Percutaneous Coronary Intervention Cases Research Articles

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

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

Effect of COVID-19 Pandemic Lockdown on Emergency Medical Service Utilisation, and Percutaneous Coronary Intervention Volume—An Australian Perspective

Acute coronary syndrome (ACS) admissions and percutaneous coronary intervention (PCI) volume declined during periods of COVID-19 lockdown internationally in 2020. The effect of lockdown on emergency medical service (EMS) utilisation, and PCI volume during the initial phase of the pandemic in Australia has not been well described. We analysed data from the Victorian Cardiac Outcomes Registry (VCOR), a state-wide PCI registry, linked with the Ambulance Victoria EMS registry. PCI volume, 30-day major adverse cardiovascular and cerebrovascular events (MACCE; composite of mortality, myocardial infarction, stent thrombosis, unplanned revascularisation, and stroke), and EMS utilisation were compared over four time periods: lockdown (26 Mar 2020-12 May 2020); pre-lockdown (26 Feb 2020-25 Mar 2020); post-lockdown (13 May 2020-10 Jul 2020); and the year prior (26 Mar 2019-12 May 2019). Interrupted time series analysis was performed to assess PCI trends within and between consecutive periods. The EMS utilisation for ACS during lockdown was higher compared with other periods: lockdown 39.4% vs pre-lockdown 29.7%; vs post-lockdown 33.6%; vs year prior 27.1%; all p<0.01. Median daily PCI cases were similar: 31 (IQR 10, 38) during lockdown; 39 (15, 49) pre-lockdown; 39.5 (11, 44) post-lockdown; and, 42 (10, 49) the year prior; all p>0.05. Median door-to-procedure time for ACS indication during lockdown was shorter at 3 hours (1.2, 20.6) vs pre-lockdown 3.9 (1.7, 21); vs post-lockdown 3.5 (1.5, 21.26); and, the year prior 3.5 (1.5, 23.7); all p<0.05. Lockdown period was associated with lower odds for 30-day MACCE compared to pre-lockdown (odds ratio [OR] 0.55 [0.33-0.93]; p=0.026); post-lockdown (OR 0.66; [0.40-1.06]; p=0.087); and the year prior (OR 0.55 [0.33-0.93]; p=0.026). Contrary to international trends, EMS utilisation for ACS increased during lockdown but PCI volumes remained similar throughout the initial stages of the pandemic in Victoria, with no observed adverse effect on 30-day MACCE during lockdown. These data suggest that the public health response in Victoria was not associated with poorer quality cardiovascular care in patients receiving PCI.

Standby extracorporeal membrane oxygenation: a better strategy for high-risk percutaneous coronary intervention.

The incidence of cardiac arrest (CA) during percutaneous coronary intervention (PCI) is relatively rare. However, when it does occur, the mortality rate is extremely high. Extracorporeal cardiopulmonary resuscitation (ECPR) has shown promising survival rates for in-hospital cardiac arrests (IHCA), with low-flow time being an independent prognostic factor for CA. However, there is no definitive answer on how to reduce low-flow time. This retrospective study, conducted at a single center, included 39 patients who underwent ECPR during PCI between January 2016 and December 2022. The patients were divided into two cohorts based on whether standby extracorporeal membrane oxygenation (ECMO) was utilized during PCI: standby ECPR (SBE) (n = 13) and extemporaneous ECPR (EE) (n = 26). We compared the 30-day mortality rates between these two cohorts and investigated factors associated with survival. Compared to the EE cohort, the SBE cohort showed significantly lower low-flow time (P < 0.01), ECMO operation time (P < 0.01), and a lower incidence of acute kidney injury (AKI) (P = 0.017), as well as peak lactate (P < 0.01). Stand-by ECMO was associated with improved 30-day survival (p = 0.036), while prolonged low-flow time (p = 0.004) and a higher SYNTAX II score (p = 0.062) predicted death at 30 days. Standby ECMO can provide significant benefits for patients who undergo ECPR for CA during PCI. It is a viable option for high-risk PCI cases and may enhance the overall prognosis. The low-flow time remains a critical determinant of survival.

