How to optimize the percutaneous treatment of bifurcated lesions: dedicated stents vs. provisional stenting.

Although provisional T-stenting with stenting of the main branch and optional side branch stenting is nowadays the default strategy generally preferred for simple bifurcation lesions, percutaneous coronary intervention (PCI) of complex true bifurcation lesions remains a difficult task to achieve also with modern second generation drug eluting stents. Treatment of complex bifurcational lesions is not only more time consuming but can lead to significantly higher rate of periprocedural myocardial infarction and late estenosis, stent thrombosis and target lesion revascularization. These clinical complications may be at least in part be due to the fact that current bifurcation techniques often fail to ensure continuous stent coverage of the SB ostium and the bifurcation branches and often leave a significant number of malapposed struts. Struts left unapposed in the lumen are not efficient for drug delivery to the vessel wall, disturb blood flow and may increase the risk of restenosis and stent thrombosis. This article summarises the various techniques of bifurcation stenting, highlighting their relative merits and disadvantages. In addition, the role of newer dedicated bifurcation stent devices, as well as the role of imaging in guiding optimal stent deployment will be discussed.

Imaging of atherosclerosis.

It is now well recognized that the atherosclerotic plaques responsible for thrombus formation are not necessarily those that impinge most on the lumen of the vessel. Nevertheless, clinical investigations for atherosclerosis still focus on quantifying the degree of stenosis caused by plaques. Many of the features associated with a high-risk plaque, including a thin fibrous cap, large necrotic core, macrophage infiltration, neovascularization, and intraplaque hemorrhage, can now be probed by novel imaging techniques. Each technique has its own strengths and drawbacks. In this article, we review the various imaging modalities used for the evaluation and quantification of atherosclerosis.

Multiple inflow pulsed arterial spin-labeling reveals delays in the arterial arrival time in minor stroke and transient ischemic attack.

Our purpose was to use multiple inflow pulsed ASL to investigate whether hemodynamic AAT information is sensitive to hemispheric asymmetry in acute ischemia. The cohorts included 15 patients with acute minor stroke or TIA and 15 age-matched controls. Patients were scanned by using a stroke MR imaging protocol at a median time of 74 hours. DWI lesion volumes were small and functional impairment was low; however, perfusion abnormalities were evident. Prolonged AAT values were more likely to reside in the affected hemisphere (significant when compared with controls, P < .048). An advantage of this ASL technique is the ability to use AAT information in addition to CBF to characterize ischemia.

Relationship of nevocytic nevi to sun exposure in dysplastic nevus syndrome.

In eighty consecutive patients who have the dysplastic nevus syndrome, the concentration of nevocytic nevi on the relatively sun-protected lateral thoracic area was compared to the concentration on the relatively sun-exposed areas of the anterior and posterior thorax. Nevocytic nevi in an area 7 X 20 cm were counted in each location. There was a total of 177 nevi on the lateral thorax (average, 2.2 nevi/person), 361 on the anterior thorax (average, 4.5 nevi/person), and 506 on the posterior thorax (average, 6.3 nevi/person). Men showed no significant difference in the number of nevi on the anterior and posterior thoracic areas, but women had fewer nevi on the anterior than on the posterior thoracic sites. These findings are consonant with the hypothesis that sunlight induces nevocytic nevi in patients who have the dysplastic nevus syndrome.