High Procedural Success Rate Research Articles

Endovascular treatment of aortic coarctation using covered balloon-expandable stents-a systematic review and meta-analysis.

Balloon dilation followed by balloon-expandable stent implantation is an effective treatment for improving hemodynamic status in patients with coarctation of the aorta (CoA). However, limited evidence exists regarding the safety and efficacy of covered balloon-expandable stents (CBSs) in a large cohort. In this meta-analysis, we aimed to evaluate the overall success rates, hemodynamic and anatomical benefits, complications, and mid-term results of CBSs in treating CoA. The PubMed, Embase, and Cochrane Library databases were systemically searched for studies reporting outcomes of CBSs in treating CoA. Single-group rate meta-analyses were performed to calculate estimated pooled procedural success rates, the incidence of complications, and re-coarctation rates. A meta-analysis using standardized mean differences was conducted to compare pre- and postoperative trans-coarctation pressure gradients (PGs), coarctation diameter, and overall changes in systolic blood pressure (SBP). Subgroup analyses were performed to identify potential sources of heterogeneity. The final analysis included 12 studies with a total of 411 patients. The estimated pooled procedural success rate was 100% [95% confidence interval (CI): 98%-100%, I2 = 0, P = 0.78]. Significant decreases in trans-coarctation PGs and SBP were observed. The pooled incidences of stent-related, aortic, and access site complications were 2% (95% CI: 0%-5%, I 2 = 30.4%, P = 0.15), 2% (95% CI: 0%-4%, I 2 = 0%, P = 0.76), and 3% (95% CI: 1%-7%, I 2 = 52.9%, P = 0.02), respectively. Subgroup analyses showed that implantation of BeGraft stents was related to a significantly higher incidence of access site complications. Covered balloon-expandable stent implantation in treating CoA is safe and effective with high procedural success rates, an acceptable incidence of complications, and a low incidence of re-coarctation. https://www.crd.york.ac.uk/PROSPERO/, PROSPERO (CRD42023430356).

Fluoroscopy-free cardioneuroablation for functional bradycardia: a single-center experience.

Cardioneuroablation (CNA) is an emerging treatment for cardioinhibitory syncope and functional AV block. This study aimed to evaluate the safety and efficacy of a fluoroless CNA approach using three-dimensional mapping and extracardiac vagal stimulation (ECVS). This prospective observational study included 22 patients (mean age 21years) with clinically significant functional bradycardia who underwent fluoroless CNA. Procedural success was defined as elimination or significant attenuation of the vagal response to ECVS. CNA was successfully performed in all patients with a mean procedure time of 251min. Fluoroscopy was avoided in 91% of cases. At a mean follow-up of 11.4months, 77% of patients remained symptom-free. Among pacemaker patients, 90% did not require further pacing, and 6/10 (60%) have had their pacemakers turned off. No complications were seen during the procedure. Fluoroscopy-free CNA is a safe and effective treatment for functional bradycardia, offering high procedural success rates and favorable symptom-free outcomes while minimizing radiation exposure.

CLINICAL AND ANGIOGRAPHIC OUTCOMES OF PERCUTANEOUS CORONARY INTERVENTION IN CHRONIC TOTAL OCCLUSION PATIENTS: A RETROSPECTIVE STUDY AT A TERTIARY CARE HOSPITAL

Chronic total occlusion (CTO) presents a unique challenge in percutaneous coronary intervention (PCI), requiring specialised techniques to achieve successful revascularisation. Despite the complexity, PCI in CTO cases has evolved significantly, showing promising outcomes. Objectives: To assess percutaneous coronary intervention's clinical and angiographic outcomes in chronic total occlusion patients. Methods: This retrospective observational study was conducted at NICVD Karachi, Pakistan, following approval from the hospital's ethical committee. It reviewed the medical records of 150 patients who underwent percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) from January 2024 to July 2024. Data was collected retrospectively from electronic medical records, including demographic details (age, gender, cardiovascular risk factors, and comorbidities), baseline clinical characteristics (presentation, symptoms, angina status, and prior cardiac history), and angiographic data (pre- and post-procedural findings, including the Thrombolysis in Myocardial Infarction (TIMI) flow grade). Clinical outcomes were assessed for both short-term and long-term results, including major adverse cardiac events (MACE) such as myocardial infarction, repeat revascularisation, target lesion revascularisation, and all-cause mortality. Statistical analysis was performed using SPSS Version 25. Results: 150 patients were enrolled, with a mean age of 54.81±8.97 years. The cohort included 54.7% males (82 patients) and 45.3% females (68 patients). Before PCI, 87.3% of patients (131) had no blood flow in the occluded artery, while 12.7% (19) had minimal flow. Post-PCI, 91.3% (137 patients) achieved full blood flow (TIMI Flow Grade 3), and 8.7% (13 patients) had partial flow. The procedural success rate was 91.3%. In terms of short-term major adverse cardiac events (MACE), 116(77.3%) patients had no events, while 22.7% (34 patients) experienced a myocardial infarction (MI). For long-term MACE, 84.0% (126 patients) had no adverse events, 10.0% (15 patients) required target lesion revascularisation, 4.7% (7 patients) underwent repeat revascularisation, and 1.3% (2 patients) experienced mortality. Conclusion: This study confirms the efficacy and safety of PCI for CTO patients, demonstrating high procedural success rates, significant clinical improvements, and relatively low long-term adverse events. However, advancing procedural techniques and fostering specialised training are essential to enhance patient outcomes due to the risks and complexities involved. Further research, including large-scale randomised controlled trials, is needed to validate these results and refine patient selection and management strategies for CTO PCI.

