teacup

Serum testosterone concentrations decrease in men with age, but benefits and risks of raising testosterone levels in older men remain controversial. In the T-Trials, a total of 790 men, age 65 and older, with a serum testosterone concentration of &lt; 275 ng/dL and symptoms of sexual dysfunction, fatigue or physical dysfunction were randomized to either testosterone gel or placebo gel for 1 year. Treatment in the testosterone arm increased serum testosterone levels to the mid-normal range for young men. Testosterone replacement was associated with a significant increase in sexual activity (p&lt;0.001), libido and erectile function. In contrast, there was no improvement in vitality or physical function. Adverse findings included increases in non-calcified plaque formation and a higher rate of prostate events. In sum, testosterone treatment in older men was associated with modest benefits, while the risk on prostate and cardiovascular health remain unclear.

579 Pre-operative computed tomography evaluation of suprarenal aortic burden predicts post-procedural acute kidney injury after transcatheter aortic valve replacement: the spread-AKI study

Aims Acute kidney injury (AKI) is a potential complication of transcatheter aortic valve replacement (TAVR). Athero-embolization linked to catheter manipulation in the supra-renal aorta is a possible pathogenetic mechanism of AKI after TAVR. We sought to determine the impact of supra-renal aortic atheroma burden (AB) on AKI, and the potential role of pre-operative multislice computed tomography (PO-MSCT) in evaluating the supra-renal aortic atherosclerosis and the pre-operative risk of AKI. Methods and results We collected PO-MSCT, as well as baseline, procedural, and post-procedural characteristics of 222 consecutive patients who underwent TAVR from January 2018 to December 2020 at a single, high-volume, Italian centre. PO-MSCT was performed using a dedicated TAVR protocol with an ECG-triggered high-pitch spiral acquisition. The non-contrast aortic valve calcium score (AV-CS) was calculated by a dedicated software. Angiographic data were analysed on a dedicated 3D workstation. Bidimensional measurements, total renal volume (TRV), and presence of significant (≥50%) renal artery stenosis (RAS) were recorded. The supra-renal AB was quantified using a ‘plaque analysis’ module that automatically segments the entire aortic root, from the sino-tubular junction to the renal arteries, by drawing a centreline across the aortic lumen and delineating the inner and outer vessel walls (including the plaque). Manual correction was applied. A set of Hounsfield unit (HU) intensity ranges were defined and mapped to a color overlay to visualize the various elements of atherosclerotic lesion by using the plaque density classification of the Society of Cardiovascular Computed Tomography (necrotic core, fibro-fatty, fibrous, and calcified plaque); calcified plaque were subcategorized on a voxel-level basis into three strata: low- (351–700 HU), mid- (701–1000 HU), and high-calcium (&gt;1000 HU, termed 1K plaque). Post-procedural complications were defined according to Valve Academic Research Consortium (VARC-3) criteria. Mean age was 83.3 ± 5.7 years, and 95 (42.8%) patients were males. AKI occurred in 67/222 (30.2%). Patients who developed AKI had higher supra-renal AB (17.6 ± 5.1% vs. 13.9 ± 4.3%, P &lt; 0.001), TRV indexed for body surface area (TRVBSA; 153.7 ± 43.1 vs. 134.9 ± 38.7, P = 0.002), mid-calcium plaque (2.2 ± 1.5% vs. 1.3 ± 1.1%, P &lt; 0.001), 1K plaque (5.4 ± 3.7% vs. 2.4 ± 2.4%, P &lt; 0.001) and suffered more post-procedural major/life-threatening (severe) bleedings [9/67 (13.4%) vs. 5/155 (3.2%), P = 0.004], whereas there was no difference in AV-CS (P = 0.691) and RAS (P = 0.077). Multivariate logistic regression analysis adjusted for other univariate predictors (male sex, baseline eGFR, baseline ejection fraction, baseline mean aortic gradient, and RAS) showed percent supra-renal AB (HR: 1.15, 95% CI: 1.06–1.26, P = 0.002), mid-to-high calcium plaque (HR: 5.67, 95% CI: 2.49–13.77, P &lt; 0.001), severe bleedings (HR: 4.93, 95% CI: 1.09–24.69, P = 0.043), and TRVBSA (HR: 1.015, 95% CI: 1.01–1.02, P = 0.021) as independent predictors of AKI. Finally, a 3-knots spline curve analysis identified percent of supra-renal AB &gt; 15.0% as the optimal threshold to predict an increased risk of AKI. Conclusions Suprarenal AB is associated with the occurrence of AKI, and this association is strengthened as the percentage of calcified plaque increases. Quantitative and qualitative pre-operative MSCT assessment of aortic atherosclerosis may help in early identification of patients at high-risk for AKI who could benefit from higher peri-operative surveillance.

The Effect of Aggressive Wire Recanalization in Calcified Atheroma and Dilatation (ARCADIA) Technique in Eccentric Calcified Lesion of No-stenting Zone

Purpose: The endovascular approach for eccentric calcified lesions of the no-stenting zone is challenging. This study aimed to investigate the effect of a novel technique for these lesions. Methods: We performed EVT for severe and eccentric calcified lesions using the technique, which is presented previously and named aggressive wire recanalization in calcified atheroma and dilatation (ARCADIA). In brief, a guidewire is passed to the residual lumen firstly. Next, another guidewire is advanced into and cross through the calcified plaque and returned to the distal original lumen with intravascular ultrasound (IVUS) guided. The calcified plaque is dilated by using a scoring-balloon or non-compliant balloon. Results: Consecutive 14 peripheral artery disease patients with isolated and eccentric calcification in a no-stenting zone were treated using ARCADIA technique between January 2018 and March 2020. In IVUS data, lumen cross-section area was significantly increased from 5.2 ± 2.0 mm2 to 18.1 ± 6.9 mm2 (p < 0.01), lumen area was expanded roundly evaluating as symmetry index from 0.45 ± 0.09 to 0.81 ± 0.12 (p < 0.01). There were no distal embolization and perforation after ARCADIA technique. One-year target lesion revascularization occurred in only 2 cases. The primary patency of 1 year was 85.7%. Conclusion: ARCADIA technique is safe and appropriate, and can be 1 option to treat for eccentric calcified lesions of the no-stenting zone as an optimal wire crossing method.

