Does stent design affect probability of restenosis? A randomized trial comparing Multilink stents with GFX stents.

BACKGROUND: Experimental studies have revealed that stent configuration influences intimal hyperplasia. The purpose of this study was to evaluate clinical outcomes for 2 stent designs in a randomized trial with quantitative coronary angiography (QCA) and intravascular ultrasonography (IVUS). METHODS: We randomly assigned 100 patients with 107 lesions and symptomatic coronary artery disease to deployment of a Multilink stent (Advanced Cardiovascular Systems, Guidant, Santa Clara, Calif) or a GFX stent (Applied Vascular Engineering, Santa Rosa, Calif) with IVUS guidance. QCA and IVUS studies were performed before and after intervention and at follow-up (4.2 +/- 1.0 months). RESULTS: There were no significant differences in baseline characteristics and QCA and IVUS parameters before and after intervention between the 2 groups. However, minimal lumen diameter at follow-up was significantly larger in the Multilink group (2.46 +/- 0.59 vs 2.08 +/- 0.79 mm, P <.05). Maximal in-stent intimal hyperplasia was significantly larger in the GFX group (2.9 +/- 1.7 vs 1.8 +/- 1.2 mm(2), P <.01). The restenosis rate differed between the 2 groups (Multilink 4% vs GFX 26%, P =.003). In multiple stepwise logistic regression analysis, the only predictor that significantly correlated with restenosis was stent type (P <.01). The odds ratio for the GFX stent-treated vessels was 18.65 (95% confidence interval 2.10-165.45). CONCLUSIONS: With deployment of the GFX stent, a thicker neointima develops within the stent. Stent configuration may affect clinical outcomes.

Dilated cardiomyopathy of Becker-type muscular dystrophy with exon 4 deletion--a case report.

The authors report a 47-year-old man with Becker-type muscular dystrophy presenting with dilated cardiomyopathy. Left ventriculography showed diffuse severe hypokinesia: left ventricular end-diastolic volume index 193 mL/m2, left ventricular end-systolic volume index 143 mL/m2, and left ventricular ejection fraction 26%. Skeletal muscle biopsy demonstrated a dystrophic process. Genetic analysis revealed a deletion of exon 4. There was a difference in immunostaining pattern between skeletal muscles and cardiac muscles. Severe cardiac dysfunction in this case may be associated with the damage in dystrophin-deficient fibers.

Relation between stent expansion and arterial remodeling: a serial intravascular ultrasound study.

Previous studies suggested that stent area (SA) did not change after the Palmaz-Schatz stent implantation. Whether these findings apply to other types of stent, however, is unknown. This study assessed vascular response to stent implantation using intravascular ultrasound (IVUS) studies. Serial (pre-intervention to follow-up) IVUS imagings were used to study 57 native coronary lesions after the GFX stent or the Multilink stent implantation. The vessel area (VA) at lesion site increased at follow-up (16.92 +/- 3.67 mm(2) after intervention to 18.17 +/- 4.66 mm(2) at follow-up, P < 0.01). The SA also increased from 8.39 +/- 1.90 mm(2) after intervention to 8.80 +/- 2.08 mm(2) at follow-up (P = 0.02). Thirty-two percent of lesions showed late stent expansion. The stent expansion [Delta (after intervention to follow-up) SA] correlated significantly with the VA growth [Delta (after intervention to follow-up) VA] (r = 0.59, P < 0.0001). In conclusion, some lesions reveal late stent expansion after both the GFX stent and the Multilink stent implantation. Adaptive vessel remodeling may be followed by stent expansion.

Heterogeneity of renal cortical circulation in hypertension assessed by dynamic computed tomography.