Practices and outcomes of rotational atherectomy in China: The Rota China registry.

Rotational atherectomy (RA) remains an integral tool for the treatment of severe coronary calcified lesions despite emergence of newer techniques. We aimed to evaluate the contemporary clinical practices and outcomes of RA in China. The Rota China Registry (NCT03806621) was an investigator-initiated, prospective, multicenter registry based on China Rota Elite Group. Consecutive patients treated with RA were recruited. A pre-designed, standardized protocol was recommended for the RA procedure. The primary safety endpoint was major adverse cardiovascular events (MACE: composite of cardiac death, myocardial infarction, or ischemia-driven target lesion revascularization) at 30 days. The primary efficacy endpoint was procedural success. Between July 2018 and December 2020, 980 patients were enrolled at 19 sites in China. Mean patient age was 68.4 years, and 61.4% were men. Radial access was used in 79.1% patients, and 32.7% procedures were guided by intravascular imaging. A total of 22.6% procedures used more than 1 burr, and the maximal burr size was ≥1.75 mm in 24.4% cases, with burr upsizing in 19.3% cases, achieving a final burr-to-artery ratio of 0.52. Procedural success was achieved in 91.1% of patients, and the rate of 30-day and 1-year MACE was 4.9% and 8.2%, respectively. Multivariable analysis identified the total lesion length (HR 1.014, 95% CI: 1.002-1.027; p = 0.021) as predictor of 30-day MACE, and renal insufficiency (HR 1.916, 95% CI: 1.073-3.420; p = 0.028) as predictor of 1-year MACE. In this contemporary prospective registry in China, the use of RA was effective in achieving high procedural success rate with good short- and long-term outcomes in patients with severely calcified lesions.

Feasibility and Effectiveness of Venoarterial Extracorporeal Membrane Oxygenation Plus Intra-Aortic Balloon Pump Assisted High-Risk Percutaneous Coronary Intervention in Complex Coronary Disease.

Mechanical circulatory support may facilitate high-risk percutaneous coronary intervention (PCI). This study aimed to assess the feasibility, safety and effectiveness of high-risk PCI under the support of venoarterial extracorporeal membrane oxygenation (VA-ECMO) combined with intra-aortic balloon pump (IABP). We enrolled patients who received VA-ECMO plus IABP-assisted PCI procedures at our center from April 2012 to June 2018. Major adverse cardiac events (MACEs) included all-cause death, myocardial infarction, and target vessel revascularization. A total of 10 patients were included, with a mean age of 71 years, EuroSCORE II of 19.9%, and SYNTAX score of 39.8. Procedural success was achieved in nine (90%) patients. The mean duration of ECMO support was 1.5 hours, and 2.6 stents were implanted per patient. Major complications included contrast-induced nephropathy needing hemodialysis in one (10%) patient, significant hemoglobin drop requiring blood transfusion in two (20%) patients, pulmonary infection in one (10%) patient, and local surgical incision infection in one (10%) patient. The accumulative mortality rates for the nine patients with procedural success were 0, 22.2%, and 44.4% at 1, 3, and 5 years follow-up, respectively. However, cardiac death occurred in only one (11.1%) patient. In addition, two patients received repeat PCI or coronary artery bypass grafting within two years following the index procedure. The overall incidence rates of MACEs were 11.1%, 44.4%, and 66.7% at 1, 3, and 5 years follow-up, respectively. VA-ECMO plus IABP-assisted high-risk PCI was feasible in patients with complex coronary disease, with a high procedural success rate and acceptable mid-term clinical outcomes.

Percutaneous Extraction of Transvenous Permanent Pacemaker/Defibrillator Leads-A Single-Center Experience.

