Percutaneous Coronary Intervention Devices Research Articles

A value approach to measuring the effect on health resource usage of specialist cardiac interventions in Wales

Objective and ApproachThe Welsh Health Specialised Services Committee wanted to demonstrate how specialised interventions reduced subsequent pressures on the health services. We analysed the variation in the cost of patient pathways for eight cardiac interventions in both planned and emergency settings. A standard cost was allocated to each health event (hospital admissions, general practitioner interactions, outpatient attendances and accident and emergency attendances). A comparison was made for each intervention relating to the condition before the intervention against costs afterwards. In addition, analysis was carried out measuring which patient's characteristics affected the likelihood that patients incurred higher post-intervention costs. Results10,480 interventions were analysed. In 9 (of the 16) intervention combinations, post-intervention costs dropped. After the implantation of a Cardiac Device, health resource usage dropped by £1,461 per annum. In addition, the likelihood of falling into a higher cost category increased depending on deprivation. For percutaneous coronary intervention (PCI) the odds ratio and 95% confidence interval was 1.34 (1.03 to 1.76) and for Cardiac Devices 2.91 (1 to 15.23). Conclusions and ImplicationsSome interventions in Cardiac realise significant post intervention savings for the health service. Deprivation affects the risk of patients falling into high post-intervention cost categories for PCI and Cardiac Devices. By using anonymised population-scale linked individual-level data, it is possible to highlight interventions that as well as benefiting patients successfully, reduce future health resource usage. This type of analysis can also highlight how deprivation is linked to increased post intervention costs.

Role of Mechanical Circulatory Support in Complex High-Risk and Indicated Percutaneous Coronary Intervention: Current Indications, Device Options, and Potential Complications.

Improved expertise and technological advancements have enabled the safe and effective performance of complex and high-risk-indicated percutaneous coronary intervention (CHIP) in patients previously considered inoperable or high-risk. Mechanical circulatory support (MCS) devices play a crucial role in stabilizing hemodynamics during percutaneous coronary intervention (PCI) -related ischemia, thereby reducing the risk of major adverse events and achieving a more complete revascularization. However, the use of MCS devices in protected PCI is not without risks, including peri-procedural myocardial infarction (MI), bleeding, and access-related complications. Despite numerous observational studies, there is a significant lack of randomized clinical trials comparing different MCS devices in various CHIP scenarios and evaluating their long-term safety and efficacy profiles. This review aims to summarize the current evidence regarding the benefits of MCS devices during CHIPs, offer a practical guide for selecting appropriate devices based on clinical scenarios, and highlight the unanswered questions that future trials need to address.

Retrospective investigation of percutaneous coronary intervention (PCI) via distal radial approach/artery(dRA) in daily practice: possible adaptability of variety of patients, diagnosis, devices

