Optimal Revascularization Strategy Research Articles

Left Main Coronary Artery Revascularization in Patients with Impaired Renal Function: Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting

Introduction: The evidence about the optimal revascularization strategy in patients with left main coronary artery (LMCA) disease and impaired renal function is limited. Thus, we aimed to compare the outcomes of LMCA disease revascularization (percutaneous coronary intervention [PCI] vs. coronary artery bypass grafting [CABG]) in patients with and without impaired renal function. Methods: This retrospective cohort study included 2,138 patients recruited from 14 centers between 2015 and 2,019. We compared patients with impaired renal function who had PCI (n= 316) to those who had CABG (n = 121) and compared patients with normal renal function who had PCI (n = 906) to those who had CABG (n = 795). The study outcomes were in-hospital and follow-up major adverse cardiovascular and cerebrovascular events (MACCE). Results: Multivariable logistic regression analysis showed that the risk of in-hospital MACCE was significantly higher in CABG compared to PCI in patients with impaired renal function (odds ratio [OR]: 8.13 [95% CI: 4.19–15.76], p < 0.001) and normal renal function (OR: 2.59 [95% CI: 1.79–3.73]; p < 0.001). There were no differences in follow-up MACCE between CABG and PCI in patients with impaired renal function (HR: 1.14 [95% CI: 0.71–1.81], p = 0.585) and normal renal function (HR: 1.12 [0.90–1.39], p = 0.312). Conclusions: PCI could have an advantage over CABG in revascularization of LMCA disease in patients with impaired renal function regarding in-hospital MACCE. The follow-up MACCE was comparable between PCI and CABG in patients with impaired and normal renal function.

Defining the optimal revascularization strategy during protected high-risk procedures with Impella.

Complete revascularization (CR) in patients with multi-vessel disease improves outcomes. The use of percutaneous left-ventricular assist devices, such as the Impella heart pump, is useful to minimize the risk of haemodynamic compromise in complex higher risk and clinically indicated patients. The recently published data from the PROTECT III trial suggest more CR during Impella-protected percutaneous coronary intervention with more extensive lesion preparation and treatment, resulting in the reduced need for repeat revascularization. To achieve CR and improve survival, procedural guidance by intravascular imaging, extensive lesion preparation, debulking with atherectomy devices, advanced chronic total occlusion revascularization techniques, and post-interventional treatment with modern anti-platelet medication are essential.

Effect of Patient-Reported Preprocedural Physical and Mental Health on 10-Year Mortality After Percutaneous or Surgical Coronary Revascularization.

Clinical and anatomical characteristics are often considered key factors in deciding between percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with complex coronary artery disease (CAD) such as left-main CAD or 3-vessel disease. However, little is known about the interaction between self-reported preprocedural physical/mental health and clinical outcomes after revascularization. This subgroup analysis of the SYNTAXES trial (SYNTAX Extended Survival), which is the extended follow-up of the randomized SYNTAX trial (Synergy Between PCI With Taxus and Cardiac Surgery) comparing PCI with CABG in patients with left-main CAD or 3-vessel disease, stratified patients by terciles of Physical (PCS) or Mental Component Summary (MCS) scores derived from the preprocedural 36-Item Short Form Health Survey, with higher PCS and MCS scores representing better physical and mental health, respectively. The primary end point was all-cause death at 10 years. A total of 1656 patients with preprocedural 36-Item Short Form Health Survey data were included in the present study. Both higher PCS and MCS were independently associated with lower 10-year mortality (10-point increase in PCS adjusted hazard ratio, 0.84 [95% CI, 0.73-0.97]; P=0.021; in MCS adjusted hazard ratio, 0.85 [95% CI, 0.76-0.95]; P=0.005). A significant survival benefit with CABG over PCI was observed in the highest PCS (>45.5) and MCS (>52.3) terciles with significant treatment-by-subgroup interactions (PCS Pinteraction=0.033, MCS Pinteraction=0.015). In patients with both high PCS (>45.5) and MCS (>52.3), 10-year mortality was significantly higher with PCI compared with CABG (30.5% versus 12.2%; hazard ratio, 2.87 [95% CI, 1.55-5.30]; P=0.001), whereas among those with low PCS (≤45.5) or low MCS (≤52.3), there were no significant differences in 10-year mortality between PCI and CABG, resulting in a significant treatment-by-subgroup interaction (Pinteraction=0.002). Among patients with left-main CAD or 3-vessel disease, patient-reported preprocedural physical and mental health status was strongly associated with long-term mortality and modified the relative treatment effects of PCI versus CABG. Patients with the best physical and mental health had better 10-year survival with CABG compared with PCI. Assessment of self-reported physical and mental health is important when selecting the optimal revascularization strategy. URL: https://www. gov; SYNTAXES Unique identifier: NCT03417050. URL: https://www. gov; SYNTAX Unique identifier: NCT00114972.

