Final Angiographic Result Research Articles

Benefit of Systematic "Jailed Wire" Technique for Bifurcation Provisional Stenting. A CABRIOLET Substudy.

Jailed wire (JW) in the side branch (SB) is recommended during coronary bifurcation provisional stenting, but there is uncertainty about the real benefit. Our objective was to evaluate the benefit of a JW technique in the Coronary Artery Bifurcation Revascularization Without kIssing ballOon infLation by rEpoT (CABRIOLET) registry. In CABRIOLET, which included 500 patients, we compared the primary composite end point of a poor final SB angiographic result (of Thrombolysis in Myocardial Infarction (TIMI) flow < III, dissection grade > B, thrombosis, residual stenosis > 70%, or additional SB stenting) whether JW was performed or not. On the basis of the usual operator practice, we also compared a systematic JW strategy: operators known to place JW frequently (> 75% performed), to a conditional strategy: selective JW practices (< 20% of JW). JW was performed in 251 patients (50.2%), without significant baseline clinical and angiographic differences compared with those who received no JW. JW was associated with higher primary end point (15.1% vs 8.4%; P < 0.05), and increased fluoroscopy time and contrast volume (15.9 ± 7.3 minutes and 181 ± 62 mL vs 13.3 ± 6.5 minutes and 161 ± 74 mL; P < 0.05). JW was performed in 12.1% of patients (26 of 214) in the conditional JW group and 78.7% (225 of 286) in systematic group. The primary end point was similar in both strategies (11.2% and 12.2%; P= 0.78), although with greater fluoroscopy time and contrast volume for systematic JW (180 ± 57 mL and 15.3 ± 7.5 minutes vs 162 ± 79 mL and 13.7 ± 6.1 minutes; P < 0.05). There was no difference in 1-year major adverse cardiovascular events depending on whether JW was performed or not and between conditional or systematic strategies. In a large registry, JW was associated with poorer final SB angiographic results than no JW. Final SB angiographic results were similar between conditional or systematic JW strategies.

Circulating Interleukin-22 in Patients with Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention.

Acute coronary syndrome (ACS) represents an important clinical manifestation of coronary artery disease (CAD) and is characterized by a particularly poor prognosis. Myocardial reperfusion through primary percutaneous coronary intervention (PPCI) is imperative in the event of acute ST elevation myocardial infarction (STEMI). Interleukin-22 (IL-22) regulates immune and inflammatory responses. This interleukin has been described in the scenario of the CAD, but there are no data in patients with STEMI undergoing PPCI. Objectives: The goals of this study were to investigate the differences in circulating IL-22 levels between patients with STEMI undergoing PPCI and healthy controls and to determine whether these differences were associated with the culprit coronary artery, door-to-balloon time (DBT), final angiographic result, CAD classification, and presence of diabetes mellitus (DM). Methods: A total of 280 participants were recruited, comprising 210 STEMI cases and 70 healthy controls. Participants underwent clinical and angiographic evaluations, and serum IL-22 levels were measured using an enzyme-linked immunosorbent assay (ELISA). Data analysis was performed using the Mann-Whitney and Fisher tests, with p < 0.05 indicating significance. Results: Serum IL-22 levels were lower in cases (149.63, 84.99-294.56) than in the controls (482.67, 344.33-641.00); p < 0.001. Lower IL-22 levels were associated with the right coronary artery (RCA) (144.57, 70.84-242.43; 146.00, 63.60-279.67; 191.71, 121.80-388.97); p = 0.033. IL-22 was lower with shorter DBT (≤60 min, 106.00, 49.60-171.71; >60 min, 153.00, 88.86-313.60); p = 0.043. Conclusions: IL-22 levels were significantly lower in patients with STEMI than in healthy controls.

Comparison of Thrombolysis In Cerebral Infarction (TICI) 2b and TICI 3 reperfusion in endovascular therapy for large ischemic anterior circulation strokes

BackgroundLandmark thrombectomy trials have provided evidence that selected patients with large ischemic stroke benefit from successful endovascular therapy, commonly defined as incomplete (modified Thrombolysis In Cerebral Infarction (mTICI) 2b) or...

