Direct Stenting Research Articles

Impact of direct stenting on myocardial injury assessed by cardiac magnetic resonance imaging and prognosis in ST-elevation myocardial infarction

BackgroundThe results of studies investigating the clinical benefit of a direct stenting (DS) strategy in ST-elevation myocardial infarction (STEMI) are inconsistent and data regarding cardiac magnetic resonance (CMR) parameters of myocardial injury are lacking. The aim of this study was to investigate the effect of DS on myocardial damage in comparison to a conventional stenting technique (CS) with predilation in patients with reperfused STEMI. MethodsIn a subanalysis of the randomized LIPSIA CONDITIONING trial (NCT02158468), STEMI patients were stratified according to the percutaneous coronary intervention technique into the DS (n = 171) or CS (n = 171) group after matching the patients for age (±5 years), gender, and TIMI flow before coronary intervention. Patients underwent CMR imaging within one week after infarction. Clinical outcome (death, reinfarction, hospitalization for heart failure) was assessed within 6 months after the index event. ResultsPatients in the DS group had significantly lower infarct size (16 vs. 19% of left ventricular mass; p = 0.046) and microvascular obstruction with significant improvement of left ventricular parameters, which was associated with favorable clinical outcome with a lower incidence of heart failure hospitalizations (4% vs. 11%, p = 0.011) and mortality (5% vs. 12%, p = 0.034) as compared to patients with CS. In multivariate Cox regression analysis, DS was identified as an independent predictor of reduced mortality (HR 0.30, 95% CI 0.11–0.87, p = 0.026). ConclusionIn patients with acute reperfused STEMI, DS is safe and feasible with a significant reduction of infarct size compared to CS and subsequent lower incidence of heart failure hospitalizations and mortality.

TCT-603 Direct Stenting Strategy is Associated with Improved Survival in Women Undergoing Primary Percutaneous Coronary Intervention for ST-elevation Myocardial Infarction: A Propensity Score Matched Comparative Study

Primary percutaneous coronary interventions (PCIs) significantly reduce mortality in patients with ST-segment elevation myocardial infarction (STEMI). But the mortality rate in women remains higher than in men. Despite considerable improvements in STEMI mortality for women and men over the last 3

TCT-380 Impact of direct stenting on myocardial injury assessed by cardiac magnetic resonance imaging and prognosis in ST-elevation myocardial infarction

TCT-380 Impact of direct stenting on myocardial injury assessed by cardiac magnetic resonance imaging and prognosis in ST-elevation myocardial infarction

Direct Absorb bioresorbable scaffold implantation in acute coronary syndrome.

Direct stent implantation is a preferred technique for primary percutaneous coronary intervention (PCI). For the deployment of a bioresorbable vascular scaffold (BVS), the current guidelines recommend aggressive predilatation. Data about direct BVS implantation in patients with acute coronary syndrome (ACS) are scarce. We sought to assess procedural characteristics and immediate outcomes of direct Absorb BVS implantation in ACS patients. A total of 91 patients with acute myocardial infarction (MI) requiring urgent coronary revascularisation were enrolled. Among them, 50 patients underwent an attempt of direct Absorb implantation. The control group consisted of 41 patients treated with PCI with BVS deployment after elective predilatation. In the direct group BVS deployment was successful in 91% of lesions, and in the remaining 9% of lesions direct implantation failed. In the control group scaffolds were successfully deployed after predilatation in 98% of lesions. In one case Absorb implantation failed even after balloon angioplasty. Type C lesions with severe tortuosity and angulation > 90° were associated with failure in direct Absorb deployment. Quantitative coronary analysis showed similar final percentages of diameter stenosis in the study and control groups. Flow analyses did not show significant differences between both methods. During hospitalisation no recurrent MI, scaffold thrombosis, or target lesion revascularisation was reported in either group. Direct Absorb implantation in ACS patients may be feasible in a suitable lesion anatomy.

Direct stenting in ST-elevation myocardials infarction: convenient, but not improving outcomes.

Direct stenting in ST-elevation myocardials infarction: convenient, but not improving outcomes.

Clinical impact of direct stenting and interaction with thrombus aspiration in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention: Thrombectomy Trialists Collaboration.