Background and Objectives: The number of cardiac pacemakers being used has increased in recent decades, and this increase has led to a rise in device-related complications, requiring percutaneous device extraction. Our aim was to present our single-center clinical experience in percutaneous lead extractions. Materials and Methods: We analyzed an observational retrospective cohort study of 93 patients for the transvenous removal of a total of 163 endocardial leads. We evaluated the device details, indications, lead characteristics, extraction methods, complications, reimplantation procedure, follow-up data, effectiveness, and safety. Results: Patients' mean age was 68.6 ± 11.6 years. Lead extraction indications were pocket infection in 33 (35.5%), lead dysfunction in 33 (35.5%), and system upgrade in 21 (23%) cases, and lead endocarditis in 6 (6%) cases. The duration from implantation to extraction time was a detected median of 43 (24-87) months. The most common retracted lead type was the RV defibrillator lead (62%), and the lead fixation type was active for one hundred (61%) patients. A new device was inserted in 74 (80%) patients, and the device type was most commonly a CRT-D (61%). Patients were followed up at a median of 17 (8-36) months, and 18 patients (19%) died at follow-up. Complete procedural success was obtained in 78 (84%) patients, and clinical procedural success was obtained in 83 (89%) patients. Procedural failure was detected in 15 (16%) patients. Major and minor complications were detected in 10 (11%) and 6 (6.5%) patients, respectively. The most common minor complication was pocket hematoma. Conclusions: Our experience suggests that transvenous lead extraction has a high success rate with an acceptable risk of procedural complications. The simple manual traction method has a high rate of procedural success, despite a high dwell time of the lead.

Clinical Outcomes of Non–Stent-Based Interventions for Symptomatic Below-the-Knee Peripheral Artery Disease in the Excellence in Peripheral Artery Disease (XLPAD) Registry

BackgroundFor endovascular treatment of below-the-knee (BTK) peripheral artery disease (PAD), independently adjudicated real-world outcomes comparing non-stent (balloon angioplasty or PTA and adjunctive treatment) with or without a concomitant ipsilateral femoropopliteal (FP) artery intervention are scarce. Methods1060 patients from the multicenter XLPAD Registry between 2006-2021 with non-stent based BTK PAD intervention are included. Primary outcome: 1-year incidence of major adverse limb events (MALE), a composite of all-cause death, any amputation, or clinically driven repeat revascularization. Results566 patients underwent BTK and 494 BTK + FP interventions; 72% men, with mean age 68.4 ± 10.9 years. Diabetes mellitus is more prevalent in BTK only group (76.5% vs. 69%, p=0.006). Mean Rutherford class 4.2 ± 1.18; chronic limb threatening ischemia is more frequent in the BTK group (55.3% vs. 49%, p=0.040). Moderate to severe calcification is higher in BTK + FP (21.2% vs. 27.1%, p=0.024), so is lesion length (110.6 ± 77.3 vs. 135.4 ± 86.3 mm; p<0.001). Nearly, 81% lesions are treated with PTA. DCB (1.6% vs 14%, p<0.001) and atherectomy (38% vs. 58.5%; p<0.001) use is greater in BTK + FP. Procedural success is higher in BTK + FP group (86% vs. 91%, p=0.009), with amputation being the most common complication at 3.3% ≤30 days. One-year MALE (21.2% vs. 22.3%, p=0.675) and mortality (4.6% vs. 3.4%; p=0.3) are similar across BTK and BTK + FP groups. ConclusionNon-stent treatment for BTK PAD with concomitant FP intervention leads to high procedural success and similar rates of 1-year MALE compared with isolated BTK intervention. Condensed abstractThe vast majority of below-the-knee (BTK) peripheral artery disease (PAD) interventions are performed with balloon angioplasty. Presence of inflow femoropopliteal (FP) PAD in patients undergoing BTK interventions can affect the outcome of the procedure. This report explores the immediate procedural success and major adverse limb events at 1 year following balloon angioplasty treatment for isolated BTK and in those undergoing an additional FP PAD intervention.

Combined Use of MITRACLIP and Ventricular ASSIST Devices in Cardiogenic Shock: MITRA-ASSIST Registry.

Background: Patients with cardiogenic shock (CS) and mitral regurgitation (MI) have a prohibitive risk that contraindicates surgical treatment. Although the feasibility of transcatheter edge-to-edge therapy (TEER) has been demonstrated in this setting, the benefit of the combined use of TEER with mechanical circulatory support devices (MCS) has not been studied. The aim of this study was to evaluate the clinical outcomes of TEER in patients with MCS. Methods: The MITRA-ASSIST study is a retrospective multicentre Spanish registry that included patients with MR and CS who underwent TEER in combination with MCS. The primary endpoint was death from any cause at 12 months. The secondary endpoint was a composite of death from any cause or hospitalisation for heart failure at 12 months. Results: A total of twenty-four patients in nine high-volume Spanish centres (66.2 (51-82) years, 70.8% female, EuroSCORE II 20.4 ± 17.8) were included. Acute ST-elevation myocardial infarction was the main CS aetiology (56%), and the most implanted MCS was the intra-aortic balloon pump (82.6%), followed by ECMO (8.7%), IMPELLACP® (4.3%), or a combination of both (4.3%). Procedural success was 95.8%, with 87.5% in-hospital survival. At 12-month follow-up, 25.0% of patients died, and 33.3% had a composite event of death from any cause or hospitalisation for heart failure. Conclusions: TEER in patients with concomitant CS and MR who require MCS appears to be a promising therapeutic alternative with a high device procedural success rate and acceptable mortality and heart failure readmission rates at follow-up.