P249 INTRAMYOCARDIAL HAEMATOMA AS A COMPLICATION OF ACUTE MYOCARDIAL INFARCTION

Abstract A 72–year–old overweight man, with known hypertension and dyslipidaemia, had an episode of high intensity chest pain, which appeared at rest and lasted for several hours. A few days later, he underwent a cardiological examination and the electrocardiogram showed normofrequent sinus rhythm, ST elevation of 3 mm and Q waves formed in the anterior and lateral wall leads. The patient was diagnosed with late ST elevation myocardial infarction and was transported to our emergency department. On blood test, troponin levels were significantly elevated. He was treated with dual antiplatelet therapy (DAPT, aspirin and ticagrelor) and then underwent percutaneous coronary intervention (PCI). The mid segment of the LAD was suboccluded and two drug eluting stent (DES) were implanted. The right coronary artery also had a critical stenosis at the second segment treated with implantation of a DES. Final angiographic result was good (TIMI 3). The patient was admitted to our coronary unit where he continued to receive DAPT. During hospitalization a routine transthoracic echocardiogram (TTE) was performed which showed dilated left ventricle with a–dyskinesis of the apex and middle segment of the septum and the anterior wall and reduced ejection fraction (FE 35%). Within the apical segment of the septum and inferior wall, was noted an area of 40x14 mm with different echogenicity, probably referable to intramyocardial haematoma (IH) of the ventricular wall or a stratified thrombus. Both Colour Doppler and echo–contrast, using Sonovue, did not show a continuity between the suspected IH and one of the ventricular cavities. On cardiac MRI, this finding was considered of uncertain interpretation (whether IH or non–protundant mural thrombus). Late transmural enhancement was also observed at the same echocardiographic sites with subendocardial hypointensity bands consistent with areas of no–reflow. As the patient was clinically stable and TTE monitoring showed no progression of IH, a joint decision was made by cardiologists and cardiac surgeon to continue conservative management with DAPT without initiating anticoagulant therapy. At 1 month follow–up, TTE showed a reduction of the IH and an improvement of the EF to 45%. IH is a rare complication of myocardial infarction and revascularization treatments. The incidence is not well documented and the finding is usually occasional by TTE. Appropriate management is still controversial and a personalised approach is recommended.

P321 NEOVASC REDUCER IMPLANTATION AS A USEFUL THERAPEUTIC CHANCE IN REFRACTORY ANGINA

Abstract Refractory angina is a clinical condition caused by myocardial ischemia inadequately controlled by medical therapy and coronary revascularization. Emblematic case of this condition concerns a 72–year–old man with chronic coronary syndrome (percutaneous transluminal coronary angioplasty [PTCA] + drug–eluting stent [DES] on the proximal portion of the left main coronary artery [LMCA] in 2009 and PTCA + 2 overlapping DES on the proximal portion of the right coronary artery [RCA] in 2017) who accessed in the emergency room for unstable angina. The patient‘s past medical history was positive for repeated hospitalizations for unstable angina: in particular, was registered an admission in 2019 with angiographic evidence of intermediate stenosis 30% at the mid–distal tract of LMCA and good distant outcome of previously implanted stents on LMCA and RCA, and a further admission in 2021 with coronary evidence overlapping the previous one. In both hospitalizations, medical therapy optimization was carried out by adding also 2nd–line drugs to the antianginal therapy with Bisoprolol 2.5 mg and Amlodipine 5 mg such as transdermal Nitroglycerin 15 mg, Ranolazine 750 mg bis in die, and subsequently Trimetazidine 20 mg ter in die during the first and second hospitalizations, respectively. In the context of this re–hospitalization, coronarography was repeated again with evidence of unchanged angiographic picture from the previous one (2021) and, in view of the refractoriness of the anginal symptoms, was placed an indication for Neovasc Reducer device implantation. This device creates a pressor gradient in the coronary sinus, determining a redistribution of blood flow from the subepicardial areas to the ischemic subendocardial areas. Therefore, by performing jugular venous access we engaged the coronary sinus with 6F diagnostic catheter then by mother and child technique we placed the 9F guide catheter advancing as distally as possible in the coronary sinus and finally we implanted the Neovasc Reducer device (4 atm for 60‘‘), obtaining a good final angiographic result. At 6–month follow–up, the patient experienced symptomatic improvement, in particular he improved by 2 Canadian Cardiovascular Society (CCS) angina classes. The Neovasc Reducer device, by improving quality of life and reducing the need for hospitalizations for unstable angina, is a viable therapeutic strategy in patients angina unresponsive to medical therapy and coronary revascularization.

