Abstract Coronary bifurcations are frequent and account for approximately 20% of all percutaneous coronary interventions. Nonetheless, they remain one of the most challenging lesion subsets in ...interventional cardiology in terms of a lower procedural success rate and increased rates of long-term adverse cardiac events. Provisional side branch stenting should be the default approach in the majority of cases and we propose easily applicable and reproducible stepwise techniques associated with low risk of failure and complications.
Abstract Objectives This study sought to develop a scoring model predicting percutaneous coronary intervention (PCI) success in chronic total occlusions. Background Coronary chronic total occlusion ...is the lesion subtype in which angioplasty is most likely to fail. Chronic total occlusion for PCI (CTO-PCI) failure is associated with higher 1-year mortality and major adverse cardiac events compared with successful CTO-PCI. Although several independent predictors of final procedural success have been identified, no study has yet produced a model predicting final procedural outcome. Methods Data from 1,657 consecutive patients who underwent a first-attempt CTO-PCI were prospectively collected. The scoring model was developed in a derivation cohort of 1,143 patients (70%) using a multivariable stepwise analysis to identify independent predictors of CTO-PCI failure. The model was then validated in the remaining 514 (30%). Results The overall procedural success rate was 72.5%. Independent predictors of CTO-PCI failure were identified and included in the clinical and lesion-related score (CL-score) as follows: previous coronary artery bypass graft surgery +1.5 (odds ratio OR: 2.49, 95% confidence interval CI: 1.56 to 3.96), previous myocardial infarction +1 (OR: 1.6, 95% CI: 1.17 to 2.2), severe lesion calcification +2 (OR: 2.72, 95% CI :1.78 to 4.16), longer CTOs +1.5 (≥20 mm OR: 2.04, 95% CI: 1.54 to 2.7), non–left anterior descending coronary artery location +1 (OR: 1.56, 95% CI: 1.14 to 2.15), and blunt stump morphology +1 (OR: 1.39, 95% CI: 1.05 to 1.81). Score values of 0 to 1, >1 and <3, ≥3 and <5, and ≥5 identified subgroups at high, intermediate, low, and very low probability, respectively, of CTO-PCI success (derivation cohort: 84.9%, 74.9%, 58%, and 31.9%; p < 0,0001; validation cohort: 88.3%, 73.1%, 59.4%, and 46.2%; p < 0.0001). Conclusions This clinical and angiographic score predicted the final CTO-PCI procedural outcome of our study population.
Abstract Contemporary clinical trials, registries, and meta-analyses, supported by recent results from the EXCEL (Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease) ...and NOBLE (Percutaneous Coronary Angioplasty Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis) trials, have established percutaneous coronary intervention of left main coronary stenosis as a safe alternative to coronary artery bypass grafting in patients with low and intermediate SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) scores. As left main percutaneous coronary intervention gains acceptance, it is imperative to increase awareness for patient selection, risk scoring, intracoronary imaging, vessel preparation, and choice of stenting techniques that will optimize procedural and patient outcomes.
The increasing number and complexity of these procedures have led to a higher number of patients at risk for tissue reactions like skin injuries. Monitoring of their dose indicators is essential in ...recognizing these patients. The aim of this work was to determine local diagnostic reference levels (DRLs) for recanalization of chronic total occlusion (CTO) and other occlusions procedures. All data from patients who underwent cardiac procedures were reviewed and classified according to their complexity. Dose indicators such as fluoroscopy time (FT), dose area product (DAP), and air kerma at patient entrance reference point (AKr ) were recorded. Correlations with patient's body mass index, operators, procedure strategy, and complexity were studied. For CTO, the mean DAP, AKr , and FT were 252 ± 234 Gycm2 , 3,985 ± 3,579 mGy, and 47 ± 36 minutes, respectively. To better reflect the non-Gaussian distribution of data, the median and the 75th percentile values were also reported: median DAP, 172 Gycm2 ; 75th percentile DAP, 350 Gycm2 ; median AKr , 2,714 mGy; and 75th percentile AKr, 5,921 mGy. A tentative new set of values were suggested to take into account the complexity difference in recanalization of total occlusions according to their antegrade or retrograde approach. These approach-specific DRLs for total occlusions were mean DAP (120 ± 114 Gycm2 ), mean AKr (1,789 ± 1,933 mGy), and mean FT (22 ± 18 minutes) for antegrade approach and mean DAP (459 ± 304 Gycm2 ), mean AKr (6,881 ± 4,243 mGy), and mean FT (82 ± 40 minutes) for retrograde approach. The other significant values were median DAP (84 Gycm2 ), 75th percentile DAP (147 Gycm2 ), median AKr (1,160 mGy), and 75th percentile AKr (2,176 mGy) for antegrade approach and median DAP (422 Gycm2 ), 75th percentile DAP (552 Gycm2 ), median AKr (6,295 mGy), and 75th percentile AKr (8,064 mGy) for retrograde approach. In conclusion, a set of local DRL values from a large center were assessed. DRLs were provided for antegrade and retrograde approaches, reflecting the difference in difficulty from these 2 kinds of CTOs. The wide dose estimator values variations were explained through procedure complexity. The values obtained for the other more classic percutaneous coronary interventions were comparable with those found in the literature.
