Left Main Percutaneous Coronary Intervention Research Articles

Percutaneous coronary intervention for bifurcation coronary lesions using optimised angiographic guidance: the 18th consensus document from the European Bifurcation Club.

The 2023 European Bifurcation Club (EBC) meeting took place in Warsaw in October, and the latest evidence for the use of intravascular ultrasound (IVUS) and optical coherence tomography (OCT) to optimise percutaneous coronary interventions (PCI) on coronary bifurcation lesions (CBLs) was a major focus. The topic generated deep discussions and general appraisal on the potential benefits of IVUS and OCT in PCI procedures. Nevertheless, despite an increasing recognition of IVUS and OCT capabilities and their recognised central role for guidance in complex CBL and left main PCI, it is expected that angiography will continue to be the primary guidance modality for CBL PCI, principally due to educational and economic barriers. Mindful of the restricted access/adoption of intracoronary imaging for CBL PCI, the EBC board decided to review and describe a series of tips and tricks which can help to optimise angiography-guided PCI for CBLs. The identified key points for achieving an optimal angiography-guided PCI include a thorough analysis of pre-PCI images (computed tomography angiography, multiple angiographic views, quantitative coronary angiography vessel estimation), a systematic application of the technical steps suggested for a given selected technique, an intraprocedural or post-PCI use of stent enhancement and a low threshold for bailout use of intravascular imaging.

Long-term outcome after unprotected left main percutaneous coronary intervention in patients with acute myocardial infarction complicated by cardiogenic shock: a landmark analysis

Abstract Funding Acknowledgements None. Background Early revascularization of culprit arteries has demonstrated to improve outcomes in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS), however, little is known about long-term outcome after unprotected left main (LM) percutaneous coronary intervention (PCI) in patients with AMI-CS. Methods We retrospectively investigated 2325 consecutive patients with AMI who underwent primary percutaneous coronary intervention (pPCI) in our institution from January 2004 to December 2017. The primary outcome was cardiovascular (CV) death up to 3yrs. Results Among the 2325 eligible patients, 272 AMI patients (11.7%) were complicated by CS on admission (AMI-CS). The mean age was 71 years, 75% of patients were male, STEMI was seen in 86%, and mechanical circulatory support was used in 61%. Of 272 AMI-CS, 35 (14.0%) patients were treated with PCI for LM and had significantly higher 30-day cardiovascular mortality (52.6%) compared with those treated with PCI for non-LM (24.8%) (p = 0.0001). Kaplan-Meier analysis showed that mortality up to 3 years was significantly higher in AMI-CS patients with LM compared those with non-LM (p < 0.0001). Multivariate Cox regression analysis showed LM was significantly associated with higher cardiovascular mortality (adjusted HR 1.90, 95%CI 1.18-3.07, p = 0.0088). Conclusions Primary PCI of the LM was performed in 14.0% of patients with AMI-CS. Short- and long-term CV mortality was significantly higher with LM AMI-CS than non-LM AMI-CS. Further studies should evaluate to improve both short- and long-term outcome among AMI-CS with LM.

Real-World Experience and Outcomes With Percutaneous Coronary Intervention for Protected Versus Unprotected Left Main Coronary Artery Disease: Insights from the Veteran Affairs Clinical Assessment Reporting and Tracking Program