P139 RETURN TO THE ORIGINS: WHEN THE THROMBOLYSIS SAVES THE ANGIOPLASTY

Abstract A 62 year old man arrived in PS for typical chest pain radiating to the jugular and associated with sweating for about three hours. History of arterial hypertension and untreated dyslipidemia, family history of CVD. ECG: sinus rithm at rate of 50 bpm with first degree AVB. Inferior ST elevation in inferior leads and ST depression in V2–V3. Echocardiogram: depressed systolic function (EF 48%) in relation to hypo–akinesia of the mid–basal segments of the inferior–posterior–lateral wall. Diagnosed with STEMI inferior–posterior, was sent to the cath lab to undergo to emergency coronary angiography, with findings of non–significant atheromas on IVA and Cx. Multiple unsuccessful attempts to search for the right coronary artery and failure to visualize the aortography in two complementary projections. During the procedure hemodynamic and electrical instability, worsening angor, marked hypotension and extreme bradycardia up to complete AVB with asystole phases. Inotropics and atropine were started, which proved ineffective, and it was therefore decided to proceed with the implantation of a temporary pacemaker. During the placement, the patient presented cardiac arrest from VF (likely an irritating effect from the passage of the lead through the tricuspid) treated with effective DC–shock. Given the technical difficulties in proceeding with mechanical revascularization and given the patient‘s instability, the decision was made to postpone PCI by attempting systemic thrombolysis. Early efficacy of thrombolysis with disappearance of precordial pain, improvement of echo motion and reduction &amp;gt; 50% of the ST–segment elevation to the rare spontaneous QRS displayed at the transient shutdown of the temporary PM. Subsequent emergence of AF at rate of 116 bpm. Approximately 12 hours after thrombolysis: complete ST resolution in absence of Q waves. AngioTC of the coronaries was performed which showed regularl origin of Cdx from the right coronary sinus but higher up and lateralized to the left, with severe lesion in the first segment. So the patient underwent falicitated PCI with detection of ostio–proximal Cdx thrombotic lesion effectively treated with PTCA and drug–eluting stent placement with good final angiographic result. Control echo: preserved global left ventricular motion (FE 55%), hypokinesia of the basal segment of the inferior wall. The remaining stay decurred without any complications and the patient was discharged with indications for a close follow–up.

Myocardial Work Evaluation—A Useful Non-Invasive Method to Predict Coronary Artery Sub-Occlusion in a Patient with Unstable Angina and Multiple Myocardial Revascularization Interventions

While lifestyle changes, management of coronary artery disease (CAD) risk factors, myocardial revascularization procedures, and medication can improve a patient's prognosis, de novo native coronary lesions and in-stent restenosis (ISR) remain significant clinical concerns. ISR is more frequent with a bare-metal stent than with a drug-eluting stent and has been documented in around 12% of DES patients. Acute coronary syndrome (ACS) manifests as unstable angina in about 30% to 60% of ISR patients. Myocardial work imaging is a modern, non-invasive technique able to identify individuals with critical coronary artery lesions with high sensitivity and specificity. We present the case of a 72-year-old Caucasian gentleman with multiple cardiovascular risk factors, admitted to the Cardiology Clinic of Timișoara Municipal Hospital with unstable angina. From 1999 to 2021, the patient experienced two myocardial infarctions, a double aortocoronary bypass graft, and multiple percutaneous coronary interventions with 11 stent implantations, including 6 for ISR. Using two-dimensional speckle-tracking echocardiography and myocardial work assessment, we detected that the lateral wall of the left ventricle had a severely impaired deformation pattern. Angio-coronarography was performed, and sub-occlusion of the posterolateral branch of the right coronary artery was found. Angioplasty was performed and a DES was inserted, with a good final angiographic result and complete release of symptoms. In patients with a history of multiple myocardial revascularization interventions and ISR, it is challenging to identify the critical ischemia region by non-invasive methods. Myocardial work imaging was beneficial in the detection of the altered deformation patterns indicating significant ischemia, its accuracy being superior to that of LV strain, as proven by coronary angiography. Urgent coronary angiography followed by angioplasty and stent implantation resolved the issue.