Abstract Background Distal radial approach(dRA) that features puncturing radial artery at snuff box is becoming well known gradually and widely in the fields of interventional cardiology. Although there are some reports about dRA, safety, feasibility and compatibility of this procedure are still unclear. Methods Total of consecutive 90 PCI attempted via dRA procedure done by the operators who has experience of more than 20 dRA catheterization before from December 2020 to January 2023 at the University of Tokyo Hospital were retrospectively investigated. Distal radial artery puncture was done with echo-guided method just before the PCI procedure. Diameter of conventional radial artery(cRA) and dRA were measured. PCI strategy and devices were decided by the operators. Results About patient characteristics, mean age was 73±10 years old, consisting of 82.2%(74/90) male and 17.8%(16/90) female. Mean height/weight/BMI was 162.8±8.5 cm, 64.1±12.4 kg and 24.0±3.5, respectively. LVEF was 56.6±15.7%. Approach side of dRA was right in 74.4%(67/90) and left in 25.6%(23/90). Former dRA prcedeure of the same side was 20.0%(18/90). There were 7 cases(7.8%) of hemodialysis patients(non-AV fistula side). Concerning antithrombotics, 100%(80/80) were on DAPT and 18.9%(17/90) were on triple therapy(DAPT + warfarin or any DOAC:direct oral anticoagulant). The dRA success rate was 90.0%(81/90) and the procedure success rate was 100%(90/90). Diagnosis were STEMI: 5.6%(5/90), NSTEMI: 2.2%(2/90), unstable AP: 10.0%(9/90), stable(effort) AP: 18.9%(17/90), staged PCI: 25.6%(23/90) and other: 37.8%(34/90). Mean sheath insertion time was about 4 minutes (255±139 seconds). There are 3 CTO cases. Rotational atherectomy was used in 3.3%(3/80) and orbital atherectomy device was used in 5.0%(4/80). ELCA(excimer laser coronary angioplasty) was used in 6.3%(5/80). More than 1 DES was deployed in 75.0%(60/80), DCB(drug coated balloon) was used in 23.8%(19/80). Imaging devices were used in 100%(80/80) consists of IVUS: 92.5%(74/80), OCT: 12.5%(10/80) and both: 10.0%(8/80). Mean total radiation dose was 1324±809 mGy and mean volume of contrast medium was 141.6±55.6 ml. Bleeding, neurological and other major complication was 0%(0/80). Blood transfusion was performed in 1 case that is not related to procedure. Procedure related dissection or perforation of dRA was observed in 2 cases(2.2%). Occlusion of dRA was observed in 1 case(1.1%). Diameter of cRA and dRA was 2.6±0.7 mm and 2.3 mm±0.7 mm, respectively. Conclusions PCI via dRA had high rate of dRA and procedure success when it is performed by experienced physicians. It is effective regardless of the preprocedural diagnosis(STEMI/NETEMI/uAP/eAP/other). As far as this study is concerned, no device(including Rota, OAC and ELCA) had limitation or malfunction during procedure. No major complications was observed. PCI via dRA seemed to be safe, feasible, and compatible for various situations and devices.

Advancements in Percutaneous Coronary Intervention Techniques: A Comprehensive Literature Review of Mixed Studies and Practice Guidelines.

Percutaneous coronary intervention (PCI) is a widely used therapy for coronary artery disease (CAD), but it carries risks and complications. Adhering to evidence-based practice guidelines is crucial for optimal outcomes. This review compares the recommendations of the 2021 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) and 2018 European Society of Cardiology (ESC) guidelines for coronary artery revascularization and discusses emerging trends and novel devices in PCI. A comprehensive literature review of mixed studies, clinical trials, and guidelines was conducted. Intravascular imaging, including intravascular ultrasound and optical coherence tomography, for stent optimization, is also recommended when feasible. However, differences reflecting variations in evidence quality interpretation and applicability were identified. Furthermore, novel devices and technologies with the potential for improving outcomes were highlighted, but their safety and efficacy compared to standard-of-care techniques require further evaluation through extensive randomized trials. Clinicians should stay updated on advancements and personalize treatment decisions based on individual patient factors. Future research should address evidence gaps and barriers to adopting innovative devices and techniques. This review provides recommendations for clinical practice, emphasizing the need to remain current with the evolving landscape of PCI to optimize patient outcomes. The discoveries provide valuable counsel for the deliberation of clinical interventions and prospective inquiries within the realm of interventional cardiology. Overall, the review underscores the importance of evidence-based practice and ongoing advancements in PCI for CAD management.