Contemporary Trends and Outcomes of Intravascular Lithotripsy in Percutaneous Coronary Intervention: Insights From BMC2

BackgroundWith an aging population and an increase in the comorbidity burden of patients undergoing percutaneous coronary intervention (PCI), the management of coronary calcification for optimal PCI is critical in contemporary practice. ObjectivesThis study sought to examine the trends and outcomes of coronary intravascular lithotripsy (IVL), rotational/orbital atherectomy, or both among patients who underwent PCI in Michigan. MethodsWe included all PCIs between January 1, 2021, and June 30, 2022, performed at 48 Michigan hospitals. Outcomes included in-hospital major adverse cardiac events (MACEs) and procedural success. ResultsIVL was used in 1,090 patients (2.57%), atherectomy was used in 1,743 (4.10%) patients, and both were used in 240 patients (0.57% of all PCIs). IVL use increased from 0.04% of PCI cases in January 2021 to 4.28% of cases in June 2022, ultimately exceeding the rate of atherectomy use. The rate of MACEs (4.3% vs 5.4%; P = 0.23) and procedural success (89.4% vs 89.1%; P = 0.88) were similar among patients treated with IVL compared with atherectomy, respectively. Only 15.6% of patients treated with IVL in contemporary practice were similar to the population enrolled in the pivotal IVL trials. Among such patients (n = 169), the rate of MACEs (0.0%) and procedural success (94.7%) were similar to the outcomes reported in the pivotal IVL trials. ConclusionsSince its introduction in February 2021, coronary IVL use has steadily increased, exceeding atherectomy use in Michigan by February 2022. Contemporary use of IVL and atherectomy is generally associated with high rates of procedural success and low rates of complications.

Contrast-enhanced excimer laser stepwise approach during PCI for resistant coronary lesions.

The treatment of resistant coronary lesions (RCL) is a great challenge for interventional cardiologists. The excimer laser coronary atherectomy (ELCA) is a plaque modification tool based on a main mechanism of photomechanical effect leading to mechanical disruption of the plaque. Contrast dye injection during laser delivery has demonstrated to enhance its power. To evaluate the effectiveness and safety of the contrast-enhanced ELCA by a stepwise approach in the treatment of RCLs. We retrospectively examined consecutive patients undergoing contrast-enhanced ELCA-assisted PCI between 2018 and 2021 at two Italian sites. RCLs were defined as novo or in-stent undilatable/uncrossable with conventional balloons (SC/NC balloon). The primary endpoint was ELCA technical success defined as the laser catheter crossing the entire length of the target lesion established by angiographic evidence of the catheter tip in the artery distal to the stenosis. We enrolled 114 patients who underwent contrast-enhanced ELCA-assisted PCI: 58% of the patients had acute coronary syndrome while the left anterior descending artery was the target vessel in 42.1% of cases. The target lesion was most commonly in-stent (56.2%). The 0.9 mm ELCA catheter tip was employed in 89.5% of cases. The most used frequency/fluency profile was 70/70 (39.5%). The use of contrast-enhanced ELCA was associated with high technical, procedural, and clinical success rates (97.4%, 93.7%, and 90.1%, respectively). The contrast-enhanced ELCA seems to be a safe and effective treatment option for the management of both de novo and in-stent-resistant coronary lesions.

Same-day discharge after percutaneous closure of persistent foramen ovale using intracardiac echocardiography and the Gore Septal Occluder.

Periprocedural and postinterventional care of patients undergoing closure of patent foramen ovale (PFO) varies significantly across care providers. Same-day discharge (SDD) after transcatheter interventions is an evolving concept. This study aimed to assess the same-day discharge rate and incidence of complications in patients undergoing PFO closure with intracardiac echocardiography (ICE) using the Gore®Cardioform Septal Occluder (GSO) device. The secondary aim was to analyse the efficacy of femoral vein closure with Perclose ProGlide. Patients who underwent PFO closure with the GSO device at a university hospital in Stockholm, Sweden, were retrospectively included between March 1, 2017, and June 30, 2020, all with cryptogenic stroke as the indication for the procedure. All patients underwent PFO closure with conscious sedation and local anaesthesia. The indication for all patients was a cryptogenic stroke. Periprocedural imaging was performed using ICE and fluoroscopy in all patients. Patient characteristics and periprocedural data were collected from patient charts. Patients were kept on bed rest for 4-6 h post-intervention. Transthoracic echocardiography and clinical examination, including groin status, were performed before discharge. No clinical routine follow-up was performed the day following the intervention. Clinical follow-up was done by phone call two weeks after the procedure, and echocardiographic follow-up was done after 12 months. Data were analysed using linear and logistic regression models. In total, 262 patients were included, of which 246 (94%) had SDD. 166 patients (63%) received the ProGlide™ system for femoral vein access closure. Post-procedural arrhythmias occurred in 17 (6%) patients, and vascular complications in 9 patients (3%). The overall closure rate at follow-up was 98.5%. 25 out of 264 patients (9.5%) had to be readmitted within the first eight weeks after PFO closure, 16 due to atrial fibrillation warranting electric cardioversion, one due to an arteriovenous fistula that was operated, four due to chest pain/pain at the access site, and four patients developed fever. There was no difference in SDD among patients who received ProGlide™ vs. patients who did not receive ProGlide™. SDD appears safe after transcatheter PFO closure with the GSO device with high procedural success rates. Low rates of complications and readmissions make the intervention suitable for this patient-friendly and cost-effective concept.

