The authors developed a global chronic total occlusion crossing algorithm following 10 steps: 1) dual angiography; 2) careful angiographic review focusing on proximal cap morphology, occlusion ...segment, distal vessel quality, and collateral circulation; 3) approaching proximal cap ambiguity using intravascular ultrasound, retrograde, and move-the-cap techniques; 4) approaching poor distal vessel quality using the retrograde approach and bifurcation at the distal cap by use of a dual-lumen catheter and intravascular ultrasound; 5) feasibility of retrograde crossing through grafts and septal and epicardial collateral vessels; 6) antegrade wiring strategies; 7) retrograde approach; 8) changing strategy when failing to achieve progress; 9) considering performing an investment procedure if crossing attempts fail; and 10) stopping when reaching high radiation or contrast dose or in case of long procedural time, occurrence of a serious complication, operator and patient fatigue, or lack of expertise or equipment. This algorithm can improve outcomes and expand discussion, research, and collaboration.
Summary Acute rheumatic fever and rheumatic heart disease remain major global health problems. Although strategies for primary and secondary prevention are well established, their worldwide ...implementation is suboptimum. In patients with advanced valvular heart disease, mechanical approaches (both percutaneous and surgical) are well described and can, for selected patients, greatly improve outcomes; however, access to centres with experienced staff is very restricted in regions that have the highest prevalence of disease. Development of diagnostic strategies that can be locally and regionally provided and improve access to expert centres for more advanced disease are urgent and, as yet, unmet clinical needs. We outline current management strategies for valvular rheumatic heart disease on the basis of either strong evidence or expert consensus, and highlight areas needing future research and development.
assessment of two techniques for electrode insertion during cochlear implantation which are the round window and the traditional cochleostomy insertions, the comparison utilized cochlear implantation ...outcomes.
a prospective cohort study.
children (n = 200) between 2 and 8 years old who had bilateral severe to profound SNHL and received a unilateral cochlear implant, 100 children had a round window insertion and were labeled the RW group while the other 100 children had a cochleostomy insertion and were labeled the C group which was taken as a control group.
all the participants in this study were followed up and tested twice for their cochlear implant outcomes, the first time when the duration of using their implants was no less than 24 months and no more than 30 months. The second time between 31 and 36 months post implantation. For speech perception; The Consonant-Nucleus-Consonant test (CNC) and The Bamford-Kowal-Bench sentence lists (BKB). For language acquisition; The Preschool Language Scale-fourth edition (PLS-4) and The Peabody Picture Vocabulary Test, Fourth edition (PPVT-4) had been utilized. For speech production; the Diagnostic Evaluation of Articulation and Phonology (DEAP).
for speech perception: The mean CNC scores for the RW group and the C group between 24 and 30 months post-implantation and at 31–36 months post-implantation were better for the round window group. Also, the mean BKB scores for the RW group were higher than the C group between 24 and 30 months post-implantation (p < 0.0013) and at 31–36 months post-implantation (p < 0.0011). for language acquisition; the PLS-4 mean scores for the RW group and the C group between 24 and 30 months post-implantation and at 31–36 months post-implantation were better for the round window group (p < 0.001). The PPVT-4 mean scores for the RW group were also higher than the C group at both durations. for speech production; The mean word intelligibility scores of the DEAP for the RW group were better at 24 to 30 and 31–36 months post-implantation.
Round window insertion is associated with superior cochlear implantation outcomes regarding speech perception, language acquisition and speech production rather than the standard cochleostomy insertion.
Aneurysmal coronary artery disease (ACAD) comprises both coronary artery aneurysms (CAA) and coronary artery ectasia (CAE). The reported prevalence of ACAD varies widely from 0.2 to 10%, with male ...predominance and a predilection for the right coronary artery (RCA). Atherosclerosis is the commonest cause of ACAD in adults, while Kawasaki disease is the commonest cause in children and adolescents, as well as in the Far East. Most patients are asymptomatic, but when symptoms do exist, they are usually related to myocardial ischemia. Coronary angiography is the mainstay of diagnosis, but follow up is best achieved using noninvasive imaging that does not involve exposure to radiation. The optimal management strategy in patients with ACAD remains controversial. Medical therapy is indicated for the vast majority of patients and includes antiplatelets and/or anticoagulants. Covered stents effectively limit further expansion of the affected coronary segments. Surgical ligation, resection, and coronary artery bypass grafting are appropriate for large lesions and for associated obstructive coronary artery disease.