PERCUTANEOUS CORONARY INTERVENTION VERSUS CORONARY ARTERY BYPASS GRAFTING FOR PATIENTS WITH LEFT VENTRICULAR SYSTOLIC DYSFUNCTION: A META-ANALYSIS OF KAPLAN-MEIER DERIVED INDIVIDUAL PATIENT DATA

Coronary artery disease is a common etiology of ischemic left ventricular systolic dysfunction (LVSD), for which the optimal revascularization strategy remains unclear. We aimed to determine whether percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) results in greater survival advantage in patients with LVSD by performing a a) study-level and b) reconstructed individual patient data meta-analysis of Kaplan-Meier (KM) survival curves.

Left Main Coronary Artery Disease-Current Management and Future Perspectives.

Due to its anatomical features, patients with an obstruction of the left main coronary artery (LMCA) have an increased risk of death. For years, coronary artery bypass grafting (CABG) has been considered as a gold standard for revascularization. However, notable advancements in the field of percutaneous coronary intervention (PCI) led to its acknowledgement as an important treatment alternative, especially in patients with low and intermediate anatomical complexity. Although recent years brought several random clinical trials that investigated the safety and efficacy of the percutaneous approach in LMCA, there are still uncertainties regarding optimal revascularization strategies. In this paper, we provide a comprehensive review of state-of-the-art diagnostic and treatment methods of LMCA disease, focusing on percutaneous methods.

Long-term outcomes following drug-eluting balloons vs. thin-strut drug-eluting stents for treatment of recurrent restenosis in drug-eluting stents

There is limited data on the optimal revascularization strategy in patients with recurrent in-stent restenosis (R-ISR). To compare the long-term outcomes of patients treated with either a thin-strut drug-eluting stent (thin-DES) or a drug-eluting balloon (DEB) for R-ISR in a drug-eluting stent (DES). A multicenter DEB-DRAGON registry was used to retrospectively identify patients with R-ISR who received either a thin-DES or a DEB. Propensity score matching was applied to adjust for baseline differences. The primary outcome was target lesion revascularization (TLR). Out of 311 patients (mean age, 67 years; 63% male) with R-ISR, 86 (27.7%) were treated with a thin-DES and 225 (72.3%) with a DEB. Median follow-up was 2.6 years. TLR occurred in 18 (20.9%) patients who received thin-DES and 61 (27.1%) patients treated with DEB (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.33-0.98; log-rank P = 0.04). The difference remained significant in a propensity score-matched cohort of 57 patients treated with thin-DES and 57 patients treated with a DEB (17.5 vs. 33.3%, respectively; HR, 0.38; 95% CI, 0.17-0.86; P = 0.01). The risks of device-oriented adverse cardiac events and all-cause mortality were similar after thin-DES or DEB in both unadjusted and propensity score-matched cohorts. In a multivariable Cox proportional hazard model, the treatment with a thin-DES was an independent predictor of a TLR-free survival (HR, 0.33; 95% CI 0.13-0.84; P = 0.02). In patients with R-ISR implantation of a thin-DES is associated with a lower risk of repeated revascularization compared with angioplasty with a DEB.