Intravascular Lithotripsy for Treatment of Severely Calcified Common Femoral Artery Disease: Results From the Disrupt PAD III Observational Study.

Surgical endarterectomy is currently considered the front-line therapy for the treatment of calcified lesions in the common femoral artery (CFA). Endovascular interventions have evolved, and their use is increasing in frequency. Intravascular lithotripsy (IVL) has shown promising safety and effectiveness in calcified CFA lesions in a small pilot study, but "real-world" evidence from a larger cohort is lacking. The Disrupt PAD III Observational Study (NCT02923193) was a prospective, multicenter registry designed to assess the acute safety and effectiveness of IVL treatment for calcified peripheral arterial disease. Any concomitant treatment with other calcium-modifying technologies as well as definitive treatment strategies was at the discretion of the operators. Patients with CFA lesions were evaluated for acute angiographic safety and effectiveness outcomes following IVL treatment as determined by an independent angiographic core lab. Common femoral artery treatment was indicated in 177 patients (n=163 could be analyzed based on core-laboratory data) enrolled at 23 sites. Characteristics for 164 treated lesions included moderate-severe calcification 95.1%, diameter stenosis 74.8±17.7%, and lesion length 53.6±53.1 mm. Concomitant calcium-modifying therapy was used in 32.3% of lesions. Final therapy included drug-coated balloons in 68.9% and stenting in 16.5% of lesions. Post-IVL and final residual stenoses were 29.2±16.5%and 23.6±11.5%, respectively. No vascular complications (flow-limiting dissections, perforations, embolization, slow or no reflow, or abrupt closure) were present at the end of the procedure by core-laboratory assessment, with 1 (0.8%) flow-limiting dissection initially occurring immediately following IVL treatment. This study represents the largest real-world experience of IVL treatment in heavily calcified CFA lesions. Intravascular lithotripsy treatment showed significant stenosis reduction and favorable periprocedural safety in this challenging patient population. In this study we show that calcified common femoral artery disease can be safely and effectively treated with shockwave balloon angioplasty with high procedural success and low complication rates and in clinical practice can now be offered as an alternative to surgical treatment in those patients reluctant to or high risk for vascular surgery. This opens another option for clinicians to treat calcified common femoral artery disease without the risk of dissection, perforation or distal embolization that are associated with atherectomy. This study shows that shockwave lithoplasty offers an innovative plaque modification technology to tackle calcified disease in the common femoral artery.

Impact of successful antegrade and retrograde CTO PCI on short-term prognosis

BackgroundChronic total occlusion (CTO) percutaneous coronary intervention (PCI) carries risk of complications and should be attempted when the anticipated benefits exceed the potential risks. The primary indication for CTO–PCI is symptom improvement. However, the impact of CTO–PCI on angina and subsequent incidence of major adverse cardiovascular event (MACE) rate remains controversial. Our aim was to study the impact of technically successful elective CTO–PCI on the procedural success rate and short-term MACE. The current study was a prospective cohort study that included a total of 80 patients who were referred to our center (Ain Shams University Hospitals) for elective CTO–PCI and underwent technically successful CTO–PCI. Data were collected on patient arrival to our department, and then, the patients were observed during hospital admission to record any In-Hospital MACE. These patients were then followed up for 6 months to record improvement or worsening of their symptoms and to assess occurrence of any MACE including hospitalization and undergoing symptom-driven coronary angiography.ResultsThe mean age of our patients was 56 ± 9.6 years, and 73 patients (91%) were men. Sixty-two patients (77.5%) were done via an antegrade approach, and 18 patients (22.5%) were done via a retrograde approach with an overall procedural success rate of 91.25% (antegrade 93.5%, retrograde 83.3%). The overall mean procedure time was 102 min, the mean contrast volume used was 371 ml, and the mean cumulative air kerma dose was 7.2 Gy. The retrograde group required longer procedure times, larger volumes of contrast and higher exposure to radiation. The overall in-hospital MACE was 8.75%. Sixty-five patients in our study (81.25%) showed an improvement in the grade of their exertional dyspnea or angina within the 6-month follow-up period. Thirteen patients in our study (16.25%) needed re-hospitalization within a 6-month period after PCI. The overall target lesion revascularization rate at 6 months was 8.75%.ConclusionsTechnically successful CTO PCI in a well-equipped center with highly qualified CTO operators resulted in high procedural success rates and low incidence of short-term MACE.

Efficacy of retrograde revascularization in diabetic patients with chronic limb-threatening ischemia after a failed antegrade approach.