Practice patterns and outcomes of protected left main (PLM) and unprotected left main (ULM) percutaneous coronary intervention (PCI) are not well defined in contemporary US clinical practice. Data collected from all Veteran Affairs (VA) catheterization laboratories participating in the Clinical Assessment Reporting and Tracking Program between 2009 and 2019. The analysis included 4,351 patients undergoing left main PCI, of which 1,306 pairs of PLM and ULM PCI were included in a propensity matched cohort. Selected temporal trends were also assessed. The primary outcome was MACE outcomes at 1-year, which was defined as a composite of all-cause mortality, rehospitalization for myocardial infarction (MI), rehospitalization for stroke or urgent revascularization. ULM PCI patients in comparison to PLM PCI were older (71.5 vs 69.2; P < 0.001), more clinically complex and more likely to present with ACS. In the propensity matched cohort, radial access was used more often for ULM PCI (21% [273] vs. 14% [185], P < 0.001), and ULM PCI was more likely to involve the LM bifurcation (22% vs 14%; P = 0.003) and require mechanical circulatory support (10% [134] vs 1% [17]; P <0.001). One-year MACE occurred more frequently with ULM PCI compared to PLM PCI (22% [289] vs. 16% [215]; P = < 0.001) and all-cause mortality was also higher (16% [213] vs. 10% [125]; P = < 0.001). In the matched cohort there was a low incidence of rehospitalization for MI (4% [48] ULM vs. 4% [48] PLM; P = 1.000) or revascularization (7% [94] ULM vs. 6% [84] PLM; P = 0.485). In this real-world experience patients undergoing PLM PCI had better one-year outcomes than those undergoing ULM PCI, but in both groups there was a high rate of mortality and MACE at one-year despite a relatively low rate of MI or revascularization.•What is known?○In contemporary practice, the use of percutaneous coronary intervention (PCI) for left main coronary artery disease has increased.○Clinical trials have demonstrated that left main PCI can be performed safely, but observational studies have shown that patients who undergo left main PCI are older and with more co-morbid conditions than trial populations.•What the study adds?○In a large multi-center sample from the United States Department of Veterans Affairs, there has been increasing use of left main PCI in patients who have not undergone prior coronary artery bypass graft surgery (CABG).○Compared to patients with prior CABG who underwent left main PCI, those who underwent left main PCI without prior CABG had a higher rate of major adverse cardiovascular events and all cause death at 12 months.○While there was an overall low rate of rehospitalization for myocardial infarction or revascularization, there was a higher 12-month incidence of major adverse cardiovascular events in this real-world population compared to clinical trial populations.

Impact of Target Lesion Revascularization on Long-Term Mortality After Percutaneous Coronary Intervention for Left Main Disease

BackgroundAlthough target lesion revascularization (TLR) after percutaneous coronary intervention (PCI) for unprotected left main coronary artery (LMCA) disease is not rare, its timing of occurrence and prognostic impact on long-term mortality is uncertain. ObjectivesThis study sought to investigate TLR incidence over time and its impact on mortality after PCI with drug-eluting stents (DES) for LMCA disease. MethodsUsing a pooled data from 4 multicenter observational registries (IRIS-DES [Interventional Cardiology Research Incorporation Society-Drug-Eluting Stents], IRIS-MAIN [Interventional Cardiology Research Incorporation Society-Left MAIN Revascularization], MAIN-COMPARE [Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization], and PRECOMBAT [PREmier of Randomized COMparison of Bypass Surgery versus AngioplasTy Using Drug-Eluting Stent in Patients with Left Main Coronary Artery Disease]), we evaluated 1,397 patients with LMCA disease treated with DES and available long-term mortality data. The association between TLR and the 10-year risk of mortality was examined by multivariable Cox proportional hazards regression, with TLR as a time-varying covariate. ResultsDuring maximum follow-up of 10 years (median 6.8 years), TLR occurred in 118 patients and its 10-year cumulative incidence was 10.8%. TLR mostly occurred within 2 years after initial PCI and decreased over time: early-stage TLR (within 2 years) in 73 (61.9%) patients and late-stage TLR (beyond 2 years) in 45 (38.1%) patients. Among all TLR patients, 23 patients underwent coronary artery bypass grafting and 95 underwent repeat PCI. In the time-varying multivariable Cox model, the presence of TLR was not significantly associated with an increased risk of mortality (adjusted HR: 0.90; 95% CI: 0.50-1.63; P = 0.73). ConclusionsAlthough the incidence of ischemia-driven TLR was mostly common within 2 years after left main PCI, TLR occurred steadily during the 10-year follow-up period. However, given that such patients were optimally revascularized, the prognostic impact of TLR on mortality was not substantial. (Evaluation of the First, Second, and New Drug-Eluting Stents in Routine Clinical Practice [IRIS-DES]; NCT01186133; Observational Study for Left Main Disease Treatment [IRIS-MAIN]; NCT01341327; Ten-Year Outcomes of Stents Versus Coronary-Artery Bypass Grafting for Left Main Coronary Artery Disease [MAIN COMPARE]; NCT02791412; Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease [PRECOMBAT]; NCT00422968)

Influence of left ventricular ejection fraction in patients undergoing contemporary pLVAD-supported high-risk PCI

