Percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has been rapidly evolving during recent years. With improvement in equipment and techniques, high success rates can be ...achieved at experienced centers, although overall success rates remain low. Prospective, randomized-controlled data regarding optimal use and indications for CTO PCI remain limited. CTO PCI should be performed when the anticipated benefit exceeds the potential risk. New high-quality studies of the clinical outcomes and techniques of CTO PCI are needed, as is the expansion of expert centers and operators that can achieve excellent clinical outcomes in this challenging patient and lesion subgroup. In the current review the authors summarize the latest publications in CTO PCI and provide an overview of the current state of the field.
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IntroductionIn patients with myocardial infarction, the decision to treat a nonculprit lesion is generally based on its physiological significance. However, deferral of revascularisation based on ...nonischaemic fractional flow reserve (FFR) values in these patients results in less favourable outcomes compared with patients with stable coronary artery disease, potentially caused by vulnerable nonculprit lesions. Intravascular optical coherence tomography (OCT) imaging allows for in vivo morphological assessment of plaque ‘vulnerability’ and might aid in the detection of FFR-negative lesions at high risk for recurrent events.Methods and analysisThe PECTUS-obs study is an international multicentre prospective observational study that aims to relate OCT-derived vulnerable plaque characteristics of nonflow limiting, nonculprit lesions to clinical outcome in patients with myocardial infarction. A total of 438 patients presenting with myocardial infarction (ST-elevation myocardial infarction and non-ST-elevation myocardial infarction) will undergo OCT-imaging of any FFR-negative nonculprit lesion for detection of plaque vulnerability. The primary study endpoint is a composite of major adverse cardiovascular events (all-cause mortality, nonfatal myocardial infarction or unplanned revascularisation) at 2-year follow-up. Secondary endpoints will be the same composite at 1-year and 5-year follow-up, target vessel failure, target vessel revascularisation, target lesion failure and target lesion revascularisation.Ethics and disseminationThis study has been approved by the Medical Ethics Committee of the region Arnhem-Nijmegen. The results of this study will be disseminated in a main paper and additional papers with subgroup analyses.Trial registration numberNCT03857971.
There is a lack of data regarding the long-term clinical efficacy of the kissing balloon inflation (KBI) after provisional stenting of coronary bifurcation lesions. The aim of this study was to ...analyze the impact of KBI on long-term clinical outcomes in patients undergoing provisional stenting for the coronary bifurcation lesions in a large real-world population.
A total of 873 patients who underwent percutaneous coronary interventions (PCI) with provisional stenting and had clinical follow up were analyzed. Patients treated with 2-stent strategy were excluded. To reduce the effect of potential confounding factors in this observational study, propensity score matching was conducted.
KBI was performed in 325 patients (37.2%). The median follow-up duration was 37.3 months. Patients treated with KBI more often had a previous PCI (48.6% vs. 42.5% SMD = 0.123). Patients in non-kissing group had more complex coronary disease with higher prevalence of calcification (14.8% vs. 21.4% SMD = 0.172), thrombosis (2.8% vs. 5.8% SMD = 0.152) and longer side branch lesions (8.3% vs. 11.7% SMD = 0.113). There were no significant differences in the major adverse cardiac events including death, myocardial infarction, target lesion revascularization after KBI versus no KBI (15.4% vs. 15.7%, p = 0.28), in total cohort or in matched patients (17.1% vs. 15.8%, adjusted HR 1.01, 95% CI: 0.65–1.65, p = 0.95). The lack of effect of KBI on clinical outcomes was consistent across various subgroups including left main disease.
In this multicenter real-world registry, KBI did not improve long-term clinical outcomes in patients with coronary bifurcation lesions treated with provisional stenting technique.
•While POT considered as a mandatory step of the provisional stenting, efficacy of KBI is still questioned due to controversial data.•In this multicenter real-world registry KBI didn't improve clinical outcomes in patients treated with 1-stent technique.•The lack of effect of KBI on clinical outcomes was consistent across various subgroups including left main bifurcation.
Background: Most complex chronic total occlusions (CTOs) require the utilization of multiple recanalization strategies. However, data on wire manipulation time within CTO percutaneous coronary ...intervention (PCI) are limited. Objectives: We sought to investigate the impact of crossover time between crossing strategies on CTO PCI technical success. Methods: A total of 1026 patients admitted to our center between 2013 and 2019 for CTO PCI were assessed, of whom 143 were included for analysis. In these patients, the primary antegrade approach was changed to retrograde within one procedure. The crossover time between strategies remained at the operator's decision. Results: In most cases the target vessel was the right coronary artery (72%), followed by the left anterior descending (18.2%) and left circumflex (9.1%) arteries. The mean J-CTO score was 2.1 ± 1.1. Logistic regression analysis was used to estimate the odds of technical success associated with various crossover times. The results showed that 33 minutes was the threshold of the initial timing at which to review crossover of antegrade to retrograde recanalization of CTO. The odds of technical success with earlier crossover were 3.4 times higher 95% confidence interval (CI): 1.3 to 8.6. The chances of success reduced by 3% for every 1 minute longer than the threshold time (odds ratio: 0.97; 95% CI: 0.94 to 0.99, p = 0.05). Conclusions: Crossover to the retrograde approach should be considered no later than 33minutes after antegrade wire manipulation in order to maintain the maximum chances of final technical success.