Chronic limb-threatening ischemia is the end stage of peripheral arterial disease. The revascularization of patients suffering from diabetes mellitus who present chronic total occlusions of below-the-knee vessels can be technically very difficult and sometimes impossible to achieve by performing only an antegrade approach. As regards retrograde recanalization, several studies have investigated the efficacy and safety of this technique in the femoropopliteal axis or in the infrageniculate arterial vessels in patients with advanced atherosclerotic disease. Currently in the literature there are still few studies analyzing the effectiveness of the retrograde approach in the treatment of occlusions of below-the-knee vessels in patients suffering from diabetes mellitus. The purpose of the study was to retrospectively evaluate safety, technical success, and clinical outcome of retrograde transpedal/transtibial recanalization in patients suffering from diabetes mellitus. This is a retrospective observational monocentric study. We retrospectively analyzed data over a three-year period (August 2019-September 2022) of patients that underwent revascularization of one or more below-the-knee vessels for chronic limb-threatening ischemia and had a retrograde transpedal/transtibial approach after a failed antegrade transfemoral revascularization. We identified and included in the study 28 out of 352 patients. We evaluated clinical comorbidities, Rutherford-Becker classification, Texas classification, and the occluded vessels (only below-the-knee or multi-level occlusions); we then analyzed technical, procedural and clinical success, survival rate, and procedural complications. All patients included in the study underwent a 6 months follow-up. Patients belonged to Rutherford-Becker stage V (18) or VI (10), Texas wound classification IIC: 7 IID: 8 IIIC: 4 IIID: 9, all suffering from diabetes, and five were on dialysis. Treatment of a femoropopliteal lesion was performed during the same procedure in 6 of 28 patients (28.6%). Technical success was obtained in 25 out of 28 patients (89.3%), and procedural success was achieved in 23 of 28 patients (82.1%). No complications occurred at the pedal/tibial access. One minor complication at the femoral access was observed. The cure rate 6 months after the procedure was 57.1% (16/28 patients), and the 6-month survival rate was 96.4%. Three major amputations (10.7%) and four minor amputations (14.2%) were performed after revascularization procedures. Two patients were readmitted for vascular causes (7.1%). Retrograde approach for revascularization of below-the-knee vessels in diabetic patients is safe and effective with high procedural and clinical success rates in the absence of significant complications. It should be considered when revascularization cannot be achieved with an antegrade transfemoral approach.

Removal of spontaneously fractured leads with their proximal ends in the heart and vasculature -experience among 3847 lead extraction procedures

Abstract Background Spontaneous fractures and insulation breaks of the intracardiac leads near their entry into the venous system cause the proximal end of the fractured lead slide into the veins, with potential subsequent looping in the heart and secondary complications. So far, this topic has not been extensively studied. As it is a relatively uncommon finding, it has been described in a few number of case studies only. The aim of the study was to describe the phenomenon of leads migrated proximal end (LMPEs) into the cardiovascular system and techniques for such leads removal. Methods Retrospective analysis of 3847 transvenous lead extractions (TLE). Results Over a 17-year period 72 (1.87%) leads with migrated proximal ends (LMPEs) (mean dwell time 148.0 months) were extracted, mainly ventricular leads (56.94%). Overall, 68.06% of MPLEs had their cut proximal ends located in the venous system. Most of them were pacing (95.83%) and passive fixation (98.61%) leads. Independent risk factors for LMPEs included abandoned leads (OR=8.473; p&amp;lt;0.001) and leads on both sides of the chest (2.981; p=0.045). Higher NYHA class lowered the probability of leads with migrated proximal ends (LMPEs) (OR=0.380; p&amp;lt;0.001). Extraction complexity was higher in the MPLE group than in remained patients. Femoral approach was most often used (62.50%), contrary to superior (23.61%) and combined approach (11.11%). Lead dilatation was necessary in 80.56%, and grasping and traction was effective in 18.06%. In 66.7%, the proximal end was strongly attached to the wall and a pulling loop had to be applied. In 15.28% of procedures the lead was wrapped around a pig-tail catheter ("spaghetti twisting technique"), which was sometimes sufficient to free the lead end. This manoeuvre was especially helpful in releasing the leads with their tip in the distal branch of the pulmonary artery. All these manoeuvres were performed from the femoral or superior approach, depending on the anatomical conditions. Extraction of MPLEs did not influence long-term survival. The rate of major complications was 2.78% but it may be attributed to long implant duration (152.2 months) and were not the result of extraction of LMPEs. Conclusions 1. Extraction of leads with migrated proximal ends (LMPEs) is rare among other TLE procedures (1.9%), 2. Risk factors include abandoned leads and presence of leads on both sides of the chest. 3. Complexity of LMPEs extraction is higher as regards procedure duration, unexpected procedure difficulties, use of advanced tools and techniques but rates of major complications are comparable to other leads but in spite of a high level of procedure complexity its effectiveness is also high (procedural success rate 93.06%) with an acceptable rate of major complications. 4. Extraction of LMPEs did not influence long-term survival.