The aim of this study was to assess the grade of heterogeneous disturbance in the renal cortical circulation using dynamic computed tomography and to investigate the relationship between the heterogeneity of renal cortical circulation and hypertension. We studied 125 patients who underwent dynamic computed tomography (CT) for various abdominal diseases and had no serious hemodynamic abnormalities. In dynamic computed tomography under appropriate conditions, each pixel (image element), less than 1 mm2, has a CT number that is in proportion to the concentration of contrast media, which reflects the blood volume in the pixel. The image was constructed at the hilus level about 50 s after the start of a continuous infusion of contrast medium. The mean and standard deviation were calculated from the CT numbers in the renal cortex. The coefficient of variation, ie, the standard deviation divided by the mean value, was used as the index of the heterogeneity of renal cortical circulation. The coefficient of variation was significantly (P < .001) greater in the hypertensive patients (n = 48, 0.174 +/- 0.006 [mean +/- SE]) than in normotensive subjects (n = 77, 0.140 +/- 0.004). The coefficient increased in parallel with the patient's age and with the grade of renal surface irregularity. In the patients whose serum creatinine levels were normal, this parameter also had a significant relationship (r = 0.367, P < .0001) with serum creatinine. These results suggest that the heterogeneity of renal cortical circulation is increased in hypertension and is also associated with aging. This parameter may become a sensitive indicator to detect slight deterioration in the renal cortical circulation.

Effects of losartan on low-density lipoprotein apheresis.

The negative charges of dextran sulfate cellulose (DSC) used for low-density lipoprotein (LDL) apheresis activate the intrinsic coagulation pathway, accompanied by bradykinin production. This study was undertaken to see whether an antagonist of angiotensin receptor (AT1), losartan, could be safely used in a patient treated by DSC-LDL apheresis. Losartan (50 mg/day) was given to a patient with coronary heart disease who had been treated by DSC-LDL apheresis and had experienced an anaphylactoid reaction by administration of an angiotensin converting enzyme inhibitor. The effects of losartan on blood pressures and humoral factors were examined by comparing these parameters between apheresis with and without losartan. Blood pressures and plasma levels of bradykinin, renin, and aldosterone were measured before and at 1,000, 2,000, and 3,000 ml of plasma treatment. Bradykinin levels during LDL apheresis tended to be higher with losartan than without losartan (without versus with, 529 +/- 121 [n = 4, mean +/- SE] pg/ml vs. 1,058 +/- 49 at the 2,000 ml stage, p < 0.01). The rise of plasma renin activity with losartan (221 +/- 26% at the 3,000 ml stage) was significantly greater than that without losartan (144 +/- 2.4%). Mean blood pressure decreased by 7% during apheresis with losartan, but blood pressure reduction was not accompanied by any complaints. These results suggest that AT1 receptor antagonists are safely used in patients treated by DSC-LDL apheresis.

Pituitary adenylate cyclase activating peptide induces cGMP-mediated relaxation in guinea-pig airways.

The mechanism of relaxation of the guinea-pig trachea induced by pituitary adenylate cyclase activating peptide (PACAP)-27 was investigated. We examined whether modulators of nitric oxide (NO) and carbon monoxide (CO) affect PACAP-induced response of tracheal strips in vitro. Pretreatment with N omega-nitro-L-arginine methyl ester hydrochloride (L-NAME) and L-arginine (L-arg) had no effect, while 1H-[1,2,4] oxadiazolo[4,3-a]quinoxalin-1-one (ODQ), haemoglobin and zinc protoporphyrin IX (ZnPP-9) partially abolished the PACAP-induced relaxation. PACAP-27 elevated cyclic GMP level in airway smooth muscle tissue. These results indicate that PACAP-27 not only induces cyclic AMP-mediated responses, but also cyclic GMP-mediated responses in the airway. In addition, CO is related to the PACAP-induced elevation of cGMP level in the tracheal tissue.

[Thoracoscopic surgery for the giant bulla complicating pulmonary eosinophilic granuloma: a case report].

We report a case of pulmonary eosinophilic granuloma (PEG) accompanied with a giant bulla successfully operated with a thoracoscopy. A 24-year-old female had been suffering from recurrent bilateral pneumothoraces with multiple bullae since February 1993. She was diagnosed as PEG with an open lung biopsy in July 1994. Repetitive pleurodesis were efficacious against the pneumothoraces. However, a bulla in the left upper lobe were growing with her respiratory function having worsened to bed rest. In May 1995, thoracoscopic surgery were performed to extinguish the bulla. Trocars were directly introduced into the lumen of the bulla. Ligation of the three communicating bronchial branches and tube drainage made the bulla disappear immediately. The patient had been well for one and a half year postoperatively.