Several observational studies have compared clinical outcome in patients with a co-existing noninfarct-related artery chronic total occlusion (n-IRA CTO) versus those without, suggesting increased ...all-cause mortality. The goal of this study was to provide a systematic review and meta-analysis evaluating the impact of the presence of an n-IRA CTO on short- and long-term mortality after primary percutaneous coronary intervention. Studies published from January 1980 to January 2014 that compared the incidence of all-cause mortality in patients with ST-segment elevation myocardial infarction with co-existing n-IRA CTO versus those without were identified using an electronic search and reviewed using meta-analytical techniques. Seven studies (5 observational studies and 2 observational analyses of randomized controlled trials) comprising 14,117 patients and 1,554 patients (11.7%) with n-IRA CTO were included. The presence of n-IRA CTO was associated with increased incidence of all-cause mortality at a median follow-up of 25.2 months (interquartile range 24 to 60) compared with no CTO (absolute risk 23.5% vs 9.0%; odds ratio OR 2.90, 95% confidence interval CI 2.09 to 4.01; p <0.0001). This finding was consistent in the analysis of studies reporting 30-day follow-up (absolute risk 17.2% vs 4.7%; OR 3.79, 95% CI 3.13 to 4.59; p <0.0001). Co-existing n-IRA CTO was also associated with increased mortality in a subanalysis of patients with multivessel disease only (absolute risk 24.2% vs 11.3%; OR 2.23, 95% CI 1.90 to 2.63; p <0.0001). In conclusion, coronary CTO in the nonculprit artery in patients presenting with ST-segment elevation myocardial infarction is associated with increased short- and long-term all-cause mortality.
2-Year Outcome of Patients Treated for Bifurcation Coronary Disease With Provisional Side Branch T-Stenting Using Drug-Eluting Stents Helen C. Routledge, Marie-Claude Morice, Thierry Lefèvre, ...Philippe Garot, Federico DeMarco, Beatriz Vaquerizo, Yves Louvard The long-term safety and efficacy of drug-eluting stents in coronary bifurcation lesions remain to be demonstrated as does the applicability of a simple stenting strategy to a large cohort of patients in everyday practice. We describe favorable results in over 450 patients treated according to a uniform strategy of 2 wires, provisional side-branch T-stenting with drug-eluting stents, and a final kissing inflation. Both safety and efficacy are demonstrated in the immediate and long term with few in-hospital adverse events, <10% need for repeat revascularization over 2 years, and a low incidence of late drug-eluting stent thrombosis.
Abstract Treatment of coronary bifurcation lesions remains an ongoing challenge for interventional cardiologists. Stenting of coronary bifurcations carries higher risk for in-stent restenosis, stent ...thrombosis, and recurrent clinical events. This review summarizes the current evidence regarding application and use of biomechanical modeling in the study of stent properties, local flow dynamics, and outcomes after percutaneous coronary interventions in bifurcation lesions. Biomechanical modeling of bifurcation stenting involves computational simulations and in vitro bench testing using subject-specific arterial geometries obtained from in vivo imaging. Biomechanical modeling has the potential to optimize stenting strategies and stent design, thereby reducing adverse outcomes. Large-scale clinical studies are needed to establish the translation of pre-clinical findings to the clinical arena.
Objectives This study sought to assess the impact of multivessel (MV) primary percutaneous coronary intervention (PCI) on clinical outcomes in patients with ST-segment elevation myocardial infarction ...(STEMI) presenting with cardiogenic shock (CS) and resuscitated cardiac arrest (CA). Background The safety and efficacy of MV primary PCI in patients with STEMI and refractory CS is unknown. Methods We conducted a multicenter prospective observational study of consecutive STEMI patients presenting to 5 French centers. Patients were classified as having single-vessel (SVD) or multivessel (MVD) coronary disease, and underwent culprit-only or MV primary PCI. Baseline characteristics and 6-month survival were compared. Results Among 11,530 STEMI patients, 266 had resuscitated CA and CS. Patients with SVD (36.5%) had increased 6-month survival compared to those with MVD (29.6% vs. 42.3%, p = 0.032). Baseline characteristics were similar in those with MVD undergoing culprit-only (60.9%) or MV (39.1%) primary PCI. However, 6-month survival was significantly greater in patients who underwent MV PCI (43.9% vs. 20.4%, p = 0.0017). This survival advantage was mediated by a reduction in the composite of recurrent CA and death due to shock (p = 0.024) in MV PCI patients. In those with MVD, culprit artery PCI success (hazard ratio HR: 0.63; 95% confidence interval CI: 0.41 to 0.96, p = 0.030) and MV primary PCI (HR: 0.57; 95% CI: 0.38 to 0.84, p = 0.005) were associated with increased 6-month survival. Conclusions The results of this study suggest that in STEMI patients with MVD presenting with CS and CA, MV primary PCI may improve clinical outcome. Randomized trials are required to verify these results.
Background Although transradial percutaneous coronary intervention (TRPCI) is widely applied for percutaneous procedures, its safety in the setting of ST-segment elevation (STEMI) is controversial. ...Our aim was to assess the safety and efficacy of TRPCI versus transfemoral PCI in the context of treating patients suffering acute myocardial infarction with STEMI. Methods Randomized, case-control, and cohort studies comparing access-related complications were analyzed. Our objective was to determine if radial access reduces major bleeding and thereby reduces death and ischemic events compared to femoral access in this setting. A fixed-effects model was used with random effects for sensitivity analysis. Results Twelve studies involving 3324 patients were identified. Transradial PCI reduced major bleeding compared to transfemoral PCI ( P = .0001), and significant reductions were found in the composite of death, myocardial infarction, or stroke ( P = .001). Mortality reduction showed a significant toward benefit in the case of TRPCI (2.04% vs 3.06%, OR 0.54 95% CI 0.33-0.86, P = .01). The fluoroscopic time was longer, and access site crossover was more frequent for TRPCI ( P = .001, P < .00001, respectively). Conclusions Transradial PCI reduces the risk of periprocedural major bleeding and major adverse events in the STEMI setting.
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