Saphenous vein grafts (SVGs) remain the most frequently used conduits in coronary artery bypass graft surgery (CABG). Despite advances in surgical techniques and pharmacotherapy, SVG failure rates ...remain high, often leading to repeat coronary revascularization. The no-touch SVG harvesting technique (minimal graft manipulation with preservation of vasa vasorum and nerves) reduces the risk of SVG failure, whereas the effect of the off-pump technique on SVG patency remains unclear. Use of buffered storage solutions, intraoperative graft flow measurement, careful selection of the target vessels, and physiological assessment of the native coronary circulation before CABG may also reduce the incidence of SVG failure. Perioperative aspirin and high-intensity statin administration are the cornerstones of secondary prevention after CABG. Dual antiplatelet therapy is recommended for off-pump CABG and in patients with a recent acute coronary syndrome. Intermediate (30%-60%) SVG stenoses often progress rapidly. Stenting of intermediate SVG stenoses failed to improve outcomes; hence, treatment focuses on strict control of coronary artery disease risk factors. Redo CABG is associated with higher perioperative mortality compared with percutaneous coronary intervention (PCI); hence, the latter is preferred for most patients requiring repeat revascularization after CABG. SVG PCI is limited by high rates of no-reflow and a high incidence of restenosis during follow-up. Drug-eluting and bare metal stents provide similar long-term outcomes in SVG PCI. Embolic protection devices reduce no-reflow and should be used when feasible. PCI of the corresponding native coronary artery is associated with better short- and long-term outcomes and is preferred over SVG PCI, if technically feasible.
Balloon uncrossable coronary lesions are lesions that cannot be crossed with a balloon after successful guidewire crossing. The strategies used to facilitate the treatment of such lesions can be ...classified into strategies that provide lesion modification and strategies that increase support. We describe a systematic, algorithmic approach to treat balloon uncrossable lesions, starting with use of small balloons, followed by increase in guide catheter support, use of microcatheters, wire cutting or puncture techniques, laser, atherectomy, and subintimal modification techniques. Sequential and simultaneous application of the aforementioned techniques can result in successful treatment of these challenging lesions.
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Intravascular imaging with either intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during percutaneous coronary intervention (PCI) is associated with improved ...outcomes, but these techniques have previously been underutilized in the real world. We aimed to examine the change in utilization of intravascular imaging-guided PCI over the past decade in the United States and assess the association between intravascular imaging and clinical outcomes following PCI for myocardial infarction (MI).
We surveyed the National Inpatient Sample from 2008 to 2019 to calculate the number of PCIs for MI guided by IVUS or OCT. Temporal trends were analyzed using Cochran-Armitage trend test or simple linear regression for categorical or continuous outcomes, respectively. Multivariable logistic regression was used to compare outcomes following PCI with and without intravascular imaging.
A total of 2,881,746 PCIs were performed for MI. The number of IVUS-guided PCIs increased by 309.9 % from 6,180 in 2008 to 25,330 in 2019 (P-trend < 0.001). The percentage of IVUS use in PCIs increased from 3.4 % in 2008 to 8.7 % in 2019 (P-trend < 0.001). The number of OCT-guided PCIs increased 548.4 % from 246 in 2011 to 1,595 in 2019 (P-trend < 0.001). The percentage of OCT guidance in all PCIs increased from 0.0 % in 2008 to 0.6 % in 2019 (P-trend < 0.001). Intravascular imaging-guided PCI was associated with lower odds of in-hospital mortality (adjusted odds ratio 0.66, 95 % confidence interval 0.60–0.72, p < 0.001).
Although the number of intravascular imaging-guided PCIs have been increasing, adoption of intravascular imaging remains poor despite an association with lower mortality.
Cardiac troponin (Tn) plays a central role in the evaluation of patients with angina presenting with acute coronary syndrome. The advent of high-sensitivity assays has improved the analytic ...sensitivity and precision of serum Tn measurement, but this advancement has come at the cost of poorer specificity. The role of clinical judgment is of heightened importance because, more so than ever, the interpretation of serum Tn elevation hinges on the careful integration of findings from electrocardiographic, echocardiographic, physical exam, interview, and other imaging and laboratory data to formulate a weighted differential diagnosis. A thorough understanding of the epidemiology, mechanisms, and prognostic implications of Tn elevations in each cardiac and non-cardiac etiology allows the clinician to better distinguish between presentations of myocardial ischemia and myocardial injury-an important discernment to make, as the treatment of acute coronary syndrome is vastly different from the workup and management of myocardial injury and should be directed at the underlying cause.
The impact of bifurcations at the proximal or distal cap on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study.
We analyzed the ...clinical, angiographic, and procedural data of 4,584 cases performed in patients between 2012 and 2020 in a global CTO PCI registry. We compared 4 groups according to the bifurcation location: “proximal cap,” “distal cap,” “proximal and distal cap,” and “no bifurcation.”
The CTO involved a bifurcation in 67% cases, as follows: proximal cap (n = 1451, 33%), distal cap (n = 622, 14%), or both caps (n = 954, 21%). “Proximal and distal cap” cases had higher J-CTO compared with “proximal cap,” “distal cap,” and “no bifurcation” cases (2.9 ± 1.1 vs 2.5 ± 1.1 vs 2.4 ± 1.2 vs 2.0 ± 1.2, P < 0.0001), and they were also associated with a lower technical success rate (79% vs 85% vs 85% vs 90%, P < 0.0001), higher pericardiocentesis rate (1% vs 1% vs 0.2% vs 0.3%, P = 0.02), and higher emergency coronary artery bypass graft surgery rate (0.3% vs 0% vs 0% vs 0%, P = 0.01).
More than two-thirds of CTO PCIs involve a bifurcation, which is associated with lower technical success and higher risk of complications.
Percutaneous coronary intervention was performed in a flush in-stent right coronary artery chronic total occlusion. Successful retrograde recanalization was performed but the lesion was balloon ...undilatable as confirmed by intravascular ultrasound. High-pressure post-dilation with noncompliant and plaque modification balloons failed, but intravascular lithotripsy successfully expanded the lesion. (Level of Difficulty: Advanced.)
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