Abstract Number ‐ 7: Final Angiographic, Clinical and Thrombus Composition Results of 1000 Patients in the EXCELLENT Registry

Introduction EXCELLENT (NCT03685578; Cerenovus) is a large, prospective, international, real‐world registry of endovascular clot removal in acute ischemic stroke (AIS) with EmboTrap as the first line mechanical thrombectomy (MT) device, which included collection and analysis of the retrieved thrombus material. Methods Between September 2018 and March 2021, 1000 “all‐comer” patients were enrolled at 34 global sites (27 US, 5 EU, 1 UK, 1 Israel) and treated according to standard of care at each center (with Embrotrap as first line). The study employed blind endpoint evaluation, including a core imaging lab and an independent 90‐day mRS assessment. Retrieved clot was collected per each MT maneuver from 538 subjects across 26 sites and clot analysis was performed by independent central labs blinded to clinical data. Results mITT population included 998 subjects. Mean age was 69.9±14.18 years (range 18–102), 51.8% (517/998) subjects were female and 9.9% (97/997) had a pre‐stroke mRS 3–5. Baseline NIHSS was 15.6±6.87 (range 0–36); 10.1% (82/815) subjects had a large core (ASPECTS 0–5); 5.8% (57/990) had posterior stroke; 56.3% (523/929) underwent MT ≤ 6hrs of onset and 38.1% (380/998) received IV‐tPA prior to MT. First pass eTICI 2c‐3 was achieved in 38.3% (377/984) and final 2b‐3 in 94.5 % (930/984; median number of passes = 1) of subjects. 90‐day mRS≤2 or ≤pre‐stroke was 46.9% (429/915) and 90‐day all‐cause mortality was 19.0% (175/921). The univariate analysis of clot components showed high red blood cell and low platelet content were significant predictors of good mRS outcome (p &lt; 0.001 and 0.009) and negative predictors of 90‐day mortality (p &lt; 0.001 and 0.017, respectively). Conclusions This large multi‐center, all‐comer cohort reflects the population undergoing thrombectomy today in a real world‐setting. Final angiographic, clinical and thrombus composition results, along with multivariate analysis of predictors of clinical outcomes, will be presented at the time of the conference.

Abstract 12718: ST Segment Elevation Myocardial Infarction Case With a Novel Therapy

History: A 78-year-old man presented with anterior ST-segment elevation. Coronary angiography demonstrated an occluded left anterior descending coronary artery (LAD Figure 1A) with stenosis of the left circumflex (Cx) coronary artery. Procedure: The LAD was crossed with a workhorse wire (Figure 1B). Predilation restored the flow in the LAD and two diagonal branches (Figure 1C). After assessing the lesion with intravascular imaging (Figure 1D), two drug-eluting stents (DES) were deployed with provisional technique (Figure 1E). The diagonal was rewired and dilated with a 2.0 mm balloon (Figure 1F). A 3.5x20 mm DES was deployed covering the proximal LAD lesion (Figure 1G). The Cx ostium appeared pinched, but the diastolic pressure ratio was 0.95, hence no PCI was performed. Given the large MI size, we administered super saturated oxygen (SSO2). A 5F FR5 catheter was inserted into the LM ostium and SSO2 was administered for 1 hour. An excellent final angiographic result was achieved with TIMI 3 flow and well-expanded stents (Figure 1H). Peak creatinine kinase was 5840 U/l. Magnetic resonance imaging on the next day showed small thrombi, prominent microvascular obstruction in the mid LAD territory, and transmural infarction (Figure 1I). Left ventricular ejection fraction of 39% with normal left ventricular volume. The patient was discharged 3 days later on dual antiplatelet therapy and warfarin and referred to cardiac rehabilitation. Conclusion: “Time is muscle”, hence immediate revascularization is essential. Large anterior STEMIs may benefit from SSO2.