Long-term outcome after catheter ablation for fascicular ventricular tachycardia in a single high-volume center in Germany

Abstract Background Idiopathic Fascicular Ventricular Tachycardia (IFVT) accounts for less than 10% of all VTs and represents the most common idiopathic ventricular tachycardia of the left ventricle. This study reports on clinical and procedural characteristics and the long-term outcome of patients undergoing catheter ablation of premature ventricular complexes (PVC) and ventricular tachycardias (VTs) arising in proximity of the left ventricular conduction system. Methods and results This study includes 27 patients (17 male, 45 ± 17 years; 10 females, 50 ± 11 years) who underwent electrophysiological examinations at a tertiary ablation center over a period of 14 years (2009 to 2022). Follow-up was performed via regular Holter-ECGs and clinical evaluations, or via structured follow-up within the prospective TRUST registry. In 21/27 patients (77.8%), the left posterior fascicle (LPF) was involved in the IFVT. In 4 (14.8%) the left anterior fascicle (LAF) was involved and in 2 (7.4%) patients an origin in the upper septal (US) area was demonstrated. 22/27 (81.5%) patients had a preserved left ventricular ejection fraction (LVEF) and only 5 (18.5%) patients had a LVEF less than 50% at the time of presentation. 14/27 (51.9%) patients presented with PVC or non-sustained VTs with the following distribution: 10 (71.4%) originating from the LPF, 3 (21.4%) from the LAF and 1 (7.1%) from the US. 21/27 (77.8%) patients presented with sustained VTs: 16 (76.2%) arising from the LPF, 4 (19%) from the LAF and 1 (4.8%) from the US. However, only 2 (7.4%) patients presented in sustained VT at the beginning of the EP procedure. In 16 (59.3%) patients a sustained VT was induced during the EP study via isoprenaline and/or programmed ventricular stimulation. Mean QRS duration of the VT was 124.5 ± 14.6 msec. In 21 (77.7%) patients only a retrograde approach was used, in 3 (11.1%) patients a retrograde and an additional transeptal approach and in only 3 (11.1%) patients solely a transeptal approach. Mean number of radiofrequency applications was 11.8 ± 12.6 (30 to 40 Watts, 27545.6 ± 30524.4 Joules). FVT ablation was acutely successful in 24 patients (88.9%). In 2 patients (7.4%) no ablation was performed due to inability to induce VT under sedation. 3/27 patients (11.1%) underwent re-ablation due to FVT recurrence after previous ablation procedures. Moreover, 3 (11.1%) additional patients underwent repeated VT ablations during follow-up, but the arrhythmia originated from a different LV area. No procedure-related complication occurred. In 4 patients (14.8%) left fascicular posterior block was caused by ablation and in 3 (11.1%) patients a complete left bundle block. Mean procedure time was 130 ± 48.9 minutes. Conclusion Ablation of FVT in a tertiary ablation center is associated with a high single procedural success rate of 88.9% during long-term follow-up, with a mild risk of fascicular injury. 11.1% of patients underwent re-ablation due to FVT recurrence.

Role of mechanical circulatory support in VT ablation procedures: data from the German PROTECT VT registry

Abstract Introduction Ventricular tachycardia (VT) ablation in patients with progressed heart failure (HF) is known to be complex and associated with a high periprocedural risk and mortality, in part due due to hemodynamic instability during ongoingVTs. Use of mechanical circulatory support (MCS) systems has been already implemented in complex high-risk percutaneous coronary intervention (CHIP-PCI) workflows. Use and benefit of MCS in VT ablation is still under debate. MCS protected VT ablation (proVT-A) might be associated with improved clinical outcomebut potentially comes along with an increased risk of periprocedural complications. Based on data of four German high-volume centers we aimed to analyze retrospective data on patient characteristics and impact of proVT-A with respect to safety and mid-term efficacy. Methods All patients undergoing proVT-A as a primary approach from four German EP centers were included in the analysis. Use of MCS in bailout scenariosin VT ablation were not included. Patient characteristics, procedural parameters and clinical outcome were evaluated. The primary endpoint was a combined endpoint of VT/VF recurrence and all-cause death. Results 41 patients who underwent proVT-A were included. Mean age was 64±11a, 92% of patients were male (38/41), 65% (27/41) suffered from ischemic cardiomyopathy, mean left ventricular ejection fraction was 33±13%,76% (31/41) of patients presented with a documented hemodynamically not tolerated VT, mean PAAIN-ESD score was 13±7, and 46% (19/41) had a history of a previous VT ablation w/o MCS. During proVT-A procedure at least one VT was inducible and mappable in 35 patients (85%). Acute procedural success was 85%, with only n=6 patients remaining inducible for VT. Mean procedure duration was 245±46min. With respect to periprocedural safety (30days)a total of n=12 relevant procedural complications were reported in 8 patients. This included n=5 vascular access complications, of which n=3 requiring transfusion or surgery. One case of periprocedural death was reported 6h post proVT-A due to PEA. Three patients developed pericardial effusion, one requiring drainage. Freedom from VT/VF was 78% (n=9 VT/VF recurrences) after a mean follow-up (FU) of 15±14 months (figure 1A). Death of any cause occurred in n=9 patients (figure 1B). In summary, after a mean FU of 15±14 months n=16 patients (39%) met the combined endpoint of VT/VF recurrence and all-cause death (figure 1C). Conclusion Patients enrolled in the German PROTECT VT Registry had significant cardiovascular comorbidities and therefore represent a high-risk population for VT ablation. Use of MCS was feasible, comparably safe, associated with high procedural and promising long-term success rate. These results highlight the need for larger registries and future prospective trials evaluating the potential benefit of proVT-A in selected patients. Further, it should be aimed for optimization of periprocedural vascular access site management.