Patient radiation exposure dose reduction using stent-enhanced image processing in percutaneous coronary intervention.

We investigated the reduction in patient radiation exposure dose during percutaneous coronary intervention (PCI) by stent enhancement processing. We examined the effects of dose reduction based on the image quality of stent enhancement processing using a purpose-built dynamic phantom. We evaluated the image contrast (IC) of the stent in stent-enhanced images (SVref), digital angiography (DA), and stent-enhanced images with a 20%, 40%, and 60% lower imaging doses (SV20, SV40, and SV60). We visually evaluated graininess and stent shape using the mean opinion score (MOS) and retrospectively evaluated the acquisition duration of stent enhancement in PCI cases; finally, we estimated the decrease in patient radiation exposure due to stent enhancement. The image contrast of SVref at phantom thicknesses of 20cm was 51.25 ± 3.82, while the image contrast of DA was significantly reduced at 14.90 ± 1.57 (p < 0.05). We observed a significant decrease in the MOS of graininess in SV60 and MOS of stent shape in DA (p < 0.05). Furthermore, the average imaging duration for stent enhancement using PCI was 22.65 ± 7.43s, and the maximum imaging duration was 68.07s. We hypothesize that patient radiation exposure dose can be reduced by up to 60.17mGy by lowering the imaging dose during the stent enhancement process. Stent enhancement processing improves the visibility of stent images, and can reduce radiation exposure by approximately 40% during confirmation imaging of stents. Our study contributes to the reduction of radiation exposure dose for operators and patients in PCI.

Streamlining same-day discharge for percutaneous coronary intervention: a single-center experience

Introduction and objectivesSame-day discharge (SDD) can be considered for patients who traditionally required overnight stay (ONS) after percutaneous coronary intervention (PCI). The authors aimed to evaluate viability of SDD-PCI. MethodsRetrospective single-center observational study of patients who underwent elective PCI. SDD patients were selected based on clinical, angiographic, and sociodemographic characteristics. Patient and procedure characteristics were collected from local databases, and SDD-PCI adverse events (all-cause mortality, acute coronary syndrome, stent thrombosis, reintervention, major bleeding, stroke, contrast-induced renal failure, vascular access complications) at 30-days were analyzed. ResultsThis study included 147 patients, 76% males with a mean age of 66±10, that underwent elective PCI during the first year after implementation of SDD protocol. Most patients undergoing elective PCI were discharged the same day (n=94, 64%). ONS group, when compared to SDD, had higher rates of acute coronary syndrome (38% vs 19%, P=.01) and left ventricular dysfunction (17% vs 6%, P=.04), higher Syntax I score (10 points [6–16] vs 8 points [5–12]; P=.01), more cases of multivessel PCI (24% vs 6%, P<.01) and a surrogate for longer procedures – fluoroscopy time (11min [7–15] vs 8min [5–13]; P=.02). There were no adverse events during the 30-day follow-up period of the patients treated in ambulatory regimen. ConclusionsSDD-PCI is a safe procedure. Protocol implementation is key to guide interventional cardiologists in low-risk patient selection. The potential role in decreasing bed-shortage, hospital overcrowding, and healthcare costs is pivotal.

Impact of intracoronary imaging-guided percutaneous coronary intervention on procedural outcomes among complex patient groups