Utilizing the balloon anchoring technique to improve device deliverability during stent revascularization for atherosclerotic renal artery stenosis.

The stent revascularization for severely calcified renal artery lesions can be challenging, due to a deficiency in back-up force provided by the guide catheter. The aim of this report is to describe the use of the balloon anchoring technique to increase device maneuverability and deliverability after the failure of conventional renal artery revascularization. This technique was adopted in a patient with subtotal occlusive and severely calcified lesion in the proximal portion of the right main renal artery. Two guidewires were separately introduced into the proximal side branch (SB) and main branch (MB) of the renal artery. Anchor balloon inflated at low pressure in SB, anchoring the MB-wire and the guide catheter, thus giving us the ability to cross the tight calcified proximal cap of the MB lesion with a non-compliant balloon. After performing pre-dilatations and retrieving the anchor balloon, we implanted a balloon-expandable stent and achieved optimal final angiographic results. The balloon anchoring technique can improve device maneuverability and deliverability during various catheterization procedures. Our report firstly demonstrates how to perform the balloon anchoring technique in renal angioplasty treatment and then explains its effectiveness in revascularization of the renal artery with challenging anatomies.

C27 SHOCKWAVE DEFERRED USE IN A CASE OF INFERIOR STEMI

Abstract A 62–years–old female patient, smoker, hypertension, dyslipidemia and TIA in history, was admitted for inferior STEMI; urgent coronary angiography from radial access was done, revealing diffuse calcific coronary artery disease with thrombotic occlusion of the proximal right coronary artery. Primary PCI was done with a direct implantation of a 3,0/24 mm drug–eluting stent. The stent expansion was not optimal in the mid–portion, due to severe calcification, requiring then post–dilatations. Nevertheless, the use of several non–compliant balloons (3,0/12 mm, 3,0/8 mm, 3,0/6 mm, 3,25/12 mm) was not effective to fully expand the stent, even dilating at very high pressure (rupturing one of the balloon). A ventricular fibrillation episode complicated the procedure, promptly resolved. After the stenting, even if not fully expanded, TIMI 3 flow was gained, with ST segment elevation resolution, in a quite asymptomatic patient; no more devices were available, so the procedure was stopped and the patient transferred in the coronary care unite. A second procedure was scheduled with the support of the intravascular lithotripsy device (Shockwave). Through the radial access the second PCI was done, using at first the Shockwave balloon 2,5/12 mm, with its total 8 treatments; then the Shockwave balloon 3,0/12 mm was used, effective at the seventh treatment in the final rupture of the calcific lesion, obtaining the full expansion of the stent. A good final angiographic result was documented, the patient tolerated very well the procedure.

P61 CORONARY ARTERY ECTASIA: AN ENEMY NOT TO BE UNDERESTIMATED IN ACUTE CORONARY SYNDROME

Abstract Coronary artery ectasia is an abnormal dilatation of coronary arterial segment of at least 1.5 times that of a narrow normal coronary artery. Even if the overall incidence ranges between 4–9% of total angiography, it is correlated with poor outcome due to lower percutaneous procedural success, an higher incidence of no–reflow, distal embolization and stent thrombosis. We present two cases of high risk acute coronary syndrome patients with right coronary artery ectasia and different management in which intravascular ultrasound played a key role in determining interventional strategy. Case #1 : 55–year–old man presented with STEMI after VT–induced cardiac arrest treated with CPR and DC–shock with subsequent ROSC. Coronary angiography showed thrombotic occlusion in the middle tract of the right coronary artery treated with thrombus aspiration and subsequent PTCA + DES from the proximal to the distal tract of the severely ectatic artery with apparent good final angiographic result. However, at the IVUS control performed to verify the possible need for an additional stent in the context of flow turbulence, malapposition of the stent to the proximal–middle tract was highlighted with an important amount of probably thrombotic material between the stent and the vessel wall. Post dilation was therefore performed with NC balloons with IVUS documentation of resolution of the malapposition. Case #2: 59–year–old man hospitalized for NSTEMI. Coronary angiography showed severe left coronary ectasia in the absence of significant stenosis and subocclusive thrombus in the posterolateral branch of the right coronary artery with TIMI 2 flow in the context of diffuse CAE . A conservative strategy was undertaken with DAPT + LMWH due to the absence of symptoms and hemodynamic stability, as well as the associated high embolic risk. A follow–up coronary angiography was performed after one week of therapy with evidence of good recanalization of the branch (TIMI 3). IVUS control showed only minimal thrombotic component adhering to atherosclerotic plaque in the posterolateral branch with a MLA of 11.47 mm2 and a low percentage of stenosis (34.5%). A conservative strategy was therefore undertaken (DAPT 12 months). ACS management in patients with CAE is still challenging and a standardized approach is difficult to please. Strategies should be individualized based on clinical presentation and anatomic characteristics but coronary imaging should be routinely performed in this context.

