Knowledge in the field of bifurcation lesions and chronic total occlusions (CTOs) has progressively improved over the past 20 years. Therefore, the European Bifurcation Club and the EuroCTO Club have ...decided to write a joint consensus statement to share general knowledge and practical approaches in this complex field. When percutaneously treating CTOs, bifurcation lesions with relevant side branches (SBs) are found in approximately one-third of cases (35% at the proximal cap, 38% at the distal cap, and 27% within the CTO body). Occlusion of a relevant SB is not rare and has been shown to be associated with procedural complications and adverse outcomes. Simple bifurcation rules are very useful to prevent SB occlusion, and provisional SB stenting is the recommended approach in the majority of cases: protect the SB as soon as possible by wiring it, respect the fractal anatomy of the bifurcation by using the 3-diameter rule, and avoid using dissection and re-entry techniques. A systematic 2-stent approach can be used if needed or sometimes to connect both branches of the bifurcation. The retrograde approach can be very useful to save a relevant SB, especially in the case of a bifurcation at the distal cap or within the CTO body. Intravascular ultrasound is also a very important tool to address the difficulties with bifurcations at the proximal or distal cap and sometimes also within the CTO segment. Double-lumen microcatheters and angulated microcatheters are crucial tools to resolve access difficulties to the SB or the main branch.
Display omitted
•Bifurcations with a relevant side branch are frequent in CTOs (one-third of cases) and add complexity to the procedure.•Provisional SB stenting is the recommended approach in the majority of bifurcation CTOs.•When treating bifurcation CTOs, IVUS may increase procedural safety and success.
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.
We sought to compare, through a meta-analytic process, the transradial and transfemoral approaches for coronary procedures in terms of clinical and procedural outcomes.
The radial approach has been ...increasingly used as an alternative to femoral access. Several trials have compared these two approaches, with inconclusive results.
The MEDLINE, CENTRAL, and conference proceedings from major cardiologic associations were searched. Random-effect odds ratios (ORs) for failure of the procedure (crossover to different entry site or impossibility to perform the planned procedure), entry site complications (major hematoma, vascular surgery, or arteriovenous fistula), and major adverse cardiovascular events (MACE), defined as death, myocardial infarction, emergency revascularization, or stroke, were computed.
Twelve randomized trials (n = 3,224) were included in the analysis. The risk of MACE was similar for the radial versus femoral approach (OR 0.92, 95% confidence interval CI 0.57 to 1.48; p = 0.7). Instead, radial access was associated with a significantly lower rate of entry site complications (OR 0.20, 95% CI 0.09 to 0.42; p < 0.0001), even if at the price of a higher rate of procedural failure (OR 3.30, 95% CI 1.63 to 6.71; p < 0.001).
The radial approach for coronary procedures appears as a safe alternative to femoral access. Moreover, radial access virtually eliminates local vascular complications, thanks to a time-sparing hemostasis technique. However, gaining radial access requires higher technical skills, thus yielding an overall lower success rate. Nonetheless, a clear ongoing trend toward equalization of the two procedures, in terms of procedural success, is evident through the years, probably due to technologic progress of materials and increased operator experience.
Radial access use has been growing steadily but, despite encouraging results, still varies greatly among operators, hospitals, countries and continents. Twenty years from its introduction, it was ...felt that the time had come to develop a common evidence-based view on the technical, clinical and organisational implications of using the radial approach for coronary angiography and interventions. The European Association of Percutaneous Cardiovascular Interventions (EAPCI) has, therefore, appointed a core group of European and non-European experts, including pioneers of radial angioplasty and operators with different practices in vascular access supported by experts nominated by the Working Groups on Acute Cardiac Care and Thrombosis of the European Society of Cardiology (ESC). Their goal was to define the role of the radial approach in modern interventional practice and give advice on technique, training needs, and optimal clinical indications.