Preliminary studies suggest that direct stenting (DS) during percutaneous coronary intervention (PCI) may reduce microvascular obstruction and improve clinical outcome. Thrombus aspiration may facilitate DS. We assessed the impact of DS on clinical outcome and myocardial reperfusion and its interaction with thrombus aspiration among ST-segment elevation myocardial infarction (STEMI) patients undergoing PCI. Patient-level data from the three largest randomized trials on routine manual thrombus aspiration vs. PCI only were merged. A 1:1 propensity matched population was created to compare DS and conventional stenting. Synergy between DS and thrombus aspiration was assessed with interaction P-values in the final models. In the unmatched population (n = 17 329), 32% underwent DS and 68% underwent conventional stenting. Direct stenting rates were higher in patients randomized to thrombus aspiration as compared with PCI only (41% vs. 22%; P < 0.001). Patients undergoing DS required less contrast (162 mL vs. 172 mL; P < 0.001) and had shorter fluoroscopy time (11.1 min vs. 13.3 min; P < 0.001). After propensity matching (n = 10 944), no significant differences were seen between DS and conventional stenting with respect to 30-day cardiovascular death [1.7% vs. 1.9%; hazard ratio 0.88, 95% confidence interval (CI) 0.55-1.41; P = 0.60; Pinteraction = 0.96) and 30-day stroke or transient ischaemic attack (0.6% vs. 0.4%; odds ratio 1.02; 95% CI 0.14-7.54; P = 0.99; Pinteraction = 0.81). One-year results were similar. No significant differences were seen in electrocardiographic and angiographic myocardial reperfusion measures. Direct stenting rates were higher in patients randomized to thrombus aspiration. Clinical outcomes and myocardial reperfusion measures did not differ significantly between DS and conventional stenting and there was no interaction with thrombus aspiration.

Direct aspiration (ADAPT) and primary stent retriever thrombectomy for acute ischemic stroke: a systematic review of radiographic and clinical outcomes in 5441 patients (P4.214)

Direct aspiration (ADAPT) and primary stent retriever thrombectomy for acute ischemic stroke: a systematic review of radiographic and clinical outcomes in 5441 patients (P4.214)

OP-33 - A New Thrombus Classification in Bifurcation Lesions: Coronary Thrombus Classification for Guiding Manual Thrombus Aspiration and Direct Coronary Stenting

Introduction: Although manual thrombus aspiration is losing popularity, the bailout use of thrombus aspiration, not only considering the thrombus load, also based on the localization, and its relationship to the carina and side branches might have a significant periprocedural aspects. We recommended a new thrombus classification in addition to current TIMI thrombus grading. This classification is based on the involvement of side branch ostium and the carina with the thrombus, and the possible thrombus shift from the main vessel to the side branch or vice versa.

Procedural Results and Immediate Outcomes following De Novo Saphenous Venous Graft Interventions.

Background Distal embolization is the detrimental factor in SVG intervention. There is no specific treatment for it except prevention. Guidelines have endorsed the use of embolic protection devices; however, their use is not without complications, and increases the procedural time and cost for the patient. The objective of this study is to analyze the procedural results and immediate outcome in de novo SVG stenting. Methods A retrospective observational study of patients who have undergone SVG-percutaneous coronary intervention at our institute. Baseline clinical, demographic data, intervention details, and in-hospital events are analyzed. Statistical analysis was done using Mini tab version 17. Chi-square testing, odds ratio, and 95% confidence intervals were calculated. Results The study population included 96 lesions in 80 patients. Average age of the graft was 8.2 ± 4 years. Embolic protection devices were used only in 10%. Angiographic and clinical success was seen in 92.5%. Distal embolization was seen in 7.5%. Drug-eluting stent and shorter stents were associated with lesser distal embolization. Stent length (> 20 mm) proved to be an independent predictor of distal embolization. There was no correlation between distal embolization and age of patient, sex, hypertension, diabetes, and smoking, left ventricular function, age of graft, direct stenting, use of embolic device, and glycoprotein 2b/3a inhibitors. Conclusion De novo SVG lesions can be stented with a high rate of angiographic and procedural success. Stent length is the only independent predictor of distal embolization. SVG interventions can be safely done in the absence of embolic protection devices irrespective of the graft age.

Clinical observation of flexible ureteroscope combined with ultramini nephrostomy tract antegrade balloon dilatation on ureteral stricture

Objective To observe the clinical effect of flexible ureteroscope combined with ultramini nephrostomy tract antegrade balloon dilatation in the treatment of ureteral stricture. Methods A total of 24 patients with ureteral stricture in our hospital underwent flexible ureteroscope combined with ultramini nephrostomy tract under general anesthesia, and the guidewire and balloon dilatation catheters were used to expand urethral stricture, and F7 catheter was placed. Results All patients were successfully implemented flexible ureteroscope under direct vision narrow segment balloon dilatation and stent implantation, after the operation regular replacement of the stent, the stent was pulled out after six months. All patients were followed up for 1 year, and no long-term complications and recurrence occured. Conclusions Flexible ureteroscope combined with ultramini nephrostomy tract antegrade balloon dilatation is safe and effective method, especially for the patients under retrograde balloon dilation unsuccessful is a better alternative select. Key words: Ureteral Obstruction; Ureteroscopes; Balloon Dilatation

Vitamin D deficiency and periprocedural myocardial infarction in patients undergoing percutaneous coronary interventions.