Factors of unfavorable prognosis for myocardial and coronary revascularization using hybrid and step-by-step percutaneous interventions and carotid endarterectomy

Aim. The study aimed at analysis of unfavorable prognostic factors and creation of a prognostic model for choosing the optimal strategy for cerebral and myocardial revascularization using carotid endarterectomy (CEE) and percutaneous coronary intervention (PCI).Material and Methods. A total of 263 myocardial and cerebral revascularizations were performed using PCI and CEE in patients with multifocal atherosclerosis and concomitant carotid and coronary artery disease from 2011 to 2017. Depending on selected treatment strategy, the patients were divided into two groups: group 1 (n = 133) comprised patients with stepby- step interventions in different sequences (CEE and PCI); group 2 (n = 130) comprised patients who underwent hybrid interventions (CEE + PCI). A binary logistic regression was performed with step-by-step inclusion and exclusion of predictors in order to identify predictive factors in the long-term period. A multivariate analysis was also performed, and the odds ratios were determined.Results. The analysis allowed to identify the significant effects of certain factors on death, favorable outcome (the absence of significant adverse cardiovascular events), and the availability of revascularization. The following protective factors increased the probability of favorable outcome in the general sample of patients throughout the entire follow-up period: the absence of chronic obstructive pulmonary disease (COPD), EUROSCORE II score of less than 1.5, compliance with prescribed therapy, no need for repeated planned revascularization in the long-term period, no emergency hospitalizations in the long-term followup period, PCI via the radial access, and CEE using the classical method. The statistically significant factors in the created model included surgical risk score by EUROSCORE II scale (for the total sample of patients and for the staged and hybrid strategies) and the coronary lesion severity by SYNTAX Score (for the total sample of patients and the hybrid strategy). It should be noted that the hybrid strategy was associated with a significantly greater availability of revascularization during the follow-up period compared with the step-by-step strategy.Conclusion. An important outcome of this study was a comprehensive analysis of a wide array of factors (clinical-instrumental, anatomic-angiographic, and perioperative), which allowed to identify predictors of adverse (favorable) outcome in the long-term follow-up period in patients with combined coronary and cerebral lesions when using PCI and CEE as the revascularization strategies.

Percutaneous Coronary Intervention of Native Artery Versus Bypass Graft in Patients with Prior Coronary Artery Bypass Graft Surgery.

Percutaneous coronary intervention (PCI) is common in patients with prior coronary artery bypass graft surgery (CABG), however, there is limited data on the association between the PCI target-vessel and clinical outcomes. In this article, we provide a state-of-the-art overview of the contemporary management of patients with prior CABG and a clear indication for revascularization. We performed a structured literature search of PubMed and Cochrane Library databases from inception to March 2021. Relevant studies were extracted and synthesized for narrative review. Twenty-six observational studies focusing on PCI of bypass graft versus native coronary artery lesions in 366,060 patients with prior CABG were included. The data from observational studies suggest that bypass graft PCI is associated with higher short- and long-term major adverse cardiac events compared to native coronary artery PCI. Whenever feasible, native coronary artery PCI should be the prioritized treatment for saphenous vein graft failure. Prospective randomized trials are needed to elucidate the optimal revascularization strategy for patients with prior CABG.

OPTIMAL REPERFUSION STRATEGY IN ACUTE HIGH-RISK PULMONARY EMBOLISM REQUIRING EXTRACORPOREAL MEMBRANE OXYGENATION SUPPORT: A SYSTEMATIC REVIEW AND META-ANALYSIS