Relationship of age, atherosclerosis and angiographic stenosis using artificial intelligence

ObjectiveThe study evaluates the relationship of coronary stenosis, atherosclerotic plaque characteristics (APCs) and age using artificial intelligence enabled quantitative coronary computed tomographic angiography (AI-QCT).MethodsThis is a post-hoc analysis of data from 303 subjects enrolled in the CREDENCE (Computed TomogRaphic Evaluation of Atherosclerotic Determinants of Myocardial IsChEmia) trial who were referred for invasive coronary angiography and subsequently underwent coronary computed tomographic angiography (CCTA). In this study, a blinded core laboratory analysing quantitative coronary angiography images classified lesions as obstructive (≥50%) or non-obstructive (<50%) while AI software quantified APCs including plaque volume (PV), low-density non-calcified plaque (LD-NCP), non-calcified plaque (NCP), calcified plaque (CP), lesion length on a per-patient and per-lesion basis based on CCTA imaging. Plaque measurements were normalised for vessel volume and reported as % percent atheroma volume (%PAV) for all relevant plaque components. Data were subsequently stratified by age <65 and ≥65 years.ResultsThe cohort was 64.4±10.2 years and 29% women. Overall, patients >65 had more PV and CP than patients <65. On a lesion level, patients >65 had more CP than younger patients in both obstructive (29.2 mm3 vs 48.2 mm3; p<0.04) and non-obstructive lesions (22.1 mm3 vs 49.4 mm3; p<0.004) while younger patients had more %PAV (LD-NCP) (1.5% vs 0.7%; p<0.038). Younger patients had more PV, LD-NCP, NCP and lesion lengths in obstructive compared with non-obstructive lesions. There were no differences observed between lesion types in older patients.ConclusionAI-QCT identifies a unique APC signature that differs by age and degree of stenosis and provides a foundation for AI-guided age-based approaches to atherosclerosis identification, prevention and treatment.

A case of picking calcified plaque in the common femoral artery with a long needle: the “calc-pick technique”

An 88-year-old man had intermittent claudication of his right leg. Angiography revealed severely calcified plaque in the common femoral artery. Endovascular treatment was performed by contralateral approach. We attempted to penetrate the center of the calcified plaque and perform balloon dilatation. However, a 0.014-inch stiff guidewire could not enter the center of the lesion. Thus, we used an inner cylinder of 15-cm 20G long needle directly through the retrograde femoral sheath and successfully introduced the guidewire into the calcified plaque. Crosser and balloon dilatation resulted in 50 % stenosis. To cross the center of calcified plaque, it is important to obtain sufficient lumen gain at the non-stenting zone.

Diagnostic Efficacy of CCTA And CT-FFR Based On Risk Factors For Myocardial Ischemia

Background: Coronary artery CCTA can observe the degree of coronary artery stenosis and FFR can evaluate the physiological function of coronary artery. However, noninvasive imaging examination that can both observe the above two methods at the same time has not yet been elucidated.Objective: To investigate the diagnostic efficacy of coronary computed tomography angiography (CCTA) and computed tomography-derived fractional flow reserve (CT-FFR) based on different risk factors for myocardial ischemia.Methods: Patients undergoing CCTA in our hospital from August 18, 2020 to April 28, 2021 were randomly selected, and the data were subjected to CT-FFR analysis. Vascular characteristics were measured, including total plaque volume, calcified plaque volume, non-calcified plaque volume, plaque length, and lumen stenosis, and the patients were categorized into a non-ischemia group (FFR>0.8) and an ischemia group (FFR≤0.8). Plaque characteristics were compared between the two groups, and logistic regression analysis was employed to explore the correlations between plaque characteristics and ischemic lesions.Results: From a total of 122 patients enrolled in the study, there were 218 vascular branches with FFR>0.8 and 174 vascular branches with FFR≤0.8. There were significant group differences in total plaque volume, calcified plaque volume, plaque length, and lumen stenosis >50% (n). The obtained data were as follows: non-ischemic group 10.57 (4.80, 259.65), ischemic group 14.87 (3.39, 424.45), Z=9.772, p=0.002, non-ischemic group 10.57 (0, 168.77), ischemic group 14.87 (0, 191.00), Z=2.503，p≤0.001), non-ischemic group 8.17 (37.05, 40.53), ischemic group 8.38 (56.66, 86.47), Z=5.923, p=0.016, and lumen stenosis >50%, non-ischemic group 46, ischemic group 90, x2=14.77，p≤0.001. The regression analysis results indicated that total plaque volume, calcified plaque volume, plaque length and lumen stenosis >50% were risk factors for myocardial ischemia, with ORs and p values of (2.311, p=0.002), (1.021, p=0.004), (2.159, p<0.001), and (0.181, p<0.001), respectively.Conclusion: Total plaque volume, calcified plaque volume, plaque length and lumen stenosis >50% are predictors for myocardial ischemia. Coronary artery CCTA combined with CT-FFR could simultaneously observe the anatomical stenosis and evaluate myocardial blood supply at the functional level. Thus, myocardial ischemia could be better diagnosed.