Vitamin D deficiency has been implicated in the progression of atherosclerosis and acute thrombotic events. We aimed at evaluating the impact of vitamin D deficiency on periprocedural myocardial infarction (PMI) in patients undergoing percutaneous coronary interventions (PCI). We included 934 patients undergoing non-urgent PCI. Assessment of myocardial biomarkers was performed from 6 to 48 h after PCI. PMI was defined as Creatine Kinase-MB increase by 3 times the Upper Limit Normal or by 50% of an elevated baseline value, periprocedural myocardial damage as Troponin I increase by 3 × ULN or 50% of baseline. Patients were divided according to vitamin D tertiles values (<10.2 ng/ml; 10.2-18.7 ng/ml; ≥18.8 ng/ml). Lower tertiles values of vitamin D were associated with age (p = 0.04), female gender, (p = 0.001), and a higher cardiovascular risk profile. Lower vitamin D levels related with PCI of descending anterior coronary artery or bypass vein grafts (p = 0.03), treatment of bifurcations (p = 0.05) and side branch loss (p = 0.05) and inversely with direct stenting (p = 0.002). However, lower vitamin D levels did not influence the risk of PMI (adjusted OR [95% CI] = 0.81[0.65,1.18], p = 0.09) or periprocedural myocardial damage (adjusted OR [95% CI] = 0.93[0.77,1.13], p = 0.48). Similar results were achieved when considering the severity of vitamin D deficiency. Therefore, in patients undergoing PCI, no association was observed between vitamin D deficiency and the risk of periprocedural MI and myocardial damage.

CLINICAL IMPACT OF DIRECT STENTING AND INTERACTION WITH THROMBUS ASPIRATION IN PATIENTS WITH ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION UNDERGOING PERCUTANEOUS CORONARY INTERVENTION: THROMBECTOMY TRIALISTS COLLABORATION

Preliminary studies suggest that direct stenting (DS) during percutaneous coronary intervention (PCI) may reduce microvascular obstruction and improve clinical outcome. Thrombus aspiration may facilitate direct stenting. We assessed the impact of DS on myocardial reperfusion and clinical outcome and

A comparison of direct aspiration versus stent retriever as a first approach (‘COMPASS’): protocol

Background and objectiveAcute ischemic stroke is a potentially devastating condition and leading cause of morbidity and mortality, affecting an estimated 800 000 people per year in the USA. The natural...

Abstract WP9: Direct Aspiration (ADAPT) and Primary Stent Retriever Thrombectomy for Acute Ischemic Stroke: A Systematic Review of Radiographic and Clinical Outcomes in 3339 Patients

Introduction: Endovascular stroke therapy has been revolutionized by the advent of modern devices for thrombectomy. It remains to be determined what is the most safe and effective way to perform stroke thrombectomy. The two most common approaches to thrombectomy currently include: 1-direct aspiration with the additional use of a stent retriever if needed (ADAPT), 2 - primary stent retriever thrombectomy. We aimed to compare radiographic and clinical outcomes in patients with acute stroke from large vessel occlusion (LVO) treated with these two approaches. Methods: Using the PubMed database, we searched for studies that included patients with acute ischemic stroke from LVO treated with direct aspiration (ADAPT) or primary stent retriever thrombectomy. The literature search included 294 studies, excluding 122 manuscripts. Statistical analysis was performed on 36 publications with a total of 2656 patients that underwent thrombectomy using a stent retriever device and 11 publications with a total of 683 patients that underwent thrombectomy using ADAPT. We compared the proportions of patients with successful recanalization, favorable functional outcomes, intracranial hemorrhage, mortality rates and occurrence of distal embolization in the two treatment groups by calculating chi 2 and confidence intervals for odds ratios. Results: 3339 patients from 47 publications were included in final analysis. There was no difference in age (p=0.7625, 95% CI -2.91–3.94), NIHSS (p=0.1135, 95% CI -3.55-0.39), the use of intravenous thrombolysis (p=0.9631, 95% CI -29.46-30.85), or location of occlusion (internal carotid artery, middle cerebral artery or posterior circulation; p=0.9679) between the two groups. We found no difference in rates of successful recanalization TICI 2b/3 (79.9% with ADAPT vs. 74.9% with primary stent retriever; p=0.4771, 95% CI -0.091-0.191) or good clinical outcome at 3 months defined as mRS 0-2 (51.0% with ADAPT vs. 46.8% with primary stent retriever; p=0.4814, 95% CI -0.161-0.077). Conclusion: According to our systematic review, endovascular treatment with direct aspiration (ADAPT) and primary stent retriever thrombectomy approaches results in similar radiographic and clinical outcomes in patients with acute stroke from LVO.