Stent enhancement allows clear visualisation of implanted stents. This method, originally intended to assess stent under-expansion, can prove extremely valuable in several other situations. We ...present three cases illustrating its potential uses in assessment of stent failure, intraprocedural stent disruption, and treatment of aorto-ostial and bifurcation lesions. Whilst stent enhancement cannot replace intravascular imaging, compared to simple angiography it can significantly improve percutaneous coronary intervention outcomes with no additional cost and with minimal procedural time.
Background
During transradial (TR) access, it remains unclear whether differences in baseline patients characteristics and hemostasis care impact the rate of radial artery occlusion (RAO). We sought ...to compare the rate of RAO after TR access with the 6 French(Fr) Glidesheath Slender (GSS6Fr, Terumo, Japan) or a standard 5 Fr sheath in Japanese and non‐Japanese patients.
Methods and Results
The Radial Artery Patency and Bleeding, Efficacy, Adverse evenT (RAP and BEAT) trial randomized 1,836 patients undergoing TR coronary angiography and/or interventions to receive the GSS6Fr or the standard 5 Fr Glidesheath (GS5Fr, Terumo, Japan). Out of this study population, 1,087 were Japanese patients and 751 non‐Japanese patients. The overall incidence of RAO was significantly higher in Japanese patients (3.6% vs. 1.2%, P = 0.002). Use of GSS6Fr was associated with higher rates of RAO than GS5Fr in Japanese patients (5% vs. 2.2%, P = 0.02) and with similar RAO rates in non‐Japanese patients (1.3 vs. 1.1%, P = 1). The mean hemostasis time was significantly longer in Japanese patients (378 ± 253 vs. 159 ± 136 min, P < 0.001) and more Japanese patients had a hemostasis time of more than 6 hr (16.2% vs. 4.9%, P < 0.0001). Longer hemostasis time was an independent predictor of RAO (OR per additional hour 1.070, 95% CI 1.008–1.136, P = 0.03).
Conclusions
Use of GSS6Fr was associated with a higher rate of RAO than a standard 5 Fr sheath in Japanese patients but not in non‐Japanese patients. Whether improvement in post‐procedural care and reduced hemostasis time could impact the incidence of RAO in Japanese patients should be further assessed.
Abstract
Aims
The accuracy and prognostic value of stress perfusion cardiac magnetic resonance (CMR) are established in coronary artery disease (CAD) patients. Because myocardial contrast kinetics ...may be altered after coronary artery bypass graft (CABG), most studies excluded CABG patients. This study aimed to assess the prognostic value of vasodilator stress perfusion CMR in CABG patients.
Methods and results
Consecutive CABG patients referred for stress CMR were retrospectively included and followed for the occurrence of major adverse cardiovascular events (MACE) including cardiovascular (CV) death or non-fatal myocardial infarction (MI). Cox regression analyses were performed to determine the prognostic association of inducible ischaemia and late gadolinium enhancement (LGE) by CMR. Of 866 consecutive CABG patients, 852 underwent the stress CMR protocol and 771 (89%) completed the follow-up median (interquartile range) 4.2 (3.3–6.2) years. There were 85 MACE (63 CV deaths and 22 non-fatal MI). Using Kaplan–Meier analysis, the presence of inducible ischaemia identified the occurrence of MACE hazard ratio (HR) 3.52, 95% confidence interval (CI): 2.27–5.48; P < 0.001 and CV death (HR 2.55, 95% CI: 1.52–4.25; P < 0.001). In a multivariable stepwise Cox regression including clinical characteristics and CMR indexes, the presence of inducible ischaemia was an independent predictor of a higher incidence of MACE (HR 3.22, 95% CI: 2.06–5.02; P < 0.001) and CV death (HR 2.15, 95% CI: 1.28–3.62; P = 0.003), and the same was observed for LGE (both P = 0.02).
Conclusion
Stress CMR has a good discriminative prognostic value in patients after CABG, with a higher incidence of MACE and CV death in patients with inducible ischaemia and/or LGE.
PDF