89 GUIDE EXTENSION CATHETER: INDICATION, USE AND RESULTS IN A LARGE SERIES OF COMPLEX PERCUTANEOUS CORONARY INTERVENTIONS

Abstract Aims The guide extension catheter (GEC) is a helpful tool to increase catheter support when facing complex percutaneous coronary intervention (PCI) in unfavorable coronary anatomies. The aim of this study was to describe indication, efficacy, and safety of the GEC in a high-volume center. Methods and results From 2014 to 2021, we retrospectively identified and analyzed 351 interventional cases in which GEC was used to complete the procedure. The endpoints of the study were PCI success, procedural success and device failure. GEC use increased over the years and was more frequently used by radial approach (92.1%) in elective setting (90.6%) and using the 6F size (95.3%). The GEC was mostly implemented as bail-out strategy (75.9%) with the aim to improve back-up (89.6%), less frequently to optimize catheter alignment or obtain selective coronary cannulation (10.4%). Intracoronary advancement was performed using the guidewire in 1.3% of cases, after positioning of a second “buddy” wire in 23.2%, with support of a deflated balloon at the distal tip in 12.2%, or with anchoring technique in 63.3%. Mean coronary deep intubation depth was 38.8±23.9mm. Vessel and lesion characteristics are reported in Table I. Overall, PCI success rate was 92.5%, while procedural success (PCI success without in hospital adverse event) was 88.6%. GEC was successfully used in 92.7% of patients with no device-dependent severe adverse events; in particular, failures were related to inability to cross the target lesion in 4.5% or to device–related complication in 2.85% of cases. Conclusions This large real-world registry on GEC use in complex PCI confirms the GEC as a valid and safe tool to increase backup support and overcome the limits of conventional technique during complex PCI.

Utilization of Non–Drug-Eluting Devices for Inpatient Percutaneous Coronary Intervention in the United States

There is a paucity of data on the contemporary use of non-drug-eluting devices (balloon angioplasty or bare-metal stents) in contemporary percutaneous coronary intervention (PCI) in the United States. We utilized the Nationwide Readmissions Database to identify patients hospitalized to undergo PCI with non-drug-eluting devices from 2016 to 2019. The main outcome of interest was the trends in utilization over the study years. Among 1,870,262 PCI procedures, 127,810 (6.8%) were performed with non-drug-eluting devices; 72% of these were in the setting of acute myocardial infarction (MI). The use of non-drug-eluting devices decreased throughout the study period from 12.9% of all PCI in the first quarter of 2016 to 3.4% in the last quarter of 2019 (p <0.001). Factors associated with their use included advanced age and high bleeding risk. Only a small percentage were used as a bridge to coronary artery bypass graft surgery (2%) and for treatment of in-stent restenosis (3%). The in-hospital mortality was 5.8% for the entire cohort and 6.6% when the indication for use was an acute MI. In patients presenting with an acute MI, reinfarction within 30 days was common and occurred in 18% of the patients. In conclusion, the use of non-drug-eluting devices in PCI in the United States decreased from 2016 to 2019. Factors associated with their use included old age and high bleeding risk. Due to suboptimal outcomes in patients currently being treated with non-drug-eluting devices, there remains an unmet clinical need for alternative treatment options.

Bleeding Complications in Patients Undergoing Percutaneous Coronary Intervention.

Percutaneous coronary intervention (PCI) is considered a relatively safe procedure associated with low rates of complications, but is inevitably associated with short and mid-to-long term increased bleeding risk. Besides the short term risk associated with the arterial access to perform PCI, enhanced bleeding risk persists for several months, given the need for antithrombotic therapy to prevent procedure-related thrombotic complications as well as ischemic recurrences. Bleeding is a powerful harbinger of adverse outcomes. This awareness has fuelled intense research on bleeding reduction strategies, including new PCI devices and techniques as well as new medications and antithrombotic regimens. We here review the mechanisms and prevalence of bleeding in PCI patients, discuss the available evidence from a practical point of view, and explore future perspectives on how to treat and prevent bleeding complications in these patients.