Left ventricular (LV) systolic dysfunction worsens outcomes in patients undergoing percutaneous coronary intervention (PCI). The objective of this study, therefore, was to evaluate outcomes of pLVAD-supported high-risk PCI (HRPCI) patients according to LV ejection fraction (LVEF). Patients from the PROTECT III study undergoing pLVAD-supported HRPCI were stratified according to baseline LVEF: severe LV dysfunction (LVEF <30%), mild and moderate LV dysfunction (LVEF ≥30% to <50%), or preserved LV function (LVEF ≥50%). Major adverse cardiovascular and cerebrovascular events (MACCE: composite of all-cause death, myocardial infarction, stroke/transient ischemic attack, and repeat revascularization), and PCI-related complications were assessed at 90 days and mortality was assessed at 1-year. From March 2017 to March 2020, 940 patients had evaluable baseline LVEF recorded in the study database. Patients with preserved LV function were older, more frequently presented with myocardial infarction, and underwent more left main PCI and atherectomy. Immediate PCI-related coronary complications were infrequent (2.7%, overall), similar between groups (P=0.98), and not associated with LVEF. Unadjusted 90-day MACCE rates were similar among LVEF groups; however, as a continuous variable, LVEF was associated with both 90-day MACCE (adj.HR per 5% 0.89, 95% CI [0.80, 0.98], P=0.018) and 1-year mortality (adj.HR per 5% 0.84 [0.78, 0.90], P <0.0001). Patients who underwent pLVAD-supported HRPCI exhibited low incidence of PCI-related complications, regardless of baseline LVEF. However, LVEF was associated with 90-day MACCE and 1-year mortality.

Dual Antiplatelet Therapy De-Escalation in Stabilized Myocardial Infarction With High Ischemic Risk

In patients with acute myocardial infarction (AMI) who have high ischemic risk, data on the efficacy and safety of the de-escalation strategy of switching from ticagrelor to clopidogrel are lacking. To evaluate the outcomes of the de-escalation strategy compared with dual antiplatelet therapy (DAPT) with ticagrelor in stabilized patients with AMI and high ischemic risk following percutaneous coronary intervention (PCI). This was a post hoc analysis of the Ticagrelor vs Clopidogrel in Stabilized Patients With Acute Myocardial Infarction (TALOS-AMI) trial, an open-label, assessor-blinded, multicenter, randomized clinical trial. Patients with AMI who had no event during 1 month of ticagrelor-based DAPT after PCI were included. High ischemic risk was defined as having a history of diabetes or chronic kidney disease, multivessel PCI, at least 3 lesions treated, total stent length greater than 60 mm, at least 3 stents implanted, left main PCI, or bifurcation PCI with at least 2 stents. Data were collected from February 14, 2014, to January 21, 2021, and analyzed from December 1, 2021, to June 30, 2022. Patients were randomly assigned to either de-escalation from ticagrelor to clopidogrel or ticagrelor-based DAPT. Ischemic outcomes (composite of cardiovascular death, myocardial infarction, ischemic stroke, ischemia-driven revascularization, or stent thrombosis) and bleeding outcomes (Bleeding Academic Research Consortium type 2, 3, or 5 bleeding) were evaluated. Of 2697 patients with AMI (mean [SD] age, 60.0 [11.4] years; 454 [16.8%] female), 1371 (50.8%; 684 assigned to de-escalation and 687 assigned to ticagrelor-based DAPT) had high ischemic risk features and a significantly higher risk of ischemic outcomes than those without high ischemic risk (1326 patients [49.2%], including 665 assigned to de-escalation and 661 assigned to ticagrelor-based DAPT) (hazard ratio [HR], 1.74; 95% CI, 1.15-2.63; P = .01). De-escalation to clopidogrel, compared with ticagrelor-based DAPT, showed no significant difference in ischemic risk across the high ischemic risk group (HR, 0.88; 95% CI, 0.54-1.45; P = .62) and the non-high ischemic risk group (HR, 0.65; 95% CI, 0.33-1.28; P = .21), without heterogeneity (P for interaction = .47). The bleeding risk of the de-escalation group was consistent in both the high ischemic risk group (HR, 0.64; 95% CI, 0.37-1.11; P = .11) and the non-high ischemic risk group (HR, 0.42; 95% CI, 0.24-0.75; P = .003), without heterogeneity (P for interaction = .32). In stabilized patients with AMI, the ischemic and bleeding outcomes of an unguided de-escalation strategy with clopidogrel compared with a ticagrelor-based DAPT strategy were consistent without significant interaction, regardless of the presence of high ischemic risk.