TYPE: Late Breaking Abstract TOPIC: Pulmonary Vascular Disease PURPOSE: Optimal pulmonary revascularization strategy in acute high-risk pulmonary embolism (PE) requiring implantation of extracorporeal membrane oxygenation (ECMO) remains controversial. METHODS: We conducted a systematic review and meta-analysis of available evidence comparing mechanical embolectomy and other strategies, including systemic or catheter-directed thrombolysis, or ECMO as stand-alone therapy, with regard to mortality and bleeding outcomes. RESULTS: We identified 835 studies;17 were included, comprising 353 PE ECMO-treated patients. Overall, 30.8% had mechanical pulmonary reperfusion, (of whom 89.9% surgical embolectomy), while 69.1% received other strategies. Mortality rate was 23.0% in the mechanical reperfusion group and 43.1% in the other strategy group. The pooled OR for mortality with mechanical reperfusion was 0.46 (95%CI, 0.213-0.997; I2 = 28.3%) versus other reperfusion strategies; and 0.37 (95% CI, 0.18-0.78; p = 0.009; I 2 = 14.8%) for any surgical embolectomy vs thrombolysis. The bleeding rate in ECMO patients was 29.1% in the mechanical reperfusion group and 26.0% in the other reperfusion group (OR, 1.09; 95% CI, 0.46-2.54; I2, 0.0%) among 10 eligible studies with available bleeding data. Meta-regression did not identify any relationship between the covariates “more than one pulmonary reperfusion therapy” and “ECMO implantation before pulmonary reperfusion therapy”, and associated outcomes. CONCLUSIONS: The results of this meta-analysis and meta-regression suggest that mechanical reperfusion, notably surgical embolectomy, yields favorable results regardless of the timing of ECMO implantation in the reperfusion timeline, and independent of thrombolysis administration. CLINICAL IMPLICATIONS: Mechanical pulmonary reperfusion, especially surgical embolectomy, seems to be more effective than other strategies, especially thrombolysis, for mitigating mortality risk, at similar bleeding risk. DISCLOSURE: Grants from BMS/Pfizer, BSC, Amgen, Bayer, Janssen, Portola (GP); Honoraria from Getinge, Drager, Fresenius (MS); Honoraria from Abbott, BMS-Pfizer, Bayer, Edwards Lifesciences, Terumo (NM); Travel support from Daiichi Sankyo, Pfizer (ISC) KEYWORD: pulmonary embolism

When to Achieve Complete Revascularization in Infarct-Related Cardiogenic Shock.

Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is a life-threatening condition frequently encountered in patients with multivessel coronary artery disease (CAD). Despite prompt revascularization, in particular, percutaneous coronary intervention (PCI), and therapeutic and technological advances, the mortality rate for patients with CS related to AMI remains unacceptably high. Differently form a hemodynamically stable setting, a culprit lesion-only (CLO) revascularization strategy is currently suggested for AMI–CS patients, based on the results of recent randomized evidence burdened by several limitations and conflicting results from non-randomized studies. Furthermore, mechanical circulatory support (MCS) devices have emerged as a key therapeutic option in CS, especially in the case of their early implantation without delaying revascularization and before irreversible organ damage has occurred. We provide an in-depth review of the current evidence on optimal revascularization strategies of multivessel CAD in infarct-related CS, assessing the role of different types of MCS devices and highlighting the importance of shock teams and medical care system networks to effectively impact on clinical outcomes.

The invasive intracoronary imaging assessment of left main coronary artery disease.

Left main coronary artery disease is associated with an unfavorable prognosis. Evidence-based decision making regardingthe optimal revascularization strategy in patients with left main disease has become a challenge, in view of the recentlypublished data. An improvement in outcomes following left main percutaneous interventions could be achieved by reducingthe rate of repeat target lesion revascularization through stent optimization techniques. In the setting of left main disease, proceduralguidance by intravascular ultrasound or optical coherence tomography is essential for good long-term results, in sucha way that intravascular imaging has gained more of a therapeutic connotation. Besides stent optimization, intracoronary imagingquantifies lesion severity, guides lesion preparation through morphological data, facilitates stent selection through accuratevessel sizing, identifies the landing zones, diagnoses acute vessel wall complications such as stent-related edge dissection orintramural hematoma, and defines procedural success.This review focuses on the two main intracoronary imaging techniques used for diagnostic evaluation and proceduralguidance in left main coronary artery disease: intravascular ultrasound and optical coherence tomography. Based on the mostrecently published data, the review discusses each technique's advantages and pitfalls, and summarizes their indications.