Abstract 12142: Intravascular Ultrasound Guided Percutaneous Coronary Intervention Improves Acute Angiographic Results &amp; 1-year Clinical Outcomes for Patients With Chronic Total Occlusion

Introduction: Intravascular ultrasound (IVUS) on long-term clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is not well established. This study aimed to evaluate IVUS-guided compared to angiography-only-guided CTO-PCI on acute angiographic result and 1-year clinical outcomes. Hypothesis: The application of IVUS in CTO-PCI could improve acute angiographic results and 1-year clinical outcomes for all-comers CTO patients. Methods: We analysed 528 consecutive patients undergoing CTO-PCI at a university affiliated hospital in Hong Kong from February 2009 to December 2016. Baseline characteristics, procedural characteristics, and 1-year clinical outcomes including cardiac death, non-fatal myocardial infarction (MI), target lesion revascularization (TLR), and composite target lesion failure (TLF) were evaluated. The use of IVUS, and the choice of PCI devices including plain old balloon angioplasty (POBA), bare metal stent (BMS), and drug eluting stent (DES), were at the discretion of the operator. Propensity score matching (PSM) was performed to reduce treatment selection bias and potential confounding factors. Results: 275 patients underwent 288 angiography-only-guided and 253 patients underwent 268 IVUS-guided CTO-PCI. IVUS-guided CTO-PCI was associated with higher procedural success compared to angiography-only-guided CTO-PCI (77.5% vs. 55.3%, p&lt;0.01). DES were used more often in the IVUS-guided CTO-PCI group (85.3% vs. 65.6%, p&lt;0.01) while BMS were used less in IVUS-guided CTO-PCI group (9.3% vs. 26.1%). After PSM for successful CTO stented patients, angiography-IVUS guidance was associated with more post stent balloon dilatation (84.7% vs. 56.3%, p&lt;0.01), lower incidence of &gt;20% residual stenosis (2.2% vs. 10.8%, p&lt;0.01), longer total stent length (44.16±23.88mm vs. 33.52±18.90mm, p&lt;0.01), and larger final angiographic stented diameter (3.12±0.63mm vs. 2.94±0.48mm, p&lt;0.01). IVUS guided CTO-PCI was associated with lower 1-year TLF rates (3.0% vs. 10.0%, p=0.01). Conclusions: The use of IVUS was associated with higher success rates, more aggressive post-dilatation and better 1-year clinical outcomes compared to angiography-only guided CTO-PCI.

Bleeding avoidance strategies in percutaneous coronary intervention.

For many years, bleeding has been perceived as an unavoidable consequence of strategies aimed at reducing thrombotic complications in patients undergoing percutaneous coronary intervention (PCI). However, the paradigm has now shifted towards bleeding being recognized as a prognostically unfavourable event to the same extent as having a new or recurrent ischaemic or thrombotic complication. As such, in parallel with progress in device and drug development for PCI, there is clinical interest in developing strategies that maximize not only the efficacy but also the safety (for example, by minimizing bleeding) of any antithrombotic treatment or procedural aspect before, during or after PCI. In this Review, we discuss contemporary data and aspects of bleeding avoidance strategies in PCI, including risk stratification, timing of revascularization, pretreatment with antiplatelet agents, selection of vascular access, choice of coronary stents and antithrombotic treatment regimens.

A Next-Generation Guide Extension System for Percutaneous Coronary Intervention

BackgroundGuide catheter extension is an integral part of percutaneous coronary intervention (PCI). First generation guide catheter extension devices are monorail, blunt ended tubular structures with limitations. The CrossLiner™ is a next generation guide extension “system” intended to allow safe, deep, coronary intubation. MethodsThe CrossLiner was tested in a head-to-head study with the GuideLiner™ and GuideZilla™ in a porcine coronary model, with stenting. Data were collected from 8 coronary vessels from four animals, to evaluate the ability to deeply intubate the vessel with the guide extension. ResultsThe CrossLiner crossed distally and through a distal stented segment in 8/8 vessels, while the first-generation devices were stuck proximal to the stent (n=2/8) or at the stent edge (n=4/8), or passed partially into the deployed stent with difficulty (2/8) vessels (p < 0.0002 for deliverability). The average depth of guide extension delivery/ “intubation” was 12.9±3.6 cm for the CrossLiner and 5.6±1.1 cm for the first-generation guide extension (p < 0.001). ConclusionsThe CrossLiner is a next generation guide extension system that may offer advantages over first generation devices. Further clinical evaluation will be required to assess the role of this new device in PCI.