Static Ultrasonographic Assessment for Central Venous Catheterization Reduces Catheter Dysfunction in the Emergency Department

Objective: This study aimed to investigate the effect of a static ultrasonographic (US) examination of the central venous structures before central venous catheterization (CVC) and the success of the procedure. Materials and Methods: In this prospective study, patients who underwent CVC, in an emergency department (ED), were divided into two groups: patients who underwent CVC using the anatomical landmark technique (n = 34) and patients who underwent CVC using a static US examination (n = 33). The procedure times, success rates, and number of catheters used were compared. Results: A total of 67 patients who underwent CVC were included in the study. Compared with the anatomical landmark technique, the static US examination had a higher procedural success rate ( P = .001), fewer total interventions ( P = .001), and fewer postprocedural catheter dysfunctions ( P = .048). While there was no difference in the duration of the CVC between groups ( P = .222), the total time spent was longer using a static US examination ( P = .022). Conclusion: The static US examination was a practical, easy-to-apply method that could be used for CVC placement in an ED. This study demonstrated sonography had a high success rate in CVC procedures and contributed to a reduction in the number of interventions and catheters used.

SHOULD WE BE CONCERNED ABOUT USING INTRAVASCULAR LITHOTRIPSY ON THE LEFT MAIN? INSIGHT FROM ROLLING STONE RETROSPECTIVE REGISTRY

Abstract Background The use of rotational atherectomy is currently prevalent in the treatment of left main coronary artery lesions. However, it often necessitates the use of a large burr to achieve adequate debulking, which, in turn, demands highly experienced operators. Intravascular lithotripsy (IVL) is a promising, user–friendly and increasingly employed technique for calcific plaque modification before percutaneous coronary intervention. Although in many cath labs it is now routinely used to treat lesions of the three main coronary arteries, there are still concerns regarding its use in the left main, primarily due to prolonged inflations required for its optimal efficacy. Methods We conducted a retrospective analysis using data from the multicenter retrospective Rolling Stone registry. The analysis involved data from 474 patients, with a stratification between IVL procedures involving left main coronary artery (46 patients) and those that did not (428 patients). The primary effectiveness endpoint was procedural success (defined as achieving residual stenosis &amp;lt; 20% with TIMI III flow); secondary endpoints included the rate of procedural related adverse events, in hospital adverse events and MACE rate at 30 days and 6 months. Results Between April 2018 and January 2023, a total of 474 underwent IVL procedures. Most patients presented with calcific lesion requiring lithotripsy in non–left main segments, while IVL was performed on the left main artery in 46 patients. No significative differences were found on baseline characteristics between LM and non–LM groups. Treatment of IVL–LM lesion was marked by a high procedural success rate (97.8%) and a low incidence of procedural and peri–procedural complications. However, there was a higher rate of contrast–induced acute kidney injury in patients treated in LM (6.5% vs. 1.6%, p=0.030), although no other differences for in–hospital outcomes were observed. Furthermore, there were no differences in 30–day and 6–month follow–up outcomes between the two groups. Conclusions This study suggests that employing intravascular lithotripsy in the left main coronary artery is not only a safe procedure but also produces excellent results comparable to its application in other coronary branches. This provides a substantial level of confidence in the safety and effectiveness of IVL when used in this specific context.

Failed bioprosthetic tricuspid valve replacement treated with transcatheter valve for valve repair

Tricuspid bioprosthetic valve failure may lead to right-sided heart failure and is traditionally managed with surgical valve replacement. However, the substantial mortality risk associated with reoperation for failed tricuspid bioprosthesis prompts the need for less invasive alternatives. Transcatheter valve-in-valve (TViV) implantation presents a promising minimally invasive option for patients with failing bioprosthetic valves. This case involves a 32-year-old man with a history of recurrent failed bioprosthetic tricuspid valves who underwent successful percutaneous TViV implantation using a 29 mm Edwards Sapien S3 valve, resulting in marked clinical and hemodynamic improvement. This case contributes essential insights to the limited literature on TViV in the tricuspid position, particularly in patients with complex surgical histories. The high procedural success rate and substantial improvement in valve function underscore the potential of TViV as an effective alternative to surgical replacement for failed tricuspid bioprosthetic valves. Keywords: Transcatheter tricuspid valve replacement; tricuspid valve-in-valve; bioprosthetic tricuspid valve; tricuspid valve stenosis