Purpose
This work aimed at studying the effect of tourniquet use on surgical performance and peri-operative outcomes of anatomic single-bundle ACL reconstruction.
Methods
Eighty-four patients ...undergoing ACL surgery were randomized into two groups: the tourniquet (A) group and the non-tourniquet (B) group. Post-operative pain, need for analgesics, the volume of blood obtained in the drain, girth diameter changes in the thigh and calf, muscle strength and amount of haemarthrosis were used as outcome measures to compare the two groups.
Results
Fifty-eight patients were available for analysis. In the A group, the degree of pain and need to analgesics was significantly higher at 4 and 10 h. The volume measured in the surgical drain, at 24 h post-operative, was higher in the A group (
p
= 0.001). The calf and thigh girth diameters at 2 weeks showed a highly significant girth difference between the two groups (
p
= 0.001).
Conclusion
This study showed that tourniquet use in ACL reconstruction increases immediate post-operative symptoms of pain and haemarthrosis and that the effects on muscle strength are only temporary. The tourniquet can be replaced by using of a mixture of morphine and adrenaline with no interference with the quality of visibility, nor operative time.
Level of evidence
I.
Ostial CTOs can be challenging to revascularize. We aim to describe the outcomes of ostial chronic total occlusion (CTO) percutaneous coronary intervention (PCI).
We examined the clinical and ...angiographic characteristics and procedural outcomes of 8788 CTO PCIs performed at 35 US and non-US centers between 2012 and 2022. In-hospital major adverse cardiac events (MACE) included death, myocardial infarction, urgent repeat target-vessel revascularization, tamponade requiring pericardiocentesis or surgery, and stroke.
Ostial CTOs constituted 12% of all CTOs. Patients with ostial CTOs had higher J-CTO score (2.9 ± 1.2 vs 2.3 ± 1.3; P less than .01). Ostial CTO PCI had lower technical (82% vs. 86%; P less than .01) and procedural (81% vs. 85%; P less than .01) success rates compared with non-ostial CTO PCI. Ostial location was not independently associated with technical success (OR 1.03, CI 95% 0.83-1.29 P =.73). Ostial CTO PCI had a trend towards higher incidence of MACE (2.6% vs. 1.8%; P =.06), driven by higher incidence of in-hospital death (0.9% vs 0.3% P less than.01) and stroke (0.5% vs 0.1% P less than .01). Ostial lesions required more often use of the retrograde approach (30% vs 9%; P less than .01). Ostial CTO PCI required longer procedure time (149 103,204 vs 110 72,160 min; P less than .01) and higher air kerma radiation dose (2.3 1.3, 3.6 vs 2.0 1.1, 3.5 Gray; P less than .01).
Ostial CTOs are associated with higher lesion complexity and lower technical and procedural success rates. CTO PCI of ostial lesions is associated with frequent need for retrograde crossing, higher incidence of death and stroke, longer procedure time and higher radiation dose.
•There is significant variation in wire utilization patterns for chronic total occlusion (CTO) percutaneous coronary intervention (PCI).•When feasible, avoidance of non–polymer-jacketed wires may ...help to improve CTO PCI outcomes.•Antegrade procedures in which polymer-jacketed wire were exclusively used had higher technical success and lower perforation rates.•Further research will be needed to explore the safety and efficacy of the wires used for CTO PCI.
There is significant variation in wire utilization patterns for chronic total occlusion (CTO) percutaneous coronary intervention. This study aimed to compare the outcomes of polymer-jacketed wires (PJWs) versus non-PJWs in anterograde procedures. We analyzed clinical and angiographic characteristics, and procedural outcomes of 7,575 anterograde CTO percutaneous coronary interventions that were performed at 47 centers between 2012 and 2023. Cases in which PJWs were exclusively used were classified in the PJW group, whereas cases where at least one non-PJW was employed were classified in the non-PJW group. Study end points were as follows: technical success, coronary perforation, major adverse cardiac event. PJWs were exclusively used in 3,481 cases (46.0%). These cases had lower prevalence of proximal cap ambiguity, blunt stump, and moderate/severe calcification. They also had lower Japanese CTO (J-CTO), Prospective Global Registry for the Study of Chronic Total Occlusion (PROGRESS-CTO), and PROGRESS-CTO complications scores, higher technical success (94.3% vs 85.7%, p <0.001), and lower perforation rates (2.2% vs 3.2%, p = 0.013). Major adverse cardiac event rates did not differ between groups (1.3% vs 1.5%, p = 0.53). Exclusive use of PJWs was independently associated with higher technical success in both the multivariable (odds ratio OR 2.66, 95% confidence interval CI 2.13 to 3.36, p <0.001) and inverse probability of treatment weight analysis (OR 2.43, 95% CI 2.04 to 2.89, p <0.001). Exclusive use of PJWs was associated with lower risk of perforation in the multivariable analysis (OR 0.69, 95% CI 0.49 to 0.95, p = 0.02), and showed a similar trend in the inverse probability of treatment weight analysis (OR 0.77, 95% CI 0.57 to 1.04, p = 0.09). Exclusive use of PJWs is associated with higher technical success and lower perforation risk in this non-randomized series of patients.