Safety and efficacy of short-term (1 to 3months) dual antiplatelet therapy in patients undergoing percutaneous coronary interventions: a meta-analysis of randomized controlled trials.

Among patients who have undergone percutaneous coronary intervention (PCI), the use of dual antiplatelet therapy (DAPT) is associated with increased risk of bleeding, but decreased stent thrombosis and myocardial infarction unrelated to the stent. As PCI techniques and devices have progressed, the optimal duration of DAPT has come into question. We identified all randomized controlled trials (RCTs) of patients undergoing PCI, who received one or more drug eluting stents (DES) for stable coronary artery disease (CAD) or acute coronary syndrome (ACS), and randomized to short (1-3months) versus standard duration DAPT. The prespecified primary outcome was major adverse cardiovascular events (MACE). Important secondary outcomes were net adverse clinical events (NACE) defined as MACE and major bleeding; any bleeding; major bleeding; all-cause death; cardiovascular death. We calculated hazard ratios (HR) and 95% confidence intervals (CI) using random-effects model. Analysis included 7 RCTs, comprising 35,857 patients and 53,321 patient-years of follow-up. The mean (SD) age of patients was 64.4 (10.6) years, 49.6% of patients presented with ACS, and 25.5% were female. There was no difference between short and standard-length DAPT in regards to MACE (HR = 0.93; 95% CI 0.84-1.03; p = 0.19), NACE (HR = 0.93; 95% CI 0.85-1.02; p = 0.12), all-cause death (HR = 0.92; 95% CI 0.80-1.05; p = 0.21), or cardiovascular death (HR = 0.85; 95% CI 0.64-1.13; p = 0.26). However, short-term DAPT was associated with significantly reduced major bleeding events (HR = 0.67; 95% CI 0.47-0.95; p = 0.03) and any bleeding event (HR = 0.63; 95% CI 0.44-0.90; p = 0.01) compared with standard-length DAPT. Among patients undergoing PCI for CAD, the use of short-term DAPT (1-3months) followed by single antiplatelet therapy was associated with a lower incidence of clinically relevant bleeding events, but with similar risk of MACE, all-cause death, and cardiovascular death compared with standard duration DAPT.

Antegrade Chronic Total Occlusion Strategies: A Technical Focus for 2020.

Chronic total occlusions (CTOs) are common in patients with ischaemic heart disease. In many countries, patients with CTOs are underserved by percutaneous coronary intervention (PCI). One of the barriers to CTO PCI is the technical challenges of these procedures. Improvements in technique and dedicated devices for CTO PCI, combined with advances in procedural strategy, have resulted in a dramatic increase in procedural success and outcomes. Antegrade wiring (AW) is the preferred initial strategy in short CTOs, where the proximal cap and course of the vessel is understood. For many longer, more complex occlusions, AW has a low probability of success. Dissection and re-entry techniques allow longer CTOs and those with ambiguous anatomy to be crossed safely and efficiently, and CTO operators must also be familiar with these strategies. The CrossBoss and Stingray system is currently the primary targeted re-entry device used during antegrade dissection and re-entry (ADR), and there continues to be an evolution in its use to increase procedural efficiency. In contrast to older ADR techniques, targeted re-entry allows preservation of important side-branches, and there is no difference in outcomes compared to intraplaque stenting.

Clinical trials of acute mechanical circulatory support in cardiogenic shock and high-risk percutaneous coronary intervention.