Left Main Percutaneous Coronary Intervention Outcomes

Left Main Percutaneous Coronary Intervention Outcomes

The Evaluation of Stent Patency Using Computed Angiography Following Left Main Coronary Artery Stenting

The increased chances of in-stent restenosis have led to repeated coronary angiography and left main percutaneous coronary intervention. However, for the evaluation of coronary arteries, computed tomography angiography (CTA) is regarded as a non-invasive intervention. Objectives: To evaluate the proportion of in-stent restenosis in the left main PCI and to determine the diagnostic efficacy of CTA in detecting in-stent restenosis. Methods: We conducted this study from June 2021 to July 2022. 130 patients were chosen for the study among the 300 LM PCI patients. The CTA was conducted 3 months after the LM PCI. The data were collected and entered into the SPSS software and the descriptive analysis was conducted. Results: In our study, the majority of the patients (n=92, 70.8%) of the patients undergoing PCI from the LM to LAD, and the number of patients who went from LM to LCX was 19 patients (14.6%). Only 14.6% of the patients in our study had bifurcation PCI and all 130 (100%) patients had DES. The average period for the development of ISD was 11 months. Conclusions: CTA is quite efficient in accurately assessing the selected patients who have undergone LM PCI and CTA can be utilized as the 1" line treatment modality.

Characteristics and outcomes of elderly patients undergoing protected percutaneous coronary intervention with impella mechanical circulatory support

Abstract Background/Introduction In high-risk patients, percutaneous coronary intervention (PCI) with Impella mechanical circulatory support has become an important part of the revascularization strategy. However, data regarding the impact of age in patients undergoing Impella-supported PCI are limited. Purpose The aim of this study was to describe the characteristics and outcomes of Impella mechanical circulatory support in patients ≥75 years of age undergoing high-risk PCI. Methods Using the PROTECT III study, a prospective, multicenter, FDA-audited cohort of the Catheter-based Ventricular Assist Device (cVAD) registry, we compared baseline characteristics and clinical outcomes of patients ≥75 years of age with those of patients &amp;lt;75 years of age treated with Impella-supported high-risk PCI. Rates of major adverse cardiovascular and cerebral events (MACCE), defined as the composite of all-cause death, myocardial infarction (MI), stroke/transient ischemic attack, and revascularization, were assessed at 30 days and 90 days, and mortality was assessed to 1 year. A multivariable Cox regression model (including covariates significant in univariable analysis) was used to examine associations between age and clinical outcomes. Results A total of 1237 patients (26.8% female) were included in the analysis; of whom 493 (39.9%) were ≥75 years of age. Patients ≥75 years of age had lower body mass index (27 kg/m² vs. 30 kg/m²), a lower prevalence of diabetes (49% vs. 61%) and prior MI (37% vs. 43%), and lower estimated glomerular filtration rates (eGFR, 60 vs. 74 mL/min/1.73 m²). They more often suffered from severe valvular heart disease (17% vs. 7%), and more frequently underwent left main PCI (58% vs. 39%). Left ventricular ejection fraction was higher in patients ≥75 years of age (37.7±15.9% vs. 32.0±14.5%). (p&amp;lt;0.05 for all comparisons). Baseline SYNTAX scores did not differ among groups. Rates of death and MACCE did not differ between age groups at either 30 days or 90 days (Figure 1). Mortality at 1 year was 24.0% in patients ≥75 years of age and 17.9% in those &amp;lt;75 years of age. Age ≥75 years was associated with an increased risk of mortality at 1 year (unadjusted HR 1.40, 95% CI 1.05-1.86, p=0.02) and the association remained significant after multivariable adjustment (adjusted HR 1.99, 95% CI 1.24-3.18, p=0.004; Figure 2). Conclusion(s) This study demonstrates that increased age ≥75 years was not associated with a higher risk of mortality or MACCE at 30 or 90 days following protected PCI with Impella mechanical circulatory support, suggesting that protected high-risk PCI in elderly patients is safe and feasible. However, age ≥75 years remained an independent predictor for 1-year mortality after protected PCI.30-day and 90-day MACCE1-year All-cause death

Abstract 18976: In-Hospital Outcomes in Patients Undergoing Protected Left Main Percutaneous Coronary Intervention With Percutaneous Left Ventricle Assist Device Protection