C80 SUDDEN CARDIAC ARREST IN A YOUNG FOOTBALL PLAYER DUE TO DOCUMENTED SPONTANEOUS CORONARY ARTERY DISSECTION

Abstract A 28–years–old male presented with sudden cardiac arrest (SCA) while playing soccer. He was quickly resuscitated and transported to the closest cardiology department. He had no ECG or echocardiographic alterations. Coronary angiography (CA) showed a spontaneous coronary artery dissection (SCAD), confirmed by optical coherence tomography (OCT), in the mid portion of left anterior descending artery (LADA). In light of his young age, and the lack of evidence of stenosis on angiography confirmed by an instant wave–free ratio (iFR) analysis that confirmed the absence of myocardial ischemia (value obtained 0.97), the patient was treated conservatively with aspirin, clopidogrel, a statin and a beta–blocker. The patient refused implantation of a cardioverter–defibrillator repeatedly. A repeat CA was performed 6–months later, showing same findings and angiographic images of the known lesion involving the LADA. Therefore, the patient was indicated as unsuitable to play soccer. At 1 year from the index event, the patient had an episode of angina pectoris associated with intensive effort and, because of this, another CA with OCT analysis were performed. On angiography the LADA showed a significant stenosis in the same region where spontaneous dissection was previously documented; finding of hyperreflectivity on OCT suggested fibrosis of the vessel wall, probably caused by anomalous immunity reaction mimicking an autoimmune disease; residual intimal–tear representing the entry–site of the dissection was also detected, and a minimal lumen area of 2.21 mm2 was calculated consistent with angiographic stenosis. PCI was indicated, implanting a 3.0/18 mm drug–eluting stent in the mid portion of the LADA, obtaining good final angiographic result and OCT analysis confirming optimal device expansion, without residual dissection. At 2 month post–PCI the patient had returned to playing football without limitation of physical activities. 1 year post–PCI follow–up the patient is still asymptomatic and healthy. In summary, we present a case of SCAD causing an acute coronary syndrome presenting with SCA, which limited subsequent physical activity. In young patients, mostly women, SCAD episode should be strongly considered in the setting of an acute coronary syndrome. Several articles had reported that medical therapy should be oriented on the pathophysiology of SCAD due to the absence of the classic atherosclerotic burst, limiting interventional therapy when strictly indicated.

377 Optimal timing for percutaneous coronary interventions in patients undergoing TAVI

Abstract Aims PCI timing in patients undergoing TAVI is still controversial, with most cases treated before TAVI, because of concerns about potential ischaemic complications during valve replacement. This study aims to compare procedural and in-hospital outcomes in patients undergoing PCI before or after TAVI. Methods and results Patients undergoing TAVI and PCI from 2010 to 2021 at Verona University Hospital were included. High-risk PCI were defined when performed in unprotected left main, proximal left anterior descending, proximal dominant right coronary artery or in 3-vessel disease. The primary endpoint was the cumulative incidence of any TAVI procedural complication and in-hospital adverse events (VARC-3 criteria). 129/940 TAVI patients underwent PCI was performed before TAVI in 33.4% of cases. Most patients (76.4%) were at high-risk. The primary endpoint occurred in 30.2% PCI pre-TAVI vs. 23.3% post-TAVI (HR: 0.72; 95% CI: 0.26–2.86; P = 0.671); and in 37.9% vs. 18.5% respectively, among high-risk PCI (HR: 1.62; 95% CI: 0.86–3.76; P = 0.102). At 24 months, MACCE-free survival was comparable (PCI pre-TAVI 91.7% vs. post-TAVI 97.5%, HR: 0.88, 95% CI: 0.13–4.77, P = 0.765). Conclusions PCI performed after TAVI does not expose patients to higher risks of peri-procedural or long-term complications when compared with pre-TAVI procedures, even in presence of high-risk lesions. 377 FigureAn example of post-TAVI high risk PCI. Pre-TAVI coronary angiography showed ostial left main critical lesion (A). After Symetis Aortic valve deployment, balloon angioplasty and stent implantation were performed (B and C) with good final angiographic result (D).