Abstract Background Intracoronary imaging (ICI) has been previously shown to improve survival and clinical outcomes after percutaneous coronary intervention (PCI). However, whether this prognostic benefit is sustained across different indications/patient groups remains unclear. Methods All PCI procedures performed in England and Wales between 1st April 2014 and 31st March 2020 were retrospectively analysed. The association between ICI use and in-hospital MACCE (major adverse cardiovascular and cerebrovascular outcomes; composite of all-cause mortality, stroke and reinfarction) and mortality was examined using multivariable logistic regression analysis for each imaging-recommended indication (stent thrombosis (ST), in-stent restenosis, stent length&amp;gt;60mm, acute coronary syndrome (ACS) indications, chronic total occlusion, left main stem (LMS) intervention, renal failure and bioresorbable vascular scaffolds (BVS)). Results Of 555,398 PCI procedures, 10.8% (n=59,752) were performed under ICI guidance. ICI use doubled between 2014 (7.8%) and 2020 (17.5%). ICI use was highest for BVS (44.7%) and LMS PCI (41.2%) cases and lowest in ACS (9%). Overall, the odds ratios (OR) of in-hospital MACCE and mortality were only reduced with ICI-guided PCI in cases with an imaging-recommended indication (OR 0.75 95% confidence interval (CI) 0.69-0.81 and OR 0.69 95%CI 0.63-0.76, respectively). Only specific imaging-recommended indications were associated with reduced MACCE and mortality, including LMS PCI (OR 0.45 95%CI 0.39-0.52 and 0.41 95%CI 0.35-0.48, respectively), ACS (OR 0.76 95%CI 0.70-0.82 and 0.70 95%CI 0.63-0.77), stent length&amp;gt;60mm (OR 0.75 95%CI 0.59-0.94 and 0.72 95%CI 0.54-0.95). ST was only associated with lower mortality (OR: 0.69 95%CI 0.52-0.91) while renal failure was associated with reduced MACCE (OR 0.77 95%CI 0.60-0.99) but not mortality. (Figure 1) Conclusion The utilisation of ICI has more than doubled over a seven-year period at a national level but remains low, with less than 1-in-5 procedures performed under ICI guidance. In-hospital survival was better with ICI-guided than angiography-guided PCI, albeit only for specific indications.Figure 1

Right and left radial access for coronary angiography and percutaneous coronary intervention after coronary artery bypass graft surgery: no need to go down

Abstract Introduction Currently is estimated that at least 90% of the coronary studies are performed through the radial access. However, in patients with prior coronary artery bypass graft surgery (CABG) the femoral access continues to be widely used due to an easier and more successful graft engagement. Evidence of the efficacy and security of the radial approach use in this population is both scarce and controversial. Purpose We aimed to compare radial (right and left) versus femoral access to perform coronary angiography (CA) and/or percutaneous coronary intervention (PCI) after CABG. Methods In this comparative historical cohort study conducted at a national reference center, all CA and PCI performed from January 2012 to October 2022 were eligible for review. Electronic and physical records were examined for demographic and interventional data. Groups were classified for comparison as CA plus PCI, CA only and PCI only. Results We identified 563 patients; radial access was used in 227 (40%). In CA plus PCI group, in only one case existed failure to cannulate bypass grafts by the initial chosen access (from right radial access [RRA] to the left internal mammary artery [LIMA]). The crossover rate for any cause other than graft cannulation failure was 11.3% with right radial access (p = 0.002), 4.2% with left radial access (p = 0.28) and 0% with the femoral route. Fluoroscopy time was greater in RRA compared to femoral, nevertheless left radial access (LRA) had lower fluoroscopy time and contrast volume compared to RRA and femoral access. In the CA only group, failure to cannulate bypass grafts occurred exclusively when the LIMA had to be cannulated from the RRA (8.3% p=0.001); with a crossover rate for any cause other than graft cannulation failure was greater in the radial access compared to femoral (RRA 18.1% p &amp;lt; 0.001; LRA 4.2% p = 0.002; femoral 0.5% P=0.001), LRA had greater fluoroscopy time but the femoral access had greater contrast volume use in relation with a higher number of venous bypass grafts [143.64 mL (±69.36), p = 0.01]. There were 15 cases of PCI only, were fluoroscopy time and contrast volume were greater in LRA (N= 2 none were for treatment of LIMA) and lower in RRA compared to LRA and femoral access. Vascular complications were infrequent in all groups, being minor bleeding in the femoral access the most frequent, with no statistical significance. Conclusion Right and left radial access are feasible to perform coronary angiography and PCI after CABG, compared to the femoral route are associated with less contrast volume despite a greater crossover rate. This analysis suggests that the LRA should be preferred over the RRA when angiography of the LIMA is needed.