Introduction: Left main disease (LMCA) is a known risk factor for patients’ poor outcomes. Percutaneous revascularization of LMCA in heart failure patients is associated with a particularly high periprocedural risk. Percutaneously introduced left ventricle assist devices (pLVAD) are a potential tool to improve patient outcomes in these high-risk procedures. Hypothesis: Our study aimed to assess short-term clinical outcomes of protected left main percutaneous coronary intervention with the use of a pLVAD. Methods: A prospective registry of patients with chronic heart failure, undergoing protected LMCA PCI included 66 patients, 89% male, the median age of 71.5 y.o, 40 (60.6%) after prior myocardial infarction, 31 (47%) after prior PCI and 12 (18.2%) after CABG, with CTO RCA in 17 (25.6%) of cases. Percutaneous LVAD was used in all patients, 72% access site was the right femoral artery, additional plaque modification techniques were used in 46 (69.7%) patients, IVL was applied in 25 (37.9%) of cases and high-speed rotational or orbital atherectomy was used in 21 (31.2%) of cases. Median of 3 [2;4] DES was implanted. Results: During the in-hospital follow-up, a significant improvement of the left ventricle ejection fraction was observed (median LVEF 30% post PCI vs22% at baseline, p&lt;0.001) as well as a significant decrease of NTproBNP levels (765 [IQR: 194, 6,370] at discharge vs 7113 pg/ml [IQR:1,945, 15,646] at baseline, p=0.01]. There was 1 in-hospital death due to cardiogenic shock. A safety monitoring revealed 11 hematomas, including 3 cases that needed vascular surgery. Bleeding according to BARC 3a was recorded in 17/66 (28%) and BARC 3b in 3/66 (5%) of cases. Conclusions: Percutaneous LVAD support is a feasible method to perform protected left main PCI with a good safety profile when applied by experienced operators A significant improvement of the LVEF can be observed after left main revascularization Further research is needed to confirm the presented results.

Is one better than two? The impact of a four-handed approach in left main percutaneous coronary intervention.

Is one better than two? The impact of a four-handed approach in left main percutaneous coronary intervention.

Intravascular lithotripsy compared to rotational atherectomy for the treatment of calcified distal left main coronary artery disease: A single center experience.

The safety and efficacy of intravascular lithotripsy (IVL) for the treatment of calcified distal left main (LM) disease remains unclear, especially compared to rotational atherectomy (RA). We retrospectively analyzed the baseline clinical, angiographic, intravascular ultrasound (IVUS) characteristics and procedural outcomes of 107 patients who underwent distal LM percutaneous coronary intervention (PCI) with IVL (with or without adjunct atherectomy) versus RA alone for plaque modification before stenting at a single center between 2020 and 2022. A total of 50 patients underwent calcium modification with IVL with or without adjunct atherectomy and 57 with RA only. The mean age was 73 years and with a high prevalence of diabetes (58.9%), chronic kidney disease (42.1%), prior revascularization (coronary artery bypass graft surgery [36.4%] or prior PCI [32.7%]). Acute coronary syndrome was the primary indication for PCI in over 50% of the patients in both groups. Medina 1-1-1 LM bifurcation disease was identified in 64% and 60% of the IVL and RA groups (p = 0.64) respectively. Final minimum stent area in distal LM (>8.2 mm2 ), ostial LAD (>6.3 mm2 ) and ostial LCX (>5.0 mm2 ) were achieved in 96%, 85% and 89% of cases treated with IVL respectively and 93%, 93% and 100% of cases treated with RA respectively (LM p = 1.00; LAD p = 0.62; LCX; p = 1.00 for difference between the two groups). Procedural success (technical success without in-hospital major adverse events) was achieved in 98% of the IVL group and 86% of the RA-only group (p = 0.04). There were eight procedural complications (flow-limiting dissection, perforation, or slow/no-reflow) in the RA group compared to four in the IVL group (NS), and one patient in the RA required salvaged mechanical support compared to none in the IVL group. Plaque modification with coronary IVL appears to be efficacious and safe for the treatment of severely calcified distal LM lesions compared to RA only. Larger randomized studies are needed to confirm these findings.

Do two operators improve outcomes in left main percutaneous coronary intervention? Insights from the ORPKI Registry.