Direct Wire Pacing for Challenging Left Main Stenting: An Old Technique Revived.

During stent positioning after predilating with a non-compliant balloon, we observed major motion of our device in the left main coronary artery. Under those conditions, accurate stent placement was uncertain. To remedy this situation, we decided to perform a rapid direct wire pacing with a good final angiographic result.

Hazy lesion in a ventricular tachycardia patient: stents or drugs?

Intravascular ultrasound (IVUS) is superior to coronary angiographyin guiding and optimizing complicated PCI. Here we report a successful treatment of a patient with ventricular tachycardia induced by treadmill test. Coronary angiography showed a hazy lesion in left anterior descending artery. IVUS revealed a 73% segment stenosis in the proximal segment of the LAD. Finally, a 3.5*21 mm drug eluting stent was implanted in the LAD and an excellent final angiographic result was achieved.

Comparison of Long-Term Angiographic Results of Wide-Necked Intracranial Aneurysms : Endovascular Treatment with Single-Microcatheter Coiling, Double-Microcatheter Coiling, and Stent-Assisted Coiling.

ObjectiveEndovascular treatment of intracranial aneurysms is challenging in case of wide-necked aneurysms because coils are prone to herniate into the parent artery, causing thromboembolic events or vessel occlusion. This study aims to compare long-term angiographic results of wide-necked aneurysms treated by stent-assisted, double-microcatheter, or single-microcatheter groups. MethodsBetween January 2003 and October 2016, 108 aneurysms that were treated with endovascular coil embolization with a neck size wider than 4 mm and a follow-up period of more than 3 years were selected. We performed coil embolization with single-microcatheter, double-microcatheter, and stent-assisted techniques. Angiographic results were evaluated using the Raymond-Roy occlusion classification (RROC). All medical and angiographic records were reviewed retrospectively. ResultsClinical and angiographic analyses were conducted in 108 wide-necked aneurysms. The immediate post-procedural results revealed RROC class I (complete occlusion) in 66 cases (61.1%), class II (residual neck) in 36 cases (33.3%), and class III (residual sac) in six cases (5.6%). The final follow-up results revealed class I in 48 cases (44.4%), class II in 49 cases (45.4%), and class III in 11 cases (10.2%). Of a total of 45 (41.6%) radiologic recurrences, there were 21 cases (19.4%) of major recurrence that required additional treatment, and 24 cases (22.2%) of minor recurrence. The final follow-up angiographic results showed statistically significant differences between the stent-assisted group and the others (p<0.01). ConclusionLong-term follow-up angiography demonstrated that the stent-assisted technique had a better complete occlusion rate than the other two techniques.

Simple Provisional Stenting or two-stent Strategies to Treat Anomalous Right Coronary Originating from the mid of left Anterior Descending Coronary Artery

Congenital anomalies of coronary arteries (CAAS) are very rare and usually documented as an incidental finding during routine catheter or CT angiograms performed for other reasons. Their prevalence ranges from 0.2% to 1.3% based published series. The most common coronary artery anomaly is origination of the left circumflex coronary (LCX) artery from the proximal of right coronary artery (RCA) or right sinus of Valsalva. The second is separate origination of the left anterior descending coronary artery (LAD) and LCX artery from the left sinus of Valsalva. Herein, we present three cases that the anomalous RCA arises from the mid of left anterior descending coronary artery (LAD). The bifurcation lesions of first case was treated using two-stent strategies of DK culotte, excellent angiography results was observed. The last two cases were treated using simple provisional stenting strategy: one stent was deployed crossover the ostium of the anomalous coronary artery, final angiographic results were excellent. These cases are extremely rare. We bring forth them in an attempt to highlight their significance, and make cardiologist to understand what important the anomalies are, and the strategy how to treatment these bifurcation lesions.