Mechanical circulatory support in cardiogenic shock: a critical appraisal

ABSTRACT Introduction Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is a life-threatening condition frequently encounter in patients with multivessel coronary artery disease (MVD). Areas covered Despite prompt revascularization, in particular percutaneous coronary intervention (PCI), and therapeutic and technological advances, the mortality rate for CS related to AMI remains high. Differently from hemodynamically stable setting, a culprit lesion-only (CLO) revascularization strategy is currently suggested in AMI-CS patients, based on the results of a recent randomized evidence burdened by several limitations and conflicting results from non-randomized studies. Furthermore, mechanical circulatory support (MCS) devices have raised as a key therapeutic option in CS, especially in case of an early implantation without delaying revascularization and before irreversible organ damage has occurred. We provide an in-depth review of current evidences on optimal revascularization strategies of multivessel CAD in infarct-related CS, assessing the role of MCS devices, and highlighting the importance of shock teams and medical care system networks to effectively impact on clinical outcomes. Expert opinion Emerging observational experience suggested that an early implantation of MCS (prior to PCI), the performance of an extensive revascularization and the implementation of shock teams and networks are key factors for improving clinical outcomes.

Clinical results after hybrid coronary revascularization with totally endoscopic coronary surgery

BackgroundThe optimal revascularization strategy remains uncertain in multivessel coronary artery disease (MVCAD). The durability of the surgical grafts should be weighed against the decreased invasiveness of percutaneous coronary intervention (PCI). Hybrid coronary revascularization (HCR), a combination of PCI and surgery, could be a feasible alternative. This study aimed to investigate the occurrence of major adverse cardiac and cerebrovascular events (MACCE) and all-cause mortality after both endoscopic coronary artery bypass grafting (Endo-CABG) and the HCR procedure.MethodsIn this single-center retrospective observational study, 347 consecutive patients have been subjected to an Endo-CABG procedure, of which 103 underwent HCR between January 2016 and January 2018. A propensity score matching analysis was performed to match 103 Endo-CABG alone patients to the 103 HCR patients. The Endo-CABG procedure was performed through 3 endoscopic ports (5 mm) in the 2nd, 3rd, and 4th intercostal space and a utility port of 3 cm.ResultsIn both the HCR and matched endo-CABG alone group, the 30-day mortality was acceptable (0% in the HCR group and 1.94% in the matched Endo-CABG alone group, p = 0.155). Additionally, the occurrence of MACCE after a mean follow-up of 1188 ± 538 days was similar in both groups (9.71% and 11.65% for the HCR and matched Endo-CABG alone group, respectively, p = 0.652). Still, the long-term all-cause mortality over this period was significantly higher in the matched Endo-CABG alone group (2.91% after the HCR procedure and 11.65% after matched Endo-CABG alone, p = 0.002).ConclusionHCR has some advantages over Endo-CABG alone regarding the all-cause mortality, cross-clamping time, intensive care unit, and hospital length of stay. Therefore, HCR may be a suitable alternative therapy for patients with MVCAD.

Optimal reperfusion strategy in acute high-risk pulmonary embolism requiring extracorporeal membrane oxygenation support: a systematic review and meta-analysis.