Activated eosinophils stimulate endothelin-1 release from airway epithelial cells by direct adherence via adhesion molecules.

Endothelin-1 (ET-1), synthesized in airway epithelial cells, has a potent constrictive action on airway smooth muscle. In this study, we investigated the effect of eosinophils on ET-1 release from guinea pig cultured tracheal epithelial cells. Eosinophils with or without the activation were directly co-cultured with tracheal epithelial cells. Eosinophils activated by GM/CSF or IL-5 potentiated ET-1 release, but non-activated ones did not. Treatment of activated eosinophils with antibodies against macrophage-1 (Mac-1) and/or very late antigen-4 (VLA-4) suppressed the potentiated ET-1 release. However, inhibition of lipid mediators derived from activated eosinophils could not suppress the potentiated ET-1 release. Moreover, separated co-culture of activated eosinophils with tracheal epithelial cells using Millicell-CM had no effect on ET-1 release. These observations suggest that adherence of activated eosinophils to epithelial cells via adhesion molecules such as Mac-1 and VLA-4 was essential for potentiation of ET-1 release. Since presence of eosinophils in the epithelial layer has been commonly demonstrated in bronchial biopsies and autopsy specimens from patients with asthma, epithelial cells would be activated by adherence of eosinophils via adhesion molecules and potentiate ET-1 release in vivo.

The effects of calcitonin gene-related peptide on tracheal smooth muscle of guinea-pigs in vitro.

1. The effect of calcitonin gene-related peptide (CGRP) on airway smooth muscle is controversial. The aim of this study was to determine whether the action of CGRP on tracheal strips of guinea-pigs is modulated by epithelium and whether this peptide-induced action involves other mediators including nitric oxide (NO) and endothelin (ET)-1. 2. CGRP produced a weak dose-dependent increase in guinea-pig tracheal tension in vitro (-logEC50 = 8.5 +/- 0.1, maximum contraction = 8.3 +/- 1.2% of 50 mM KCl-induced contraction, n = 6). In epithelium-depleted preparations, CGRP (10(-7) M)-induced contraction was significantly potentiated from 9.0 +/- 1.9% to 41.1 +/- 6.0% (n = 6). 3. L-NG-nitro-arginine methyl ester (L-NAME, 10(-4) M), which inhibits NO synthesis, enhanced the contractile response to CGRP from 9.0 +/- 1.9% to 31.2 +/- 1.1% (n = 6). Indomethacin (10(-5) M) also enhanced the response to CGRP, although the effect was weak (13.4 +/- 3.2%, n = 6). 4. Anti-ET-1 serum changed the CGRP-induced contraction into a relaxation. After incubation of the trachea with ET-1 (10(-7) M) to attenuate ET-1-induced responses, the CGRP-induced contraction also changed into a relaxation. BQ-123 (an ETA receptor antagonist) and BQ-788 (an ETB receptor antagonist) caused the same conversion of the CGRP response, from contraction to relaxation, although the relaxing effect elicited by BQ-788 was more potent than that by BQ-123. Maximum inhibitory responses were -31.0 +/- 3.3% and -13.0 +/- 2.3% of 50 mM KCl-induced contraction, respectively (n = 6). 5. In primary culture, guinea-pig tracheal epithelial cells released ET-1, and CGRP (10(-5) M) significantly increased the release of ET-1. 6. These data suggest that the action of CGRP is modulated by airway epithelium and this mechanism involves the release of NO and ET-1. Especially, the majority of contractile action elicited by CGRP consists of an action of ET-1 via the predominant ETB receptor.

[Antigen-induced dynamic alterations of endothelin receptors--guinea pig lung tissues].