Mid-Term Results of Endovascular Aneurysm Sealing in the Treatment of Abdominal Aortic Aneurysm With Unfavorable Morphology.

To report mid-term results of endovascular aneurysm sealing (EVAS) of abdominal aortic aneurysms (AAA) deemed unsuitable for a standard endovascular aneurysm repair (EVAR). A prospectively maintained database of 42 patients with EVAR-unfavorable anatomy treated by EVAS combined with chimney grafts in case of the proximal AAA neck shorter than 5 mm was analyzed. Early outcomes included final angiographic result, intra- and early post-operative deaths, and complications. Mid-term outcomes included all-cause mortality (ACM), aneurysm-related mortality (ARM), patency of the stents, occurrence of endoleaks, serious complications and graft failures defined as the AAA growth of more than 5 mm, type I endoleak, occlusion of the stent-graft or chimney graft, aorto-duodenal fistula, or aneurysm rupture. The procedure was completed in all patients. Twenty-eight chimney grafts were implanted in 19 patients. Patients were followed for a median of 24 months (range 12-34 months). There were 2 intraoperative ruptures and 1 patient died in an early postoperative period. The cumulative ACM was 15, 21, and 36% at 12, 24, and 36 months, respectively, and the cumulative ARM was 8, 11, and 27% at 12, 24, and 36 months, respectively. Three out of 5 aneurysm-related deaths were due to a secondary aorto-duodenal fistula. The cumulative incidence of graft failure was 20, 27, and 42% at 12, 24, and 36 months, respectively. The cumulative incidence of an endoleak was 5, 9, and 23% at 12, 24, and 36 months, respectively. The graft failure increased significantly both ACM (p = .012) and ARM (p = .00003). The implantation of chimney grafts at the initial procedure increased ARM significantly (p = .008). The presence of an endoleak did not have any significant influence on ACM and ARM. Patients treated with EVAS for AAAs with EVAR-unfavorable anatomy, especially those with chimney grafts, exhibit a high risk of graft failure and subsequent death.

Thrombolysis in Cerebral Infarction 2b Reperfusions: To Treat or to Stop?

In patients undergoing mechanical thrombectomy, achieving complete (Thrombolysis in Cerebral Infarction 3) rather than incomplete successful reperfusion (Thrombolysis in Cerebral Infarction 2b) is associated with better functional outcome. Despite technical improvements, incomplete reperfusion remains the final angiographic result in 40% of patients according to recent trials. As most incomplete reperfusions are caused by distal vessel occlusions, they are potentially amenable to rescue strategies. While observational data suggest a net benefit of up to 20% in functional independence of incomplete versus complete reperfusions, the net benefit of secondary improvement from Thrombolysis in Cerebral Infarction 2b to 3 reperfusion might differ due to lengthier procedures and delayed reperfusion. Current strategies to tackle distal vessel occlusions consist of distal (microcatheter) aspiration, small adjustable stent retrievers, and administration of intra-arterial thrombolytics. While there are promising reports evaluating those techniques, all available studies show relevant limitations in terms of selection bias, single-center design, or nonconsecutive patient inclusion. Besides an assessment of risks associated with rescue maneuvers, we advocate that the decision-making process should also include a consideration of potential outcomes if complete reperfusion would successfully be achieved. These include (1) a futile angiographic improvement (hypoperfused territory is already infarcted), (2) an unnecessary angiographic improvement (the patient would not have developed infarction if no rescue maneuver was performed), and (3) a successful rescue maneuver with clinical benefit. Currently there is paucity of data on how these scenarios can be predicted and the decision whether to treat or to stop in a patient with incomplete reperfusion involves many unknowns. To advance the status quo, we outline current knowledge gaps and avenues of potential research regarding this clinically important question.