Occlusion Length Research Articles

Predictors of successful endovascular recanalization in patients with symptomatic nonacute intracranial large artery occlusion

BackgroundEndovascular recanalization in patients with symptomatic nonacute intracranial large artery occlusion (ILAO) has been reported to be feasible, but technically challenging. This study aimed to determine the predictors of successful endovascular recanalization in patients with symptomatic nonacute ILAO.MethodsThe outcomes of endovascular recanalization attempts performed in 70 consecutive patients showing symptomatic nonacute ILAO with hemodynamic cerebral ischemia between January 2016 to December 2022 were reviewed. Potential variables, including clinical and radiological characteristics related to technical success, were collected. Univariate analysis and multivariate logistic regression were performed to identify predictors of successful recanalization for nonacute ILAO.ResultsTechnically successful recanalization was achieved in 57 patients (81.4%). The periprocedural complication rate was 21.4% (15 of 70), and the overall 30-day morbidity and mortality rates were 7.1% (5 of 70) and 2.9% (2 of 70), respectively. Univariate analysis showed that successful recanalization was associated with occlusion duration, stump morphology, occlusion length, slow distal antegrade flow sign, and the presence of bridging collateral vessels. Multivariate analysis showed that occlusion duration ≤ 3 months (odds ratio [OR]: 22.529; 95% confidence interval [CI]: 1.636-310.141), tapered stump (OR: 7.498; 95% CI: 1.533–36.671), and occlusion length < 10 mm (OR: 7.049; 95% CI: 1.402–35.441) were independent predictive factors for technical success of recanalization.ConclusionsOcclusion duration ≤ 3 months, tapered stump, and occlusion length < 10 mm were independent positive predictors of technical success of endovascular recanalization for symptomatic nonacute ILAO. These findings may help predict the likelihood of successful recanalization in patients with symptomatic nonacute ILAO and also provide a reference for the selection of appropriate patients. Further prospective and multicenter studies are required to validate our findings.

Clinical feasibility of endovascular recanalization with intravascular ultrasound-guided wiring for chronic total occlusion of below-the-knee arteries

BackgroundRevascularization with endovascular therapy (EVT) for complex below-the-knee (BTK) chronic total occlusion (CTO) remains a challenging problem. The Japanese-BTK (J-BTK) CTO score is reported as an indicator of the difficulty of BTK CTO, with the guidewire (GW) passage success rate decreasing as the grade increases. We previously reported an effective GW crossing method for the intravascular ultrasound (IVUS)-guided parallel wiring of complex BTK CTO. In this study, we investigated the feasibility of EVT using IVUS-guided wiring for BTK CTO.Materials and methodsThis single center, retrospective study analyzed 65 consecutive BTK CTO vessels in which IVUS-guided wiring was attempted after the failure of a conventional antegrade wiring approach from November 2020 to November 2022. The primary endpoint was the clinical success of the target CTO vessel. The secondary endpoints were the GW success rate per grade based on the J-BTK CTO score, number of GW used for CTO crossing, fluoroscopy time, and complications.ResultsTarget vessels were the anterior tibial artery (66.2% of cases), peroneal artery (9.2%), and posterior tibial artery (24.6%). Blunt type CTO entry was performed in 55.4% of cases, calcification of entry was observed in 24.6% of cases, the mean occlusion length was 228.2 ± 93.7 mm, mean reference vessel diameter was 2.1 ± 0.71 mm, and outflow was absent in 38.5% of cases. J-BTK CTO scores of 0/1 (grade A), 2/3 (grade B), 4/5 (grade C), and 6 (grade D) were seen in 18.5%, 43.1%, 36.3%, and 1.5% of cases, respectively. The clinical success rate was 95.4%. The GW success rate by J-BTK CTO grade was as follows: grade A (100%), B (100%), C (91.7%), and D (0%). The mean number of GW used was 3.4 ± 1.4, the mean fluoroscopy time was 72.3 ± 32.5 min, and complications occurred in 7.7% of cases.ConclusionThis study showed a very high clinical success rate despite the difficulty of BTK CTO. IVUS-guided EVT might be a feasible strategy for complex BTK CTO.

CT Arterioportography for Complex Portomesenteric Venous Interventions

AbstractAuthors report the use of computed tomography arterioportography (CTAP) in the diagnosis and endovascular treatment of portomesenteric venous occlusion. Three patients (2 male and 1 female; median age: 51 years) with an extrahepatic portal or mesenteric venous occlusion and variceal bleeding were included in this institutional review boards-approved retrospective study. CTAP was performed with an angiographic catheter positioned in the proximal superior mesenteric artery, and CT was obtained during the venous phase following the intra-arterial injection of contrast material. CTAP provided excellent opacification and delineation of portomesenteric veins, including occlusion length, intravascular webs, venous collaterals, and bleeding varices. This enabled preoperative planning for complex recanalization or extra-anatomic bypass to treat extrahepatic portal and mesenteric venous obstruction. There were no complications related to CTAP.