Endothelins (ETs) are a family of peptides with potent constrictive activity in vascular and treacheal smooth muscle. The lung tissues are abundant in these peptides and their receptors; the peptides are produced by endothelial cells and airway epithelial cells, while its receptor is mainly located on smooth muscle. Therefore, it has been proposed that endothelins act in a paracrine fashion on nearby smooth muscle, thus regulating its tone. However, little is known about its physiological and pathological roles in pulmonary functions. We hypothesized that ET plays an important role in bronchoconstriction elicited by antigen challenge. In order to test this hypothesis, we investigated tracheal contractile activities and ET-receptors by employing an animal model in guinea pigs. Here, we report that guinea pigs who were sensitized followed by multiple challenges with the antigens had alterations of ET receptor(s) with respect to number and affinity.

[Enkephalinase activity in the guinea pig model of asthma].

Enkephalinase exists in airway epithelial cells, smooth muscle, and submucosa near glands, and cleaves tachykinins to inactive metabolites, thereby reducing there effects. To study the role of enkephalinase in asthmatic response, we measured its activity in guinea pig model of asthma. When compared with the control values, the enkephalinase activity was reduced during in immediate asthmatic response (IAR) and late asthmatic response (LAR). Compared with the control values (100%), each value was 79.7%, 73.4% in the trachea and 74.3%, 55.7% in the lung respectively. Tracheal muscle preparation taken from the control, IAR, and LAR groups were made and mounted in oxygenated modified Krebs-Ringer solution. The response was monitored by isometric transducer. Concentration response curves to NKA with or without phosphoramidon were obtained. The contractile responses of the LAR groups were enhanced in potency and efficiency. Phosphoramidon potentiated the NKA induced contraction of control and the IAR groups but was less potent in enhancing the contractile response in the LAR group, showing less enkephalinase activity in the LAR. These results suggest that the enkephalinase plays an important role in LAR. In LAR, the enkephalinase activity may be inhibited and the responsiveness of the smooth muscle to some bronchoconstrictor, such as tachykinins, may be increased.

Endothelins constrict guinea pig tracheas by multiple mechanisms.

When tracheal rings isolated from guinea pigs were treated with endothelins (ETs), a dose-dependent constriction was observed and measured isometrically. ET potencies were ET-1 = ET-2 greater than ET-3. Dose-response curves of epithelium-denuded tracheas were shifted to the left by approximately one order of magnitude. Lung tissue contained saturable binding sites to 125I-labeled ET-1. These binding sites were replaced by ET-1 = ET-2 greater than ET-3. Because the airway tissue contained primarily ET-1 as measured by immunoassay after high-performance liquid chromatography separation, we investigated the mechanism of ET-1-induced tracheal constriction. Tracheal constriction induced by ET-1 required Ca++ in the medium. Because suppression of the contractile response by nicardipine and diltiazem was small, Ca++ entry appeared to be gated primarily through Ca++ channels rather than via voltage-dependent ones. FPL55712, SC47014A, indomethacin and OKY046 suppressed the dose-response curves, suggesting that lipid mediators are formed in response to ET-1. Diphenhydramine also altered dose-response curves, suggesting that histamine release from mast cells was partially responsible for the constriction. Pretreatment of tracheas with compound 48/80 resulted in suppression of the contractile responses. Furthermore, the combination of indomethacin, FPL55712 and diphenhydramine gave essentially identical effects. Our observations suggest that ET-1 provokes the contractile response of guinea pig tracheas not only by direct actions on smooth muscle but also by indirect actions through production of chemical mediators in mast cells and other inflammatory cells.

[Effect of enkephalinase inhibitor on endothelin-1 induced bronchoconstriction in guinea pigs].

Endothelin-1 (ET-1) is one of the most potent bronchoconstrictors in the guinea pig. The mechanism of its metabolism is still unclear. Phosphoramidon is known to be an enkephalinase inhibitor. We studied the effect of phosphoramidon on bronchoconstriction induced by ET-1. In the first in vitro study, a tracheal preparation was mounted in oxygenated Krebs-Ringer solution. The response was monitored by isometric transducer. Dose-response curves to ET-1 with or without phosphoramidon were obtained. Phosphoramidon potentiated ET-1 induced bronchoconstriction significantly. Next, the specific airway conductance (sGaw) was measured in conscious guinea pigs exposed to an aerosol of phosphoramidon or saline, followed by ET-1 aerosol inhalation. The ET-1 dose was increased by successively doubling the concentration. sGaw, after inhalation of phosphoramidon, was significantly reduced when exposed to ET-1. Phosphoramidon also potentiated ET-1 induced bronchoconstriction in vivo. Next, lung parenchymal tissues were prepared and placed in oxygenated Krebs-Ringer solution with or without phosphoramidon. ET-1 was added and incubated, and samples were injected into a high performance liquid chromatography column. Phosphoramidon inhibited an analysis of ET-1. These data suggest that enkephalinase plays a role in the break down of ET-1 in the airway of the guinea pig. Under the condition of decreased enkephalinase, ET-1 would potentiate bronchoconstriction.