Balloon uncrossable lesions are defined as lesions that cannot be crossed with a balloon after successful guidewire crossing.
We analyzed the association between balloon uncrossable lesions and ...procedural outcomes of 8671 chronic total occlusions (CTOs) percutaneous coronary interventions (PCIs) performed between 2012 and 2022 at 41 centers.
The prevalence of balloon uncrossable lesions was 9.2%. The mean patient age was 64.2 ± 10 years and 80% were men. Patients with balloon uncrossable lesions were older (67.3 ± 9 vs. 63.9 ± 10,
< 0.001) and more likely to have prior coronary artery bypass graft surgery (40% vs. 25%,
< 0.001) and diabetes mellitus (50% vs. 42%,
< 0.001) compared with patients who had balloon crossable lesions. In-stent restenosis (23% vs. 16%.
< 0.001), moderate/severe calcification (68% vs. 40%,
< 0.001), and moderate/severe proximal vessel tortuosity (36% vs. 25%,
< 0.001) were more common in balloon uncrossable lesions. Procedure time (132 (90, 197) vs. 109 (71, 160) min,
< 0.001) was longer and the air kerma radiation dose (2.55 (1.41, 4.23) vs. 1.97 (1.10, 3.40) min,
< 0.001) was higher in balloon uncrossable lesions, while these lesions displayed lower technical (91% vs. 99%,
< 0.001) and procedural (88% vs. 96%,
< 0.001) success rates and higher major adverse cardiac event (MACE) rates (3.14% vs. 1.49%,
< 0.001). Several techniques were required for balloon uncrossable lesions.
In a contemporary, multicenter registry, 9.2% of the successfully crossed CTOs were initially balloon uncrossable. Balloon uncrossable lesions exhibited lower technical and procedural success rates and a higher risk of complications compared with balloon crossable lesions.
A 68-year-old woman was initially admitted with 2 subannular pseudoaneurysms of the aortic root after aortic valve replacement. The aneurysm expanded after 10 days and was treated using endovascular ...closure devices. (Level of Difficulty: Advanced.)
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A 68-year-old woman was initially admitted with 2 subannular pseudoaneurysms of the aortic root after aortic valve replacement. The aneurysm expanded…
Background: Since 2021, transarterial chemoembolization of the hepatic arteries (TACE) has been included in the recommendations of professional communities for the treatment of metastases of ...neuroendocrine liver tumors (NEO). However, the heterogeneity of both this group of patients and types of chemoembolization with a limited range of cytostatics used in the treatment makes it difficult to analyze the data and introduce the method into the combination therapy regimens. Aim: to study the effectiveness of transarterial chemoembolization with irinotecan-loaded drug-saturable microspheres for the treatment of patients with neuroendocrine tumors with liver metastases. Methods: A retrospective, observational, uncontrolled study of 34 patients with liver metastases from neuroendocrine cancer who underwent 52 TACE with irinotecan-loaded drug-saturable microspheres. Group 1 consisted of 15 patients who already had liver metastases at the time of the primary focus detection, group 2 included 19 patients with liver metastases having appeared some time after the detection of the primary focus. To plan and evaluate the effectiveness of chemoembolization, computed tomography and magnetic resonance imaging were used every 10–15 weeks during the systemic treatment. All the patients received systemic NEO therapy before and after the embolization. Results: An increase in the progression-free time from 101 57; 120 and 145 89; 263 days after chemotherapy up to 300 134; 344 and 304 240; 342 days after TACE in groups 1 and 2, respectively, with no difference between the groups (p=0.31 and p=0.57, respectively). We did not find a linear relationship between the doubling time of the tumor and the change in the volume of the tumor lesion (R2=0.1085 and R2=0.0265 in groups 1 and 2). When comparing the intragroup scores, there was a statistically significant difference (p=0.009, p=0.046) in the tumor volume reduction and progression-free time between the patients who underwent TACE immediately and those who underwent TACE after chemotherapy. The diagnostic and angiographic images of liver metastases varied within the same organ and depended on the size of metastases. There were no adverse events after TACE. Conclusions: TACE with irinotecan-loaded drug-saturable microspheres is an effective method for the treatment of liver metastases of neuroendocrine cancer, allowing one to increase the time without progression.
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