Deflated Balloon-Facilitated Direct Stenting in Primary Angioplasty (The DBDS Technique): A Pilot Study.

BackgroundSeveral studies and meta-analyses have shown that direct stenting (DS) may improve clinical outcomes in patients with acute ST-elevation myocardial infarction (STEMI). But in most cases, the thrombolysis in myocardial infarction (TIMI) flow remains ≤ 1 after wire placement. We used deflated balloon to facilitate DS in patients with totally occluded culprit arteries. The aim of this study was to evaluate the feasibility, safety and outcomes of this novel technique in patients with STEMI in real-world clinical practice.MethodsThis was a prospective, observational, single-center pilot study. From September 2016 to June 2018, 454 patients were enrolled in the study. DS was performed when the culprit vessel was visualized with at least TIMI flow grade 1. Patients with complete occlusion of the vessel after wire placement were subjected to deflated balloon-facilitated DS technique (DBDS technique) and DS was done wherever possible.ResultsDS was done in 74% (n = 336) of the patients and 26% (n = 118) patients received stenting after pre-dilatation (PD). DBDS technique to facilitate DS was successful in 68% patients (211/309). Final TIMI 3 flow was achieved more frequently in the DS group as compared to PD group (96.7% versus 92.3%, P = 0.04). The procedural complications were also significantly lower in DS group (0.6% versus 7.6%, P < 0.001). DS group had significantly lower procedure time (33 ± 19 min versus 41 ± 17 min, P < 0.001), fluoroscopy time (6.2 ± 3.4 min versus 7.8 ± 32 min, P < 0.001), required lesser contrast volume (112 ± 16 mL versus 123 ± 18 mL, P < 0.001) and had lower procedural cost (310 ± 45$ versus 402 ± 56$, P < 0.001). ST-segment resolution > 50% after percutaneous coronary intervention (PCI) were significantly higher in the DS group (85.7% versus 71.1%, P < 0.001). At 30 days, the major adverse cardiac event (MACE) rate was significantly lower in the DS group (2.4% versus 9.3%, P = 0.02), mainly driven by lower rates of target lesion revascularization (TLR) (0.9% versus 4.2%, P = 0.01).ConclusionThis cost-effective technique appears to be simple, feasible and safe and is associated with superior clinical outcomes. It helps in maximizing DS and could offer an alternative to PD and aspiration thrombectomy in total occlusion. However, larger studies with longer follow up are required before a wider application of this technique.

2 cases of non-surgical treatment of stent loss during percutaneous coronary intervention

Background: Percutaneous coronary intervention with stents is widely used for coronary artery disease. Stent loss is a rare complication. Incidence is estimated at 1.3%. Although Stent has been retrieved in most cases; urgent coronary artery bypass graft, myocardial infarction and death are poor outcomes associated with this complication. Cases report: First case is about a 55 years old male, heavy smoker, admitted to the cathlab for a non ST elevation myocardial infarction (NSTEMI). Ejection fraction (EF) was 55% with inferior wall hypokinesis. Coronary angiogram showed a long stenosis in a tortuous mid-right coronary artery (RCA) with a TIMI 2 flow. Ad-hoc angioplasty was attempted. Direct stenting was attempted but stent couldn't be delivered to the target lesion and attempts resulted in stent retention. Stent couldn't be retrieved and finally was successfully crushed with a drug eluting stent with good final result. Patient had uneventful recovery. Second case is about a 59 years old Male type 2 diabetes mellitus and former smoker. He was hospitalized for a NSTEMI. EF was 50% with anterior hypokinesis. Angiogram showed a long stenosis in the mid left anterior descending artery with a TIMI 2 flow. Ad-hoc angioplasty was attempted with a long drug eluting stent (DES) but wasn't successful. The stent was partially detached and deformed. It was successfully retrieved using the stent's balloon. Patient was successfully treated with a second successful procedure with a DES. Conclusion: No algorithm or stepwise approach exists to treat stent loss. Tortuous lesions and failure to cross the stenosis are common angiographic finding associated with this complication. Stent retrieval, deployment or crushing is the frequently used techniques to deal with this issue.