Arterial dissection during peripheral vascular interventions

ObjectiveArterial dissection (AD) is a known complication of peripheral vascular interventions (PVIs), but its incidence and significance have not been well-characterized. This study examines AD in the Vascular Quality Initiative database for patients treated for peripheral arterial disease. Our hypothesis is that AD is associated with decreased patency and worse limb outcomes. MethodsThe Vascular Quality Initiative PVI registry (2016-2021) was reviewed. Patients were divided based on the presence or absence of reported AD during the procedure. Trend of incidence and management of AD was derived. The characteristics and outcomes of patients with and without AD were compared. The primary endpoint was primary patency. ResultsThere was a total of 177,790 cases, and 3% had AD. The incidence of AD significantly increased over the study period from 2.4% to 3.6% (P = .007). Endovascular therapy was used to treat AD in 83.7% of cases, 14.5% were treated medically, and only 1.8% required open surgery. Patients with AD were significantly more likely to be female (47.4% vs 39.7%; P < .001). Patient with AD were more likely to have a history of smoking (79.7% vs 77.2%; P < .001), but were significantly less likely to be on dialysis (8.2% vs 9.3%; P < .001) compared with patients without AD. Patients with AD were more likely to have femoropopliteal disease (45.2% vs 38.0%; P < .001) and undergo treatment of more complex disease as denoted by higher mean number of lesions treated (1.95 ± 1.01 vs 1.71 ± 0.89; P < .001), longer occlusion length (8 ± 16 vs 7 ± 15 cm; P < .001), and more severe TransAtlantic Inter-Society Consensus grade (Grade D: 36.2% vs 29.1%; P < .001). The proportion of stenting as a treatment modality was higher in the dissection group (55.4% vs 41.1%; P < .001). After a mean follow-up of 828 days, patients with AD had significantly lower primary patency than patients without AD. Kaplan-Meier curves demonstrated that the AD group had lower primary patency (86.9% vs 91%; P < .001) and reintervention-free survival (79.5 % vs 84.1%; P < .001) at 1 year with difference in amputation-free survival. Cox proportional hazard regression confirmed the independent association of AD with primary patency and reintervention-free survival. ConclusionsAD is more common in women and is more likely to occur during treatment of the femoropopliteal segment. AD is associated with decreased primary patency and reintervention-free survival after PVI for peripheral arterial disease.

Balloon-assisted subintimal entry (BASE) in chronic total occlusion percutaneous coronary interventions.

There is limited data on the use of the balloon-assisted subintimal entry (BASE) technique in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We analyzed the baseline clinical and angiographic characteristics and outcomes of 155 CTO PCIs that utilized the BASE technique at 31 US and non-US centers between 2016 and 2023. The BASE technique was used in 155 (7.9%) of 1968 antegrade dissection and re-entry (ADR) cases performed during the study period. The mean age was 66 ± 10 years, 88.9% of the patients were men, and the prevalence of diabetes (44.6%), hypertension (90.5%), and dyslipidemia (88.7%) was high. Compared with 1813 ADR cases that did not use BASE, the target vessel of the BASE cases was more commonly the RCA and less commonly the LAD. Lesions requiring BASE had longer occlusion length (42 ± 23 vs. 37 ± 23 mm, p = 0.011), higher Japanese CTO (J-CTO) (3.4 ± 1.0 vs. 3.0 ± 1.1, p < 0.001) and PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention chronic total occlusion) (1.8 ± 1.0 vs. 1.5 ± 1.0, p = 0.008) scores, and were more likely to have proximal cap ambiguity, side branch at the proximal cap, blunt/no stump, moderate to severe calcification, and proximal tortuosity. Technical (71.6% vs. 75.5%, p = 0.334) and procedural success (71.6% vs. 72.8%, p = 0.821), as well as major adverse cardiac events (MACE) (1.3% vs. 4.1%, p = 0.124), were similar in ADR cases that used BASE and those that did not. The BASE technique is used in CTOs with longer occlusion length, higher J-CTO score, and more complex angiographic characteristics, and is associated with moderate success but also low MACE.