The optimal pulmonary revascularisation strategy in high-risk pulmonary embolism (PE) requiring implantation of extracorporeal membrane oxygenation (ECMO) remains controversial. We conducted a systematic review and meta-analysis of evidence comparing mechanical embolectomy and other strategies, including systemic thrombolysis, catheter-directed thrombolysis or ECMO as stand-alone therapy, with regard to mortality and bleeding outcomes. We identified 835 studies, 17 of which were included, comprising 327 PE patients. Overall, 32.4% were treated with mechanical pulmonary reperfusion (of whom 85.9% had surgical embolectomy), while 67.6% received other strategies. The mortality rate was 22.6% in the mechanical reperfusion group and 42.8% in the "other strategies" group. The pooled odds ratio for mortality with mechanical reperfusion was 0.439 (95% CI 0.237-0.816) (p=0.009; I2=35.2%) versus other reperfusion strategies and 0.368 (95% CI 0.185-0.733) (p=0.004; I2=32.9%) for surgical embolectomy versus thrombolysis. The rate of bleeding in patients under ECMO was 22.2% in the mechanical reperfusion group and 19.1% in the "other strategies" group (OR 1.27, 95% CI 0.54-2.96; I2=7.7%). The meta-regression model did not identify any relationship between the covariates "more than one pulmonary reperfusion therapy", "ECMO implantation before pulmonary reperfusion therapy", "clinical presentation of PE" or "cancer-associated PE" and the associated outcomes. The results of the present meta-analysis and meta-regression suggest that mechanical reperfusion, notably by surgical embolectomy, may yield favourable results regardless of the timing of ECMO implantation in the reperfusion timeline, independent of thrombolysis administration or cardiac arrest presentation.

Comparison of coronary revascularization strategies in older adults presenting with acute coronary syndromes.

The optimal coronary revascularization strategy to maximize the patient-centered outcome of days alive and out of hospital (DAOH), in multimorbid older (≥65-years) adults after an acute coronary syndrome (ACS) is incompletely understood. Using Kaiser Permanente Northern California Health Plan databases, we identified 3871 patients ≥65-years presenting with ACS between 1/1/2010-3/1/2018 who underwent coronary revascularization with either coronary artery bypass grafting (CABG, N=1575) or multivessel percutaneous coronary intervention (PCI, N=2296). Selection bias was accounted for through propensity score modeling techniques and inverse probability of treatment weighting. Cox proportional hazards models were fit to evaluate the association of revascularization type with outcomes. Absolute DAOH and the relative risk of achieving ≥90%DAOH during three time intervals. All-cause mortality, recurrent MI, stroke, rehospitalization, repeat revascularization, and dialysis initiation. CABG (compared to PCI) was associated with greater absolute number of DAOH, significant after the first year (mean difference at 1-year: +5.8 days, 95% confidence interval [CI], -1.6 to 13 days; 3-years: +56 days, 95%CI, +25 to +88 days; 5-years: + 131 days, 95%CI, +57 to +205 days). The relative risk of achieving ≥90% DAOH significantly favored CABG after the first year (1-year:1.02, 95%CI, 0.98-1.05; 3-years:1.06, 95%CI 1.002-1.11, 5-years:1.12, 95%CI, 1.03-1.22), and was related to lower incidences of all-cause mortality, repeat revascularization, rehospitalization, incident dialysis, and nonfatal MI with CABG. In older adults with multivessel or left main coronary artery disease who presented with ACS, CABG, after the first year, was associated with a greater absolute number of DAOH-a geriatric and patient-centered outcome, compared to PCI. CABG patients also had a higher probability of achieving ≥90%DAOH-with lower all-cause mortality, recurrent MI, repeat revascularization, new dialysis, and rehospitalization rates. Future randomized trials should study the impact of optimal revascularization strategies on the quality of life of older adults with multimorbidity.

Heart Team risk assessment with angiography-derived fractional flow reserve determining the optimal revascularization strategy in patients with multivessel disease: Trial design and rationale for the DECISION QFR randomized trial.