Acute mechanical circulatory support devices have become widely used in cardiogenic shock and high-risk percutaneous coronary intervention (PCI) but there remains significant controversy over the evidence supporting their use and the specific roles of various devices. In this review, we summarize major recent studies and identify key areas of future investigation. In cardiogenic shock, uncontrolled single arm studies emphasizing early mechanical circulatory support (MCS) have showed promising results, but randomized trials have either been stopped prematurely or enrolled patients with advanced shock unlikely to benefit from MCS. In high-risk PCI, only one randomized controlled trail has been performed, with practice guided largely by observational data. Randomized trials of current-generation mechanical support devices incorporating contemporary best-practices and performed in clearly defined populations are badly needed to clarify the role of acute MCS devices in cardiogenic shock and high-risk PCI.

Outcomes of Impella-supported high-risk nonemergent percutaneous coronary intervention in a large single-center registry.

We aimed to evaluate the early and one-year outcomes of Impella-supported high-risk nonemergent percutaneous coronary intervention (PCI). The evidence for the use of mechanical circulatory support (MCS) devices in high-risk nonemergent PCI is limited and nonconclusive. We performed a single-center retrospective study including all patients who underwent high-risk nonemergent PCI supported by Impella 2.5/CP at our institution between January 2009 and June 2018. This patient population was propensity score matched with subjects undergoing PCI with no MCS. The primary endpoint was major adverse cardiac events (MACE: all-cause death, myocardial infarction [MI], and target lesion revascularization) at one-year follow-up. Two-hundred fifty patients undergoing Impella-supported nonemergent PCI were matched to 250 controls. The two groups were well balanced in terms of clinical and angiographic characteristics. Left main PCI was performed more frequently among Impella-supported patients (26% vs. 11%, p < .001), who also had numerically higher prevalence of rotational atherectomy use (44% vs. 37%, p = .10) and a higher number of vessels treated (1.8 ± 0.8 vs. 1.3 ± 0.6, p < .001), compared with controls. Impella-supported patients suffered a higher incidence of periprocedural MI (14.0% vs. 6.4%, p = .005), major bleeding (6.8% vs. 2.8%, p = .04), and need for blood transfusions (11.2% vs. 4.8%, p = .008). However, at one-year follow-up there were no differences in the rates of MACE (31.2% vs. 27.4%, p = .78) or any of its individual components between Impella-supported patients and controls. Although Impella-supported patients suffer a higher incidence of periprocedural adverse events (partially linked to more aggressive PCI), the incidence of one-year MACE was similar between the Impella and control group.

Percutaneous Treatment and Outcomes of Small Coronary Vessels: A SCAAR Report

ObjectivesThe aim of this study was to investigate the outcomes of patients with de novo lesions in small coronary vessels undergoing percutaneous coronary intervention (PCI) with drug-coated balloons (DCBs) or newer-generation drug-eluting stents (n-DES). BackgroundNotwithstanding the available evidence from a few randomized clinical trials and meta-analyses, the best device for PCI in patients with small-vessel coronary artery disease is not yet established. MethodsThe study included all consecutive patients with de novo lesions in small coronary vessels undergoing PCI in Sweden from April 2009 to July 2017. A small coronary vessel was defined by a device diameter ≤2.5 mm. The primary outcomes were restenosis and definite target lesion thrombosis at 3-year follow-up. The secondary outcomes were the occurrence of all-cause death and myocardial infarction. ResultsThe study population included 14,788 patients: 1,154 treated with DCBs and 13,634 with n-DES. Overall, 35,541 PCIs were performed using 2,503 DCBs and 33,038 n-DES. The propensity score–adjusted regression analysis showed a significantly higher risk for restenosis in the DCB group compared with the n-DES group (adjusted hazard ratio [HR]: 2.027; 95% confidence interval [CI]: 1.537 to 2.674). Conversely, no difference in the risk for target lesion thrombosis (adjusted HR: 0.741; 95% CI: 0.412 to 1.331) was detected. The risk for all-cause death (adjusted HR: 1.178; 95% CI: 0.992 to 1.399) and myocardial infarction (adjusted HR: 1.251; 95% CI: 0.960 to 1.629) was comparable between groups. ConclusionsBecause of the significantly higher risk for restenosis up to 3 years, this research suggests that DCBs are not an equally effective alternative to n-DES for percutaneous treatment of small coronary vessels.