Significant enhancement of occluded segment on magnetic resonance imaging predicts severe stenosis in atherosclerotic occlusion

PurposeThe difficulty of recanalization for intracranial atherosclerosis–related large vessel occlusion (ICAS-LVO) is closely related to the severity of stenosis. This study sought to investigate the characteristics of enhancement based on high-resolution magnetic resonance imaging (HR-MRI) so as to judge the severity of stenosis. MethodsSixty-two patients with symptomatic ICAS-LVOs who underwent endovascular treatment were prospectively recruited for HR-MRI (33 patients with severe stenosis and 29 without). The diagnostic agreements in locating occlusion segments were assessed between HR-MRI and angiographic assessment. The severity of atherosclerotic stenosis was evaluated by enhancement grade and quantitative enhancement index. Univariate and multivariate analyses were used to identify the parameters associated with the severity of stenosis. ResultsHR-MRI showed good agreement with angiographic assessments for evaluating the occlusion site (κ ​= ​0.97) and length (concordance correlation coefficient ​= ​0.70). Compared with patients without severe stenosis, patients with severe stenosis exhibited higher enhancement index (0.69 versus 0.19; p ​< ​0.001) of occlusion segments. In multivariate analysis, the enhancement index was an independent factor associated with the severity of stenosis (OR ​= ​2.92; 95% CI, 1.60–5.34, p ​< ​0.001). The enhancement index had an AUC of 0.89, with a sensitivity of 76.0% and a specificity of 86.0%. The model fit improved when including the enhancement index (AUC ​= ​0.93 versus 0.72). All of patients with severe stenosis required additional rescue treatments, which have a longer procedural time (104.0 versus 91.0 ​min; p ​= ​0.002). ConclusionHigher enhancement index of occlusion segments was associated with the severe atherosclerotic stenosis.

Safety and effectiveness assessment of endovascular recanalization for non-acute middle cerebral artery occlusion.

Endovascular treatment for patients with symptomatic nonacute middle cerebral artery occlusion remains clinically challenging, and proof of a beneficial effect on functional outcome is lacking. We aim to evaluate the effectiveness and safety of endovascular recanalization for patients with symptomatic nonacute middle cerebral artery occlusion. Ninety-eight patients with symptomatic atherosclerotic nonacute middle cerebral artery occlusion were divided into drug treatment groups (42) and endovascular treatment groups (56). The rate of recanalization, peri-procedural complications, and follow-up results were evaluated. Among the 56 patients who received endovascular treatment, 53 (94.6%) achieved successful recanalization. The rate of peri-procedural complications was 7.1% (4/56), and the death rate was 1.8% (1/56). Any stroke within 90 days was 7.1% (4/56). Among the 42 patients in drug treatment group, any stroke within 90 days was 19.0% (8/42), death rate was 0. Among patients with symptomatic nonacute middle cerebral artery occlusion with a short length of occlusion and a moderate-to-good collateral circulation, endovascular treatment seems to be safe. And endovascular treatment could reduce the recurrence rate of stroke.

Retrograde tibial access for revascularization of chronic total occlusions in patients with chronic limb-threatening ischemia.

To evaluate tibial single access in treatment of chronic total occlusions (CTO) in patients with ipsilateral chronic-limb ischemia (CLTI). In this retrospective study, data was collected on patients treated for ipsilateral CTO via a tibial artery access between March 2017 and March 2021. Fifty-nine limbs in 57 patients, (42 men, average age 73years; range 47-96) were treated. Patient's symptoms were classified in accordance with the Rutherford category. The end points were freedom from major amputation and the need for reintervention up to 1year of follow up. Out of the 59 treated limbs, technical success was achieved in 57 (97%). The treated multilevel segments involved 5 common and 12 external iliac arteries, 23 common and 37 superficial femoral arteries, 23 femoropopliteal segments, 14 popliteal arteries, and 4 bypasses. Mean length of occlusion was 186 mm (range 7-670). Rutherford classification of the treated limbs was category 5 and 6 in 45 patients and category 4 in 14 patients. Three procedural complications occurred and were successfully treated during the same procedure. No immediate post-procedural complication was encountered. Median follow-up was 13months (range 1-45.3). Reintervention was required in 9 limbs, after an average of 6months. One year free from amputation rate was 91.2%. Single access via the ipsilateral tibial artery can be a useful, effective, and safe approach for treating CTO in CLTI patients.