Significant left main coronary artery (LMCA) disease is prevalent in 7% of patients undergoing angiography. Limited data exists on the impact of double scrubbing in LMCA PCI. We sought to assess periprocedural outcomes in two-operator LMCA percutaneous coronary intervention (PCI). Using data from the Polish National Registry of PCI (ORPKI), we collected data on 28,745 patients undergoing LMCA PCI from 154 centers. Patients were divided into two groups based on the number of operators performing PCI (one vs. two operators). LMCA PCI was performed by a single operator in 86% of the cases and by two operators in 14% of cases. Patients treated by two operators had a greater comorbidity burden including diabetes mellitus, arterial hypertension, previous myocardial infarction, and previous revascularization. In addition, these were more likely to be treated in high-volume centers, by operators with higher volume of LMCA PCIs. The risk of periprocedural death (2.37% vs. 2.44%; P=0.78), as well as cardiac arrest, coronary artery perforation, no-reflow, and puncture site bleeding was comparable between the two groups. On multivariable analysis, we found that a two-operator strategy was an independent predictor of periprocedural death, with this effect being much more profound in an elective setting (OR=5.13 [1.37-19.26]; P=0.015), compared to an urgent (ACS) setting (OR=1.32 [1.00-1.73]; P=0.047). Our study suggests that a two-operator approach is not necessarily routinely recommended for LMCA interventions, although it can be considered for more complex cases.

TCT-511 Impact of Adjunctive Intravascular Imaging on Cardiovascular Outcomes in Unprotected Left Main Percutaneous Coronary Intervention at a High-Volume Center

TCT-511 Impact of Adjunctive Intravascular Imaging on Cardiovascular Outcomes in Unprotected Left Main Percutaneous Coronary Intervention at a High-Volume Center

TCT-509 Impact of Coronary Trifurcation Anatomy on Cardiovascular Outcomes in Unprotected Left Main Percutaneous Coronary Intervention.

TCT-509 Impact of Coronary Trifurcation Anatomy on Cardiovascular Outcomes in Unprotected Left Main Percutaneous Coronary Intervention.

The impact of left circumflex coronary artery ostium stenosis on outcomes for patients after percutaneous coronary intervention for unprotected left main disease.

The impact of left circumflex coronary artery (LCX) ostium atherosclerosis in left main coronary artery (LM) bifurcation disease is not well-known. The study aimed to assess whether the involvement of LCX ostium carries prognostic implications in patients undergoing unprotected LM percutaneous coronary intervention (PCI). Consecutive 564 patients with unprotected LM (ULMCA) disease who underwent LM PCI between January 2015 and February 2021, with at least 1 year of available follow-up were included in the study. The first group was composed of 145 patients with ULMCA disease with LCX ostium stenosis, and the second group consisted of 419 patients with ULMCA disease without LCX ostium stenosis. Patients in the group with ULMCA disease with LCX ostium stenosis were significantly older and had more comorbidities. The two-stent technique was used more often in the group with LCX ostium stenosis (62.8% vs. 14.6%; P <0.001). During 7-year follow-up, all-cause mortality did not differ significantly between groups with and without LCX ostium stenosis (P = 0.50). The use of one-stent or two-stent technique also did not impact mortality in patients with LCX ostial lesions (P = 0.75). Long-term mortality subanalysis for three groups of patients: (1) patients with LM plus LCX ostium stenosis; (2) LM plus left anterior descending artery (LAD) ostium stenosis; (3) LM plus LCX ostium plus LAD ostium stenosis also did not differ significantly (P = 0.63). LCX ostium involvement in LM disease PCI is not associated with adverse long-term outcomes, which is highly beneficial for the Heart Team's decision-making process.

Complex high-risk percutaneous coronary intervention types, trends, and outcomes according to vascular access site.

Radial access is associated with improved outcomes following percutaneous coronary intervention (PCI); however, its role in complex, high-risk percutaneous coronary intervention (CHiP) remains poorly studied. We studied retrospectively all registered patients's records from the British Cardiovascular Intervention Society dataset and compared the baseline characteristics, trends and outcomes of CHiP procedures performed electively between January 2006 and December 2017 according to the access site. Out of 137,785 CHiP procedures, 61,825 (44.9%) were undertaken via transradial access (TRA). TRA use increased over time (14.6% in 2006 to 67% in 2017). The TRA patients were older, with a greater prevalence of previous stroke, hypertension, peripheral vascular disease, and smokers. TRA was used more frequently in most CHiP procedures (elderly (51.6%), chronic renal failure (52.6%), poor left ventricular (LV) function (47.6%), left main PCI (48.0%), treatment for severe vascular calcification (50.3%); although transfemoral access (TFA) was used more commonly in those with prior history of coronary artery bypass graft surgery, and PCI to a chronic total occlusion and LV support patients. Following adjustment for differences in clinical and procedural characteristics, TFA was independently associated with higher odds for mortality [adjusted odds ratio (aOR): 1.3 (1.1-1.7)], major bleeding [aOR: 2.9 (2.3-3.4)], and MACCE (following propensity score matching) [aOR: 1.2 (1.1-1.4)]. The same was found with multiple accesses: mortality [aOR: 2.1 (1.5-2.8)], major bleeding [aOR: 5.5 (4.3-6.9)], and MACCE [aOR: 1.4 (1.2-1.7)]. TRA has become the predominant access site for CHiP procedures and is associated with significantly lower mortality, major bleeding and MACCE odds than TFA.