P5614The association between tissue morphology assessed with optical coherence tomography and mid and late-term results after percutaneous coronary intervention for in-stent restenosis lesions

Abstract Background It was reported that tissue morphology of in-stent restenosis (ISR) lesions assessed with optical coherence tomography (OCT) had an effect on midterm results including ISR and target lesion revascularization (TLR) rates after percutaneous coronary intervention (PCI). However, little was known about the association between tissue morphology assessed with OCT and late-term results. Methods We performed PCI treated with paclitaxel coated balloon (PCB) or drug-eluting stent (DES) for 452 ISR lesions (260 lesions with fibrous plaque and 192 lesions with lipid-laden plaque) using OCT between May 2008 and July 2016. Six- to eight-month (midterm) angiographic follow-up was performed on 422 of the 452 ISR lesions (follow-up rate: 93.4%). Furthermore, eighteen- to twenty-month (late-term) angiographic follow-up was performed on 337 of the 361 ISR lesions (follow-up rate: 93.4%) which were free from midterm TLR. We examined the association between tissue morphology, midterm-results and late-term results including ISR and TLR rates. Fibrous plaque was defined as homogeneous, signal-rich regions with low attenuation. Lipid-laden plaque was defined as diffuse border, signal poor regions with high attenuation. Results The patients were 353 men and 69 women, and the mean age was 68.8±9.6 years. PCI were performed with PCB in 285 lesions (PCB group) and DES in 137 lesions (DES group). The figure shows the angiographic midterm results of the 422 lesions and late-term results of the 337 lesions with respect to each tissue morphology and each PCI device. There was no difference in ISR and TLR rates of lesions with both fibrous and lipid-laden plaque at midterm between the two groups. ISR and TLR rates of lesions with lipid-laden plaque at late-term were significantly higher in the PCB group than in the DES group, while there was no difference in ISR and TLR rates of lesions with fibrous plaque at late-term between two groups. Figure 1 Conclusion Tissue morphology of ISR lesions might have an impact on outcomes after PCI. Morphological assessment of ISR tissue using OCT might suggest favorable types of PCI for ISR lesions.

Recent advances in microcatheter technology for the treatment of chronic total occlusions

ABSTRACTIntroduction: Use of a microcatheter is essential for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Several microcatheters have recently been introduced in clinical practice aiming to improve deliverability and resistance to deformation.Areas covered: We review the technical characteristics of several new microcatheters (Mamba, Mamba Flex, Teleport Control, Teleport, Nhancer Rx, Sasuke, and ReCross) and compare them with existing microcatheters.Expert opinion: The recently developed microcatheters offer additional options for guidewire support during CTO PCI. Accumulation of clinical experience and performance of comparative effectiveness studies are needed for better understanding the role of these devices in contemporary CTO PCI.

Feasibility of Implanting 50-60 mm-Tapered Drug Eluting Stents in Chronic Total Occlusions.