Procedural Time and Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention

Chronic total occlusion (CTO) percutaneous coronary interventions (PCIs) can be lengthy procedures. We sought to investigate the effect of procedural time on CTO PCI outcomes. We examined the procedural time required for the various steps of CTO PCI in 6,442 CTO PCIs at 40 US and non-US centers between 2012 and 2022. The mean and median procedure times were 129 ± 76 and 112minutes, respectively, with no significant change over time. The median times from access to wire insertion, guidewire manipulation time, and post crossing were 20, 32, and 53minutes, respectively. Lesions crossed in <30minutes were less complex, as reflected by lower Japanese CTO score (1.89 ± 1.19, p <0.001) than lesions that were not successfully crossed (2.88 ± 1.22) and lesions that were crossed in ≥30minutes (2.85 ± 1.13). The likelihood of successful crossing if crossing was not achieved after 30, 90, and 180minutes were a 76.7%, 60.7%, and 42.7%, respectively. The parameters independently associated with ≥30minutes guidewire manipulation time in patients with a primary antegrade approach included left anterior descending target vessel, proximal cap ambiguity, blunt/no stump, occlusion length, previous failed attempt, medium/severe calcification, and medium/severe tortuosity. The mean duration of CTO PCI is approximately 2hours (∼20% of time for access to wire insertion, ∼30% wire manipulation time, and ∼50% postwiring time). Guidewire crossing time was shorter in less complex lesions and in cases without complications.

High-Risk Characteristics for Clinical Failure after Isolated Femoropopliteal Peripheral Vascular Interventions

Recent studies suggesting increased late mortality with paclitaxel-coated devices (PCD) in femoropopliteal peripheral vascular interventions (PVI) prompted the U.S. Food and Drug Administration to recommend limiting the use of PCDs to "patients at particularly high-risk for restenosis". This study's aim is to characterize patients at high-risk for restenosis, and develop a risk score to guide clinicians in selecting patients for treatment with PCDs. Patients who underwent isolated femoropopliteal PVI for claudication or rest pain from 2016-2019 in the Vascular Quality Initiative were included. Patients who received intervention with a PCD, hybrid procedures, died within one year, or had missing follow up data were excluded. The primary endpoint was clinical failure at one year defined as > 50% restenosis, loss of patency, reintervention, or major amputation. Data was split randomly into 2/3 for development and 1/3 for validation. A parsimonious multivariable hierarchical logistic regression for clinical failure was developed and a risk score was created using beta-coefficients. The risk score was applied to the validation dataset and tested for goodness of fit and discrimination. Among 4,856 treated patients, 718 (14.8%) experienced clinical failure within one year. Clinical failure was associated with age ≤ 50, female sex (48.1% vs 39.5%), insulin-dependent diabetes (29.9% vs 23.1%), creatinine >2.0 mg/dL (9.9% vs 5.7%), prior ipsilateral lower extremity revascularization (48.5% vs 38.5%), prior ipsilateral minor amputation (5.3% vs 1.7%), rest pain vs claudication (30.8% vs 18.7%), occlusion length ≥ 20 cm (18.8% vs 15.0%), and Trans-Atlantic Inter-Society Consensus (TASC) II Classification C or D (40.4% vs 28.0%), all P ≤ 0.01. Risk score development was performed using a multivariable regression. The model demonstrated good fit and discrimination (C-statistic 0.71 in development and 0.72 in validation dataset). Predicted clinical failure was 8.9% for standard-risk (45.9% of interventions), 15.5% for high-risk (44.2% of interventions), and 33.8% for very high-risk patients (9.8% of interventions). A novel risk score was created with good discrimination for identifying patients at high-risk for clinical failure at one year after femoropopliteal PVI for claudication and rest pain. Patients at high-risk and very high-risk for clinical failure may benefit from alternative strategies including PCDs.

Endovascular recanalization of symptomatic non-acute occlusion of the vertebrobasilar artery.

The study aimed to investigate the safety, effect, and risk factors of endovascular recanalization of symptomatic non-acute occlusion of the vertebrobasilar artery (SNOVA). Patients with SNOVA were retrospectively enrolled and treated with endovascular recanalization. The clinical data, endovascular treatment, peri-procedural complications, and follow-up outcomes were analyzed. A total of 88 patients were enrolled, with an interval to recanalization of 2-89 days (median 23) and an mRS of 2-5 (median 3 and IQR 1). Occlusion was in the intracranial vertebral artery in 68 (77.27%) patients and basilar artery in 20 (22.73%), with an occlusion length of 4.5-43.7 mm (mean 18.3 ± 8.8). Endovascular recanalization was successful in 81 (92.0%) patients. Post-dilatation was performed in 23 (28.4%) patients. After stenting, the residual stenosis was 10%-40% (mean 20.2% ± 7.6%). Peri-procedural complications occurred in 17 (19.3%) patients, with a mortality rate of 5.7%. In total, 79 (95.18%) patients underwent follow-up 5-29 (mean 16.9 ± 5.5) months later, with an mRS score of 0-6 (median 1 and IQR 1) at follow-up, being significantly (p < 0.0001) better than that at discharge. Stroke occurred in 9 patients (11.4%) in 1 year. In-stent restenosis occurred in 19 (25.33%) patients. Significant (p < 0.05) independent risk factors were blunt occlusion for successful recanalization, duration to recanalization and blunt occlusion for peri-procedural complications, and post-dilatation for both in-stent restenosis and 1-year stroke or death events. Endovascular recanalization of symptomatic non-acute occlusion of the vertebrobasilar artery is feasible even for a long occlusion segment, with a high recanalization rate, a low complication rate, and a good prognosis. Blunt occlusion and duration from the onset to recanalization may affect successful recanalization and peri-procedural complications while post-dilatation may affect in-stent restenosis and prognosis.