Microcatheter-Facilitated Primary Angioplasty in ST-Segment Elevation Myocardial Infarction

BackgroundDirect stenting is the best method for achieving reperfusion in primary percutaneous coronary intervention (PPCI). We hypothesized that the use of a microcatheter (MC) during PPCI when Thrombolysis in Myocardial Infarction (TIMI) flow ≤ 1 after wire crossing would allow visualization of the downstream artery with an optimal TIMI 3 flow at the end of the procedure. MethodsIn this pilot study, PPCI patients with TIMI flow ≤ 1 after wire crossing formed the MC group (n = 60); the MC was positioned in the distal part of the culprit artery and a small amount of contrast was injected through it to determine stent size and length to treat the culprit lesion. The MC group was compared with previous consecutive patients treated using standard PPCI (n = 94; similar characteristics except for the rate of previous percutaneous coronary intervention). ResultsIn the MC group, downstream arteries were visualized in 98% of cases and direct stenting was achieved in 72% vs 31% (P < 0.0001). Final TIMI 3 flow was similar in both groups (97%). There was less manual thrombectomy (20% vs 63%; P < 0.001) and bailout glycoprotein IIb/IIIa inhibitor use (6.7% vs 29.8%; P < 0.002). The incidence of major adverse events (death, shock, severe arrhythmia) and left ventricular ejection fraction were similar. The peak cardiac enzymes level was significantly lower in the MC group. ConclusionsThe MC strategy appears feasible and safe. It could allow exploring new strategies on the basis of more systematic direct stenting and prepared reperfusion by injecting drugs through the MC before reperfusion.

Endovascular Treatment of Middle Cerebral Artery M2 Occlusion Strokes: Clinical and Procedural Predictors of Outcomes.

Patients with strokes from M2 segment middle cerebral artery (MCA) occlusion have been underrepresented in recent randomized trials of endovascular therapy. To better understand the clinical, imaging, and procedural predictors of successful recanalization and clinical outcomes in this population of patients. We performed a multicenter retrospective analysis of consecutive patients with acute MCA M2 segment occlusion who underwent thrombectomy with stent retrievers or primary aspiration thrombectomy (including A Direct Aspiration First Pass Technique approach). We correlated clinical and radiographic outcomes with demographic, clinical, and technical characteristics. One hundred and seventeen patients were included in analysis (median admission National Institutes of Health stroke scale [NIHSS] score 15, mean age 67.0 ± 14.5, 42% females). Good clinical outcome at 3 months (modified Rankin scale [mRS] ≤ 2) was achieved in 56% of patients. Treatment beyond 6 h of symptoms onset (P = .69, OR 0.80, 95% CI 0.38-1.73) and age over 80 (P = .47, OR 0.65, 95% CI 0.25-1.70) were not predictive of poor outcome. NIHSS > 15 was a strong predictor of clinical outcome, based on mRS distribution at 3 months (P = .0085, OR 0.35, 95% CI 0.16-0.74). Direct aspiration and primary stent retriever thrombectomy approaches showed similar radiographic and clinical success rates. Advanced age and time to treatment beyond 6 h from symptom onset were not predictive of clinical outcome with thrombectomy. NIHSS score above 15 was a strong predictor of outcome. Direct aspiration and primary stent retriever thrombectomy showed similar efficacy.

Gestion des charges thrombotiques importantes en angioplastie primaire

A large thrombus burden is not uncommon in primary percutaneous coronary intervention, and is associated with more frequent complications. The role of intracoronary thrombolysis and glycoprotein IIb/IIIa inhibitors in the management of a large thrombus burden is discussed. The use of thromboaspiration must follow a particular logic and used with rigorous manipulations; the capacities of the protective filters are often exceeded. Stents dedicated to thrombus management can be used. Interest and limits of these stents are developed. Direct stenting should be encouraged, and delayed stenting probably considered for the most important thrombotic burden despite “negative” results in studies.

TIMI (Thrombolysis In Myocardial Infarction) flow in direct and conventional stenting during primary angioplasty for acute myocardial infarction, our experience

TIMI (Thrombolysis In Myocardial Infarction) flow in direct and conventional stenting during primary angioplasty for acute myocardial infarction, our experience