Comparison of Orbital Atherectomy and Rotational Atherectomy in Calcified Left Main Disease: Short-Term Outcomes.

Coronary calcifications, particularly in left main disease (LMD), are independently associated with adverse outcomes of percutaneous coronary intervention (PCI). Adequate lesion preparation is pivotal to achieve favorable short- and long-term outcomes. Rotational atherectomy devices have been used in contemporary practice to obtain adequate preparation of the calcified lesions. Recently, novel orbital atherectomy (OA) devices have been introduced to clinical practice to facilitate the preparation of the lesion. The objective of this study is to compare the short-term safety and efficacy of orbital and rotational atherectomy for LMD. we retrospectively evaluated a total of 55 consecutive patients who underwent the LM PCI supported by either OA or RA. The OA group consisted of 25 patients with a median SYNTAX Score of 28 (26-36). The Rota group consisted of 30 patients with a median SYNTAX Score of 28 (26-33.1) There were no statistical differences in MACCE between the RA and OA subpopulations when recorded in-hospital (6.7% vs. 10.3% p = 0.619) as well as in a 1-month follow-up after the procedure (12% vs. 16.6% p = 0.261). OA and RA seem to be similarly safe and effective strategies for preparating the lesion in the high-risk population with calcified LMD.

Contemporary Left Main Percutaneous Coronary Intervention: A State-of-the-art Review.

The majority of the left ventricular myocardium is supplied by the left main coronary artery. Atherosclerotic obstruction of the left main coronary artery therefore leads to significant myocardial jeopardy. Coronary artery bypass surgery (CABG) has been the gold standard for left main coronary artery disease in the past. However, advancements in technology have established percutaneous coronary intervention (PCI) as a standard, safe and reasonable alternative to CABG, with comparable outcomes. Contemporary PCI of left main coronary artery disease comprises careful patient selection, accurate technique guided by either intravascular ultrasound or optical coherence tomography and - if necessary - physiological assessment using fractional flow reserve. This review focuses on current evidence from registries and randomised trials comparing PCI with CABG, procedural tips and tricks, adjuvant technologies and the triumph of PCI.

Outcomes After Left Main Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock (from the German ALKK PCI Registry)

Early revascularization therapy with percutaneous coronary intervention (PCI) has been shown to improve outcomes in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). Data from consecutive patients with AMI and CS treated with PCI enrolled into the prospective Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte-PCI registry were centrally collected and analyzed. Patients were divided into 4 groups with PCI for left main (LM), 1-vessel, 2-vessel, and 3-vessel diseases. Patients' characteristics, procedural features, antithrombotic therapies, and in-hospital complications were compared between the 4 groups. Between 2010 and 2015 a total of 2,348 consecutive patients with AMI and CS were treated by PCI in 51 hospitals, 295 for LM (15 for protected, 280 for unprotected) and single-vessel (n=491), 2-vessel (n=524), and 3-vessel disease (n=1,038). Thrombolysis in myocardial infarction 3 patency of the culprit lesion after PCI was 84.3%, 84.0%, 80.8%, and 84.6% in single-vessel, 2-vessel, 3-vessel disease, and LM PCI, respectively, whereas in-hospital mortality was 27.9%, 33.9%, 46.5%, and 55.9%. Bleeding rates were low (2.0%-2.3 %) and not different between groups. In a multivariate analysis a higher age, thrombolysis in myocardial infarction flow <3 after PCI, 3-vessel disease, and LM PCI were independent predictors of mortality. In conclusion, PCI of the LM is performed in about 12.5% of patients with AMI and CS and was associated with a high procedural success rate, whereas mortality is increased with LM PCI.