Novel Therapeutic Concepts for Complex Femoropopliteal Lesions Using the Jetstream Atherectomy System

Introduction: The presence of severe arterial calcification is associated with less favorable outcomes in terms of procedural and clinical success as well as higher rates of major adverse limb events. Recent studies incorporating rotational atherectomy for effective preparation of severely calcified lesions demonstrate beneficial procedural outcomes by obtaining maximal luminal gain and improved long-term outcomes. Methods: This prospective single-center, observational study includes patients with severely calcified femoropopliteal lesions with chronic limb ischemia Rutherford 1–5 between January 2017 and July 2019, who underwent atherectomy using the Jetstream Atherectomy system, followed by drug-coated balloon angioplasty. Lesion calcification was categorized by the Peripheral Arterial Calcium Scoring System (PACSS), whereas lesion complexity was classified by the Transatlantic Inter-Society Consensus (TASC). Safety and efficacy aspects in terms of vessel injury, thromboembolism, and clinical success were systematically analyzed up to 12 months of follow-up (FU). Results: In 162 consecutive patients, 210 non-stented and 22 stented lesions were treated. Twelve (7.4%) patients received bail-out stenting. Mean lesion length was 24.2±4.8 cm; 51% were chronic total occlusions (mean occlusion length 18.2±5.1 cm). TASC C lesions were present in 38 patients (23.5%) and TASC D lesions in 124 patients (76.5%). The mean PACCS score was 3.3±0.9. Device success was achieved in 88%; procedural success was noted in 99% of the lesions. Embolic protection device was used in 11.7%. Perforation or dissection occurred in none of the cases. Asymptomatic peripheral embolization was noted in 10 patients (6.2%). Clinical FU at 12 months was available in 157 of 162 patients (96.9%). At 12 month FU, (1) mean Rutherford classification at baseline of 3.7±0.6 significantly dropped to 1.0±0.9 (p<0.05), (2) baseline mean anke-brachial index (ABI) of 0.4±0.1 significantly increased to 0.8±0.2 (p<0.05), (3) 92.6% were free from target lesion revascularization (TLR), (4) 95.1% were free from target vessel revascularization (TVR), and (5) binary restenosis measured by duplex occurred in 22 patients (13.6%). Multivariate analyses showed lesion length as predictive of stent placement (p=0.02), whereas both lesion length (p=0.006) and PACCS score (p=0.02) are predictive of clinical success. Conclusion: Rotational atherectomy in combination with drug-coated balloon (DCB) can be safely performed in long, calcified (non-) occlusive lesions with a relatively low rate of bail-out stenting and favorable clinical mid-term results. Clinical Impact: In this prospective, single arm study we demonstrated that combination treatment using rotational atherectomy and DCB is safe and effective in complex and calcified TASC C/D femoropopliteal lesions in patients with claudication or CLTI in a real-world clinical setting. Despite mean lesion length of >20cm and a relatively high rate of chronic total occlusions, the rate of bail-out stenting was surprisingly low (7.4%), whereas the rates of freedom from TLR and TVR were surprisingly high. Thus, our study may encourage vascular specialists to choose an endovascular -first approach even in such complex and calcified femoropopliteal lesions and occlusions in daily clinical practice.

The value of quantitative plaque analysis based on coronary computed tomography angiography in predicting the percutaneous coronary intervention outcome of chronic total occlusion lesions.