In patients with multivessel disease (MVD), functional information on lesions improves the prognostic capability of the SYNTAX score. Quantitative flow ratio (QFR®) is an angiography‐derived fractional flow reserve (FFR) that does not require a pressure wire or pharmacological hyperemia. We aimed to investigate the feasibility of QFR‐based patient information in Heart Teams' discussions to determine the optimal revascularization strategy for patients with MVD. We hypothesized that there is an acceptable agreement between treatment recommendations based on the QFR approach and recommendation based on the FFR approach. The DECISION QFR study is a prospective, multicenter, randomized controlled trial that will include patients with MVD who require revascularization. Two Heart Teams comprising cardiologists and cardiac surgeons will be randomized to select a revascularization strategy (percutaneous coronary intervention or coronary artery bypass graft) according to patient information either based on QFR or on FFR. All 260 patients will be assessed by both teams with reference to the anatomical and functional SYNTAX score/SYNTAX score II 2020 derived from the allocated physiological index (QFR or FFR). The primary endpoint of the trial is the level of agreement between the treatment recommendations of both teams, assessed using Cohen's κ. As of March 2022, the patient enrollment has been completed and 230 patients have been discussed in both Heart Teams. The current trial will indicate the usefulness of QFR, which enables a wireless multivessel physiological interrogation, in the discussions of Heart Teams to determine the optimal revascularization strategy for MVD.

Sex Differences in Outcomes After Percutaneous Coronary Intervention or Coronary Artery Bypass Graft for Left Main Disease: From the DELTA Registries.

BackgroundControversy exists over whether sex has significant interaction with revascularization strategy for unprotected left main coronary artery disease. Higher mortality has been reported among women treated with percutaneous coronary intervention compared with coronary artery bypass grafting.Methods and ResultsThe DELTA (Drug‐Eluting Stents for Left Main Coronary Artery Disease) and DELTA‐2 registries are international, multicentric registries evaluating the outcomes of subjects undergoing coronary revascularization for unprotected left main coronary artery disease. The primary outcome was a composite of death, myocardial infarction, or cerebrovascular accidents. The population consisted of 6253 patients, including 1689 (27%) women. Women were older and more likely to have diabetes and chronic kidney disease than men (P<0.05). At a median follow‐up of 29 months (interquartile range 12–49), a significant interaction between sex and revascularization strategy was observed for the primary end point (pint=0.012) and all‐cause death (pint=0.037). Among women, compared with percutaneous coronary intervention, coronary artery bypass grafting was associated with lower risk of the primary end point (event rate 9.5% versus 15.3%; adjusted hazard ratio [AHR], 0.53; 95% CI, 0.35–0.79, P<0.001) and all‐cause death (event rate 5.6% versus 11.7% AHR, 0.50; 95% CI, 0.30–0.82) and no significant differences were observed in men.ConclusionsIn women undergoing coronary revascularization for unprotected left main coronary artery disease, coronary artery bypass grafting was associated with lower risk of death, myocardial infarction, or cerebrovascular accidents whereas no significant differences between coronary artery bypass grafting and percutaneous coronary intervention were observed in men. Further dedicated studies are needed to determine the optimal revascularization strategy in women with unprotected left main coronary artery disease.

Contemporary treatment of below-the-knee peripheral arterial disease in patients with chronic limb threatening ischemia: Observations from the Vascular Quality Initiative.

We sought to determine trends in percutaneous transluminal angioplasty (PTA) versus non-PTA interventions over time, as well as factors that influence the decision for non-PTA intervention. Although the optimal strategy for revascularization in patients with below-the-knee (BTK) chronic limb-threatening ischemia (CLTI) remains under investigation, PTA has been the preferred endovascular approach. Recently, there has been an increase in the use of non-PTA approaches for revascularization. We performed a retrospective analysis of the Vascular Quality Initiative. Between 2011 and 2020, a total of 23,850 procedures corresponding to 33,098 arteries in 19,404 patients with CLTI were included. After application of exclusion criteria and removal of missing variables, 18,644 arteries were included in the study cohort. The primary analysis was factors associated with receiving non-PTA intervention. Secondary analysis included trends in PTA versus non-PTA intervention over time. Throughout the study period, the majority of interventions (72%) were PTA alone. The percentage of non-PTA interventions, on a per-artery basis, increased over the study period from 18% to 33%, p < 0.01. Advanced age, increasing TransAtlantic Inter-Society Consensus classification, and concomitant above-the-knee disease were associated with an increased likelihood for non-PTA intervention. In contrast, longer lesion length, insulin-dependent diabetes mellitus, bilateral disease, and discharge to location other than home were associated with an increased likelihood of PTA. We observed a significant increase in the percentage of non-PTA interventions for patients with CLTI requiring BTK interventions over the last decade, with lesion- and patient-specific characteristics associated with the type of endovascular approach.