[Endothelin-1 induced relaxation of guinea pig trachea after an anaphylactic reaction].

Endothelin-1 (ET-1), one of the most potent constrictors of airway smooth muscles, is reported to act on such inflammatory cells as mast cells and release several chemical mediators. We observed a transient relaxation response to ET-1 after an anaphylactic constriction of guinea pig tracheal smooth muscle. The guinea pig was actively sensitized with ovalbumin, and the tracheal strip was challenged with ovalbumin in vitro. ET-1 induced a transient relaxation followed by a constriction of the tracheal strip. The potency of the relaxation induced by 10(-9) M of ET-1 was 16.0 +/- 1.3%, compared to the response to isoproterenol (2 x 10(-5) M), and the duration of the relaxation was 7.2 +/- 0.7 minutes. Indomethacin (10(-6) M) had no effect on the response, indicated that prostaglandins have no relation. Mechanical denudation of the tracheal epithelium did not reduce the relaxation, but rather augmented it. These results indicate that ET-1 induces a relaxation, associated with a relaxation factor from non-epithelial tissue.

Endotoxin stimulates endothelin release from cultured epithelial cells of guinea-pig trachea.

We examined the release of endothelin from cultured epithelial cells of guinea-pig trachea in response to treatment with endotoxin, using a sandwich-enzyme immunoassay. Cultured epithelial cells released endothelin in a time-dependent fashion (3, 6, 12, 24 h), and endotoxin (4-40 micrograms/ml) significantly increased endothelin release. Endotoxin (4-10 micrograms/ml) showed no cytotoxicity against epithelial cells. These results suggest that guinea-pig airway epithelial cells are capable of producing endothelin and this peptide may be related to the pathophysiological effects of endotoxin.

Multiple mechanisms of bronchoconstrictive responses to endothelin-1.

We investigated the mechanism of the endothelin-1 (ET-1)-induced bronchoconstriction of guinea pig tracheal smooth muscles. ET-1 contracted the tracheas in a dose-dependent manner. A combination of FPL55712 (leukotriene antagonist), diphenhydramine (histamine antagonist), and indomethacin (cyclooxygenase inhibitor) shifted the dose-response curve of ET-1 to the right and suppressed the maximal constriction. Azelastine, an antiallergic agent, exerted essentially similar results. The present data suggest that ET-1 constricts the airway smooth muscles not only by direct action on the tracheal smooth muscles but also by indirect action mediated through production of various chemical mediators in cells other than muscles.

Endothelin-1-induced relaxation of guinea pig trachealis muscles.

Our accompanying paper demonstrated that endothelin-1 (ET-1 constricts guinea pig airways directly and indirectly through mediators such as histamine and arachidonate metabolites. In order to exclude the role of mast cells in bronchoconstriction, we sensitized guinea pigs and challenged them in vitro with an antigen (ovalbumin). In the postanaphylactic trachea, ET-1 caused a transient relaxation followed by constriction. Such relaxation by ET was also observed in the tracheas constricted with carbamylcholine. The relaxation was completely blocked by nordihydroguaretic acid and AA861, lipooxygenase inhibitors, but not by indomethacin, a cyclooxygenase inhibitor, and FPL 55712, a leukotriene antagonist. Because the relaxation was not affected even in the presence of methylarginine, an inhibitor of NO synthesis, and superoxide dismutase, an enzyme for destroying NO radical, we concluded that ET-1 induces the relaxation of the tracheal muscles by producing lipooxygenase products, probably hydroperoxides of arachidonic acid.