Due to the uncertainty of the success of percutaneous coronary intervention (PCI) and the complexity of selecting suitable treatment cases, the interventional outcome of coronary chronic total occlusion (CTO) remains challenging. The purpose of this study was to evaluate the role of quantitative plaque analysis based on coronary computed tomography angiography (CCTA) in predicting the CTO-PCI outcome. We retrospectively included 78 patients with CTO (80 lesions) confirmed by invasive coronary angiography from July 2016 to December 2018. All patients underwent PCI treatment according to standard practice. A total of 47 lesions in 47 patients were successfully treated with PCI. PCI failed in the remaining 33 lesions in 31 patients. The following conventional CCTA morphologic parameters were evaluated and compared between the PCI-success and PCI-failure groups: stump morphology; occlusion length, tortuous course; CTO lesion calcium; bridging collateral vessel; retrograde collateral vessel; the appearance of the occluded distal segment; and quantitative CTO plaque characteristics, including total plaque volume, calcified plaque (CP) volume, noncalcified plaque (NCP) volume, low-density noncalcified plaque (LDNCP) volume, and plaque length. Univariate and multivariate logistic regression analyses were performed to determine independent parameters predictive of CTO-PCI outcomes. The predictive performances were assessed using receiver operating characteristic curve analysis. The blunt stump was the only independent CCTA morphologic parameter to predict the outcome of CTO-PCI [odds ratio (OR): 10.807; P<0.001]. NCP volume (OR: 1.018; P<0.001), CP volume (OR: 1.026; P=0.049), and plaque length (OR: 1.058; P=0.037) were independent quantitative CTO plaque characteristics predictive of CTO-PCI outcomes. The plaque-based model combining NCP volume with CP volume and plaque length had a higher area under the curve (AUC =0.96) than did the morphology-based model that included blunt stump (AUC 0.68) in predicting the outcomes of CTO-PCI (P<0.001). The CCTA-based plaque characteristics, including NCP volume, CP volume, and plaque length, outperformed morphologic parameters in predicting the CTO-PCI outcomes.

Intraplaque wiring enables drug-coated balloons to be utilized for percutaneous recanalization of chronically occluded coronary arteries.

This study aimed to determine whether drug-coated balloon (DCB) angioplasty following intraplaque wiring and the use of modified balloons is safe and effective in the percutaneous treatment of coronary chronic total occlusions (CTOs). DCB is an alternative therapeutic option without the limitations of permanent vascular implants. However, its efficacy in CTOs has yet to be confirmed. The combination of modified balloons and DCB can be effectively applied when the intraplaque passage of the guidewire is achieved in CTOs. Data from 124 consecutive CTO lesions (105 patients) treated at our hospital between February 2016 and December 2020 were screened for inclusion and retrospectively analyzed. Among the 118 lesions successfully recanalized, intraplaque wiring was achieved in 108, and 85 were treated by the DCB-only approach following cutting/scoring balloon dilatation. Follow-up data were available for 82 lesions (71 patients). The median occlusion length was 18.5 mm, and the J-CTO score was 1.7 ± 0.9. No in-hospital major adverse cardiac events occurred, including abrupt vessel closure. During the median 29-month follow-up period, target lesion revascularization was performed for 10 lesions. Follow-up coronary angiography (8.7 ± 3.9 months after the index procedure) was performed for 64 lesions, demonstrating late lumen loss of -0.15 mm (interquartile range -0.4 to 0.23 mm), binary restenosis (diameter stenosis ≥50%) in 12 lesions (18.8%), and late lumen enlargement in 37 (57.8%). The DCB-only approach following the use of modified balloons is a promising strategy for coronary CTOs when intraplaque wiring is achieved.

Impact of lesion length on the outcomes of chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS-CTO registry.

The impact of occlusion length on the procedural techniques and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We examined the clinical and angiographic characteristics and procedural outcomes of 10,335 CTO PCIs at 42 US and non-US centers between 2012 and 2022. The cohort was divided into two groups based on lesion length (≥20 mm vs. <20 mm). Long lesions were present in 7208 (70%) patients. Comorbidities were more common in patients with long CTOs. Compared with short lesions, long lesions had higher J-CTO score (2.8 ± 1.1 vs. 1.3 ± 1; p < 0.001) and retrograde wiring was more often the initial (15.5% vs. 4.0%; p < 0.001) and successful (22.8% vs. 8.2%; p < 0.001) crossing strategy. Long lesions were more likely to require longer procedure (123 vs. 91 min; p < 0.001) and fluoroscopy (47.1 vs. 32.2 min; p < 0.001) time, larger contrast volume (218 vs. 200 mL; p < 0.001) and higher air kerma radiation dose (2.4 vs. 1.7 Gy; p < 0.001). After adjusting for potential confounders, long lesions were associated with lower technical success (odds ratio [OR]: 0.91 per 10 mm increase; 95% confidence interval [CI]: 0.88, 0.94) and higher major adverse cardiovascular events (MACE) (OR: 1.08 per 10 mm increase; 95% CI: 1.02, 1.15). CTO PCI of long occlusions is independently associated with lower rates of technical success and higher rates of in-hospital MACE.