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) usually involves multiple overlapping stents implantation to cover long coronary segments. A higher rate of restenosis has been described with stent overlapping. Recently, new long tapered stents emerged as a potential tool for treating long coronary lesions. Feasibility of using these new devices for the CTO PCI has not been described. The aim of this work was to describe our initial experience with 50 and 60 mm-long tapered sirolimus-eluting stents (SES) in CTO PCI. We included 54 consecutive patients who underwent a CTO PCI and in whom an attempt to implant a 50 or 60 mm-long tapered SES was performed. Baseline clinical, angiographic, and procedural characteristics were recorded. The median (IQR) age was 64 (58-73) years, and 45 (83.3%) patients were male. The tapered SES 50 and 60 mm-long was successfully implanted in 51 (94.4%) patients. In three patients, a 60 mm-long stent could not be implanted, and two or three overlapped shorter drug-eluting stents were deployed instead. An average of 1.4 ± 0.6 stents per patient was implanted. A single stent was deployed in 32 (59.3%) patients. During a median follow-up of 330 (149-551) days, repeat PCI in the target vessel was performed in two patients. The use of the new BioMime Morph™ tapered SES for the treatment of CTO appears to be feasible in a high proportion of procedures. Further studies confirming the feasibility of this approach and its potential clinical advantages are needed.

Adverse Events Associated with the Use of Guide Extension Catheters during Percutaneous Coronary Intervention: Reports from the Manufacturer and User Facility Device Experience (MAUDE) database.

We aimed to assess the reported complications and event modes for the GuideLiner and Guidezilla extension catheters. The US Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database was queried for reported events. Of the 65 cases with reported GuideLiner-related issues, 15 (23%) involved the inability to pass equipment through or damage to percutaneous coronary intervention (PCI) devices in the GuideLiner catheter, 38 (58%) involved GuideLiner catheter fracture, 9 (14%) involved coronary artery dissection, 2 (3%) involved coronary artery perforation, and 1 (1.5%) involved thrombus formation in the catheter. Of the 408 cases with reported Guidezilla-related issues, 53 (13%) involved inability to pass or damaged PCI devices into the Guidezilla catheter, 117 (29%) involved inability to advance the Guidezilla catheter to the target lesion, 59 (14%) involved kinked Guidezilla catheter, mostly because of partial or complete catheter fracture upon further investigation, 164 (40%) involved a broken Guidezilla catheter, 10 (2.5%) involved coronary artery dissection, 2 (0.5%) involved coronary artery perforation, 1 (0.2%)involved aortic dissection, 1 (0.2%) involved thrombosis formation, and 1 (0.2%) involved no-reflow phenomenon. Findings from the MAUDE database highlight the complications and modes of events associated with the use of GuideLiner and Guidezilla extension catheters. To assess the reported complications and event modes for the GuideLiner and Guidezilla extension catheters, the US Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database was queried. There were more reports on Guidezilla-related events during the search period. The events for both extension catheters mainly involved the inability to pass equipment through or damage to percutaneous coronary intervention (PCI) devices in the extension catheter, extension catheter fracture, coronary artery dissection and perforation and, occasionally, the death of the patients.

SYNTAX II and SYNTAX III trials: what is the take home message for surgeons?

Percutaneous coronary intervention (PCI) has evolved greatly in the last 40 years since its introduction by Andreas Grüntzig in 1977. Since then, we've observed an evolution in balloons, the development of stents, changes in stent structure, development of drug eluting stents, improvements in strut design, thickness and even their polymeric coating. Most recently we saw the rise and "fall" of bioabsorbable scaffolds for PCI. Trials with the most diverse devices for PCI and diagnostic techniques have been conducted. Two of the most recent trials were reported in the last year and deserve special attention-SYNTAX II and SYNTAX III. These trials are completely different in design but present valuable information for doctors managing coronary artery disease (CAD). Both trials take into account contemporary technology for assessing and treating CAD. The first uses so-called "state-of-the-art" PCI and compares the outcomes of that approach with the outcomes of the PCI arm of the pivotal SYNTAX trial. SYNTAX III Revolution on the other hand does not focus on clinical endpoints: it is a blinded trial that does not randomize patients but randomizes doctors ("the heart team") to make a decision on the best treatment for complex CAD. This decision was based either on multi-slice CT with physiological assessment using FFRCT or on conventional angiography. In this review we bring the most important aspects of those trials and the key messages for surgeons together; also, what the surgeon may expect in the future after the publication of these interesting concepts.