Use of mechanical pulmonary reperfusion and fibrinolysis in acute massive pulmonary embolism requiring extracorporeal membrane oxygenation support: A systematic review and meta-analysis

The optimal pulmonary revascularization strategy in acute massive pulmonary embolism (PE) requiring the implantation extra corporeal membrane oxygenation remains controversial, and data are sparse. We conducted a systematic review and meta-analysis of available evidence regarding the use of mechanical reperfusion (i.e. surgical or catheter-based embolectomy) and fibrinolytic strategies (i.e. systemic fibrinolysis, catheter-directed fibrinolysis, or as stand-alone therapy) in terms of mortality and bleeding outcomes. The literature search identified 835 studies, 17 of which were included or a total of 321 PE patients with ECMO. In total, 31.1% were treated with mechanical pulmonary reperfusion, while 78.9% received fibrinolytic strategies. The mortality rate was 23.0% in the mechanical reperfusion group and 43.1% in the fibrinolysis group ( Fig. 1 ). The pooled OR for mortality with mechanical reperfusion was 0.46 (95% CI: 0.213–0.997; I2 = 28.3%) versus fibrinolysis. The rate of bleeding in PE patients under ECMO was 29.1% in the mechanical reperfusion group and 26.0% in the fibrinolytic reperfusion (OR: 1.09; 95% CI: 0.46–2.54; I2, 0.0%) among 10 eligible studies with available bleeding data. The meta-regression model did not identify any relationship between the covariates “more than one pulmonary reperfusion therapy” and “ECMO implantation before pulmonary reperfusion therapy”, and outcomes. The results of the present meta-analysis and meta-regression suggest that surgical embolectomy yields the best results, regardless of the timing of VA-ECMO implantation in the reperfusion timeline, and regardless of whether fibrinolysis has been administered or not.

Abstract 10824: High Bleeding Risk is Associated with a Higher Prevalence of Severe Calcified Plaque in Patients Requiring Percutaneous Coronary Intervention

Introduction: Optimal revascularization strategy and shorter duration of dual antiplatelet are required in patients with coronary artery disease concomitant with high bleeding risk (HBR). More complex percutaneous coronary intervention (PCI) and subsequent high thrombotic risk in patients with HBR have been also demonstrated. However, the characteristics of culprit plaque in patients with HBR remains to be elucidated. Hypothesis: HBR is associated with more complex plaque in culprit lesion in patients requiring PCI. Methods: A total of 362 consecutive patients with stable coronary disease, who underwent optical coherence tomography (OCT) imaging of the culprit lesion during PCI were included. The characteristics of culprit plaque assessed by OCT were compared between the HBR group (n=196) and the non-HBR group (n=166), which were classified based on the Academic Research Consortium for High Bleeding Risk (ARC-HBR). Results: The prevalence of severe calcified plaque (angle &gt;180 degee, thickness &gt;0.5mm and length &gt;5mm) was significantly higher in the higher HBR group than in the non-HBR group (48 vs. 35%, p =0.016), although other characteristics were comparable (Panel A). Among patients with HBR, the incremental prevalence of severe calcified plaque according to the number of major ARC-HBR criteria met was observed ( p &lt;0.001) (Panel B). Conclusions: HBR was associated with a higher prevalence of severe calcified plaque in culprit lesion in patients with stable coronary disease requiring PCI. The greater number of major ARC-HBR criteria met was associated with a higher prevalence of severe calcified plaque among patients with HBR.