Clinical study on endovascular recanalization of non-acute symptomatic middle cerebral artery occlusion.

Endovascular recanalization in patients with non-acute symptomatic middle cerebral artery occlusion remains clinically challenging. Here, we aimed to evaluate the feasibility and safety of endovascular recanalization for non-acute symptomatic middle cerebral artery occlusion and propose a new patient classification. Between January 2019 and December 2021, 88 patients with non-acute symptomatic middle cerebral artery occlusion underwent prospective endovascular recanalization at our hospital. All patients were divided into three groups according to occlusion length, occlusion duration, occlusion nature, calcification of the occlusion site, and occlusion angulation. The indicators of each group were analyzed, including general baseline data, imaging data, surgical conditions, and follow-up results. Of the 88 patients, 73 were successfully recanalized and 15 were abandoned because the instruments either could not reach the distal true lumen of the occlusion or broke through the blood vessels. The overall technical success rate was 83.0% (73/88), and perioperative complications occurred in 15 patients. Preoperatively, all patients were divided into three risk groups: low, medium, and high. From the low- to high-risk groups, the recanalization rate gradually decreased (100.0, 91.7, and 16.7%, respectively, P = 0.020), the perioperative complication rate gradually increased (0, 13.9, and 83.3%, respectively, P < 0.001), the proportion of the modified Rankin scale scores >2 at 90 days increased (0, 11.7, and 50.0%, P < 0.001), and the restenosis/reocclusion rates in the 73 cases of successful recanalization increased (0, 16.1, and 100%, P = 0.012) during follow-up. Endovascular recanalization may be feasible and safe in well-selected patients with non-acute symptomatic middle cerebral artery occlusion, especially in the low- and medium-risk groups.

Real Time In Vivo Evaluation of Mitochondrial Activity and Brain Functions during Ischemic Stroke

More than 50% of total energy consumed by the brain is utilized by active transport processes which are responsible for keeping the ionic homeostasis in the brain. Under an ischemic condition, energy availability is limited, and, as a result, inhibition of the ion pumps is unavoidable. The initial consequence of such inhibition is a gradual accumulation of K+ in the extracellular space leading to a second phase of the ischemic depolarization phenomenon. During ischemic depolarization, extracellular K+ will increase 15-20-fold, while extracellular Ca2+ is decreasing 10 fold. Another optional effect of mild ischemia is the development of Cortical Spreading Depression due to the leakage of K+ into the extracellular space. The Mongolian gerbil provides a very useful animal model to study the effects of ischemia on brain functions. The aims of the study were as follows: (1) To elucidate the mechanism behind the development of ischemic depolarization or cortical spreading depression under unilateral and bilateral carotid artery occlusion. (2) To correlate the kinetics of the recovery processes to the level of ischemia. We tested the correlation between energy depletion level (evaluated by intramitochondrial NADH redox state and Cerebral Blood Flow) and the development of ischemic depolarization or cortical spreading depression (evaluated by extracellular K+, H+, Ca2+, DC potential and 366 nm reflectance changes) under partial and complete ischemia using the multiparametric monitoring system. The results could be summarized as follows: (1) Under bilateral occlusion, in all gerbils the ischemic depolarization was recorded within 1-2 min. (2) Under unilateral occlusion, the level of ischemia obtained was significantly smaller and led to the ischemic depolarization in about 60% of the gerbils. (3) The K+ leakage during the ischemic depolarization had an 'all or none' nature in terms of maximal K÷ levels and time to reach it. (4) The main effect of various lengths of bilateral occlusion was on the recovery time of extracellular K+ level. (5) Cortical spreading depression develop in most cases during the recovery from the ischemic event when ischemic depolarization was not recorded under the ischemic episode.

Predictive performance of the perivascular fat attenuation index for interventional antegrade percutaneous coronary intervention for chronic total occlusion.