•The Carlino technique is increasingly being used in chronic total occlusion percutaneous coronary interventions for complex cases.•Carlino cases had lower technical and procedural success, but ...similar major adverse cardiac events.•The Carlino technique reported higher procedural success when used for retrograde.
We examined the outcomes of the Carlino technique in chronic total occlusion (CTO) percutaneous coronary interventions (PCIs). We analyzed the baseline clinical and angiographic characteristics and outcomes of 128 CTO PCIs that included the Carlino technique at 22 US and no-US centers between 2016 and 2023. The Carlino technique was used in 128 (2.8%) of 4,508 cases that used anterograde dissection and reentry (78.9%) or the retrograde approach (21.1%) during the study period, and it increased steadily over time (from 0.0% in 2016 to 8.3% in 2023). The mean patient age was 65.6 ± 9.7 years, and 88.7% of the patients were men with high prevalence of hypertension (89.1%) and dyslipidemia (80.2%). The Carlino technique was more commonly used in cases with moderate to severe calcification (77.2% vs 55.5%, p <0.001) with higher J-CTO (3.3 ± 0.9 vs 3.0 ± 1.1, p = 0.007), Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) (1.7 ± 1.0 vs 1.4 ± 1.0, p = 0.001), PROGRESS-CTO Mortality (2.6 ± 0.9 vs 2.0 ± 0.9, p = 0.013) and PROGRESS-CTO Perforation (3.7 ± 1.1 vs 3.5 ± 1.0, p = 0.029) scores. Carlino cases had longer procedure and fluoroscopy time, and higher contrast volume and radiation dose. Carlino cases had lower technical (65.6% vs 78.5%, p <0.001) and procedural (63.3% vs 76.3%, p <0.001) success, similar major adverse cardiac events (6.2% vs 3.2%, p = 0.101) and higher incidence of pericardiocentesis (3.9% vs 1.3%, p = 0.042), perforation (18.0% vs 8.9%, p = 0.001) and contrast-induced acute kidney injury (2.3% vs 0.4%, p = 0.012). The Carlino technique was associated with higher procedural success when used for retrograde crossing (81.5% vs 58.4%, p = 0.047). The Carlino technique is increasingly being used in CTO PCI especially for higher complexity lesions.
Coronary artery perforation is a feared complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) and often leads to serious adverse clinical events.
We sought to develop ...a risk score to predict clinical coronary artery perforation in patients undergoing CTO PCI.
We analysed clinical and angiographic parameters from 9,618 CTO PCIs in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO). Logistic regression prediction modelling was used to identify variables independently associated with clinical perforation, and the model was internally validated with bootstrapping. Clinical coronary artery perforation was defined as any perforation requiring treatment.
The incidence of clinical coronary perforation was 3.8% (n=367). Five factors were independently associated with perforation and were included in the score: patient age ≥65 years +1 point (odds ratio OR 1.79, 95% confidence interval CI: 1.37-2.33), moderate/severe calcification +1 point (OR 1.85, 95% CI: 1.41-2.42), blunt/no stump +1 point (OR 1.45, 95% CI: 1.10-1.92), use of antegrade dissection and re-entry +1 point (OR 2.43, 95% CI: 1.61-3.69), and use of the retrograde approach +2 points (OR 4.02, 95% CI: 2.95-5.46). The resulting score showed acceptable performance on receiver operating characteristic (ROC) curve (area under the curve AUC: 0.741, 95% CI: 0.712-0.773). The Hosmer-Lemeshow test indicated a good fit (p=0.991), and internal validation with bootstrapping demonstrated good agreement with the model with observed AUC: 0.736 (95% bias-corrected CI: 0.706-0.767).
The PROGRESS-CTO perforation score may be a useful tool for predicting clinical coronary perforation during CTO PCI.
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