Dear Readers,

This issue of the Journal of Invasive Cardiology includes original research articles, case reports, case reports with reviews of the literature, editorials, and articles from the some of the journal’s special sections.

Several clinical studies have demonstrated that diabetes mellitus is an important predictor of angiographic restenosis and late mortality after conventional balloon angioplasty.^1,2 Stent implantation has been shown to improve the clinical outcomes for diabetic patients,³ however, patients with diabetes mellitus still continue to have increased clinical events and restenosis after coronary stenting.^4–6 Endothelial dysfunction, increased platelet reactivity and thrombogenicity, and dysregulation of growth factors may contribute to the exaggerated neointimal hyperplasia occurring in diabetic patients.^7,8

There are more than 150 million adults worldwide estimated to have diabetes mellitus (DM), with Type 2 diabetes accounting for up to 95% of all cases.¹ In 2001, the prevalence of DM in the United States was 8%, a relative increase of approximately 61% over a 10-year time span.² Coronary artery disease (CAD) is virtually ubiquitous in adults with DM compared with non-diabetic patients and portends a worse prognosis. Diabetic patients are 2 to 4 times more likely to develop CAD than non-diabetic patients and have the same likelihood of experiencing a myocardial infarction (MI) as those without DM but who have a previous history of MI.³ As the prevalence of DM increases, the challenges for the health care of these individuals are magnified.

Percutaneous angioplasty of aorto-coronary venous bypass grafts is associated with a higher incidence of adverse events compared to interventions in native vessels.¹ Reasons for this well-known phenomen are emboli of pieces of friable lipid-rich plaque² and thrombus,³ resulting in the no-reflow phenomen and myocardial ischemia after angioplasty.

Predictors of complications in peripheral percutaneous interventions (PPI) with bivalirudin as a base anticoagulant have not yet been defined. The Angiomax Peripheral Procedure Registry of Vascular Events (APPROVE)¹ offers a unique opportunity to analyze predictors of complications with bivalirudin in renal, iliac and femoral interventions.

Multiple publications have addressed complications of PPI in the periphery with unfractionated heparin (UFH)

Potent inhibition of platelet aggregation during percutaneous coronary intervention (PCI) using intravenous antagonists of the platelet glycoprotein (GP) IIb/IIIa receptor results in a significant and sustained reduction in the occurrence of ischemic complications.^1–4 In all of these clinical trials, the GP IIb/IIIa inhibitors were strated prior to the first balloon inflation or device activation. However, in clinical practice, these intravenous agents are often used in a rescue, or “bailout” mode after procedural complications arise.⁵ This bailout strategy has not been formally or prospectively studied.

Coronary calcification is an important process of atherosclerosis and represents advanced coronary disease.^1,2 The presence and extent of coronary calcification is an important determinant of the outcome of percutaneous intervention (increases the risk of dissection after balloon dilation, may indicate plaque rotational ablation as initial treatment, or may dissuade from direct stenting).^3–6

For these reasons, the detection of calcium is relevant in the evaluation of the coronary arteries. Coronary angiography has been the “gold standard” for diagnosis and interventional treatment of coronary disease, despite its many inherent limitations. Intravascular ultrasound provides transmural images of coronary arteries in vivo, being free of the constraints of angiography, and has been extensively used to evaluate the extent and depth of coronary calcification.^7–11

Optical coherence tomography (OCT) represents a promising new technology^1–2 for imaging the vascular microstructure at a level of 10–20 mm,^3–6 which has not yet been achieved with the use of other imaging modalities.^7–9 It may permit the determination of small structural details such as intimal flap width and the presence of fissures, as well as the width of intimal caps^10–12 or malapposition of a stent.¹³

Increasing evidence supports the use of bivalirudin as an adjunct to percutaneous coronary intervention to minimize bleeding complications.^1,2 We describe a patient who developed an acute myocardial infarction one hour following total knee arthroplasty. During emergent percutaneous coronary intervention, bivalirudin was used for anticoagulation with the intent of minimizing bleeding complications. Intervention was successful and he suffered no post-interventional bleeding from the surgical site. In this peri-operative setting, bivalirudin’s short half-life offered a potentially safer alternative to combination heparin and glycoprotein IIb/IIIa inhibitors.