This study aimed to investigate the association between the perivascular fat attenuation index (FAI) and the success of the antegrade percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). This study evaluated patients with only one CTO lesion observed on conventional coronary angiography (CAG) who underwent coronary computed tomography angiography (CCTA) < 1 month before CAG, from 2018 to 2019. The clinical data, CCTA-based CTO lesion morphologic characteristics, and perivascular FAI of CTO lesions were recorded and analysed. In total, 156 patients with CTOs were enrolled in this study. Successful antegrade PCI (A-PCI) was achieved in 105 CTO lesions (67.3%). The perivascular FAI of the failed A-PCI group was significantly lower than the successful A-PCI group (-84.76 ± 10.44 Hounsfield unit (HU) vs. -67.54 ± 9.94 HU; p < 0.001), and the cut-off value determined by the receiver operating characteristic (ROC) curve was -77.50 HU. Multivariable analysis revealed no statistical significance in the clinical data, FAI ≤ -77.50 HU (odds ratio (OR): 33.96), negative remodeling (OR: 4.36), severe calcification degree (OR: 4.43) and occlusion length ≥ 20.25 mm (OR: 3.89) were independent predictors of A-PCI failure. The prediction performance of combining the three morphologic characteristics (severe calcification, occlusion length ≥ 20.25 mm, and negative remodeling) with FAI ≤ -77.50 HU was better than that of the three morphologic characteristics alone (0.93 versus 0.77, p < 0.001). As a non-invasive index for detecting coronary inflammation, FAI complements indicators based on coronary CTA well and may be helpful for choosing appropriate interventional strategies. • Perivascular FAI of CTO was significantly higher in the failed A-PCI group. • The combination of FAI with other morphological predictors showed higher predictive performance of failed A-PCI for CTOs. • FAI is a good complement to indicators based on coronary CTA.

A TERTIARY CARE HOSPITAL’S DENTATE PATIENTS’ RIGHT RING FINGER LENGTH AND VERTICAL DIMENSION OF OCCLUSION HAVE AN ANTHROPOMETRIC CORRELATION

OBJECTIVE: To determine if there is an anthropometric relationship between dentate patients’ right ring finger(RRFL) length and vertical dimensions of occlusion (VDO) when they attend a tertiary care institution to have theirroot canal-treated teeth crowned.STUDY DESIGN: A cross-sectional studyDuration and place of study: BKMC Mardan, KPK, from August 2019 to Feb 2020METHODOLOGY: A cross-sectional study was done. The study was done at the outpatient prosthodonticsdepartment at BKMC in Mardan, KPK, from August 2019 to February 2020. Each participant sat on a dentalchair with their heads raised while a computerized Vernier scale recorded their VDO. Second, the finger was RRFLrecorded from tip to palmar digital crease farthest point. The data collection form includes age, gender, residence, andpurpose of visit to assess whether the measured lengths—the VDO and the RRFL—are related.RESULTS: There was a significant relationship (r=0.4057) between age and VDO and RRFL in the 18–25age bracket (p = 0.000336). The age group from 26 to 30 has a p-value of 0.028398 and an R-value of 0.2549.The gender-related correlation between VDO and RRFL in the male group was r = 0.3465, with a p-value of0.002493. The female group had a p-value of 0.01717 and a correlation coefficient of 0.2763.CONCLUSION: RRFL and VDO have a favorable association, suggesting that it might help determine VDO.For accurate VDO selection, using this reference point in conjunction with further measurements is advised.KEYWORDS: Prosthodontics, Vertical Dimension of Occlusion, and Right Ring Finger Length

Validation of the OPEN-CLEAN Chronic Total Occlusion Percutaneous Coronary Intervention Perforation Score in a Multicenter Registry

Coronary artery perforation is one of the most common and feared complications of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We evaluated the utility of the recently presented OPEN-CLEAN (Coronary artery bypass graft, Length of occlusion, Ejection fraction, Age, calcificatioN) perforation score in an independent multicenter CTO PCI dataset. Of the 2,270 patients who underwent CTO PCI at 7 centers, 150 (6.6%) suffered coronary artery perforation. Patients with perforations were older (69 ± 10 vs 65 ± 10, p <0.001), more likely to be women (89% vs 82%, p=0.010), more likely to have history of previous coronary artery bypass graft (38% vs 20%, p <0.001), and unfavorable angiographic characteristics such as blunt stump (64% vs 42%, p <0.001), proximal cap ambiguity (51% vs 33%, p <0.001), and moderate-severe calcification (57% vs 43%, p=0.001). Technical success was lower in patients with perforations (69% vs 85%, p <0.001). The area under the receiver operating characteristic curve of the OPEN-CLEAN perforation risk model was 0.74 (95% confidence interval 0.68 to 0.79), with good calibration (Hosmer-Lemeshow p=0.72). We found that the CTO PCI perforation risk increased with higher OPEN-CLEAN scores: 3.5% (score 0 to 1), 3.1% (score 2), 5.3% (score 3), 7.1% (score 4), 11.5% (score 5), 19.8% (score 6 to 7). In conclusion, given its good performance and ease of preprocedural calculation, the OPEN-CLEAN perforation score appears to be useful for quantifying the perforation risk for patients who underwent CTO PCI.