Efficacy of the tip-detection method over the retrograde approach for chronic total occlusion percutaneous coronary intervention

Abstract Background The tip-detection method has been acknowledged as a novel strategy for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) when conventional antegrade wiring strategies are ineffective, but a comparison with the retrograde approach has yet to be carried out. Method We retrospectively enrolled 170 consecutive CTO PCI cases and separated them according to the adopted strategies. The wire-manipulation time for each strategy was compared between the tip-detection method and the retrograde approach. The rate of successful wire crossing was analyzed according to the variables in the complexity scores. Results Fifty-six attempts with the tip-detection method were observed, with 46 (82.1%) successful cases. Sixty-one retrograde approaches were performed, in which 29 (47.5%) cases achieved procedural success. In the successful attempts, the wire-manipulation time was significantly shorter with the tip-detection method (20.0 [12.2-36.7] min) than with the retrograde approach (35.0 [20.7-49.7] min) (p=0.008). Incomplete tip-detection wire crossing (taking &amp;gt;30 min) was seen in severely tortuous lesions (odds ratio: 0.26, 95% confidence interval: 0.06–0.97, p = 0.037). Conclusions The tip-detection method can improve the rate and time required for successful CTO PCI compared with the retrograde approach. However, the success rate of the tip-detection method is hampered by lesion tortuosity.Figure

Abstract 18298: 10-Year Trends of In-Hospital Outcomes of Patients That Underwent Percutaneous Coronary Intervention for Cardiogenic Shock Complicating Acute Coronary Syndrome

Background: Cardiogenic shock complicating acute coronary syndrome (CS-ACS) is a life-threatening condition and percutaneous coronary intervention (PCI) remains a fundamental approach in its management. In recent years, notable advancements have emerged, including the utilization of mechanical circulatory support (MCS) devices and an enhanced understanding of patient selection for PCI. This study aims to assess the temporal trends in patient background and outcomes of patients who underwent PCI for CS-ACS. Methods: The Keio interhospital Cardiovascular Studies (KiCS)-PCI registry prospectively collects approximately 200 variables, which were defined in accordance with the National Cardiovascular Data Registry (NCDR), from the major teaching hospitals in Tokyo metropolitan area in Japan. Between 2009 and 2019, 24,671 consecutive cases were registered, 10,053 patients (40.7%) undergoing PCI for ACS, of which 870 patients (8.5%) had CS-ACS. We stratified CS-ACS patients into 4-time frame groups (T1: 2009-2011, T2: 2012-2013, T3: 2014-2016, and T4: 2017-2019), and examined the temporal trends in patient risk profiles using the NCDR score (ranging 0-100, reflecting predicted mortality rates). Additionally, we assessed the incidence and types of employed MCS as well as the in-hospital mortality rate. Results: During the study period, the proportion of CS-ACS remained stable, accounting for 8.0% in T1 to 8.2% in T4 of ACS-related PCI cases. The calculated NCDR risk score demonstrated minimal variation, ranging from 70.6 in T1 to 70.1 in T4. There was a notable decrease in the utilization of MCS (66.5% in T1 to 56.7% in T4), mainly driven by a reduction in the use of intra-aortic balloon pump (70.3% to 55.0%, p for trend&amp;lt;0.001), with a increase in the concomitant use of veno-arterial-extracorporeal membrane oxygenation (27.6% to 36.2%, p for trend&amp;lt;0.001). However, the in-hospital mortality rate for CS-ACS patients remained persistently high at 30%. Conclusion: Over the past decade, there have been notable changes in the peri-procedural management of CS-ACS, albeit no significant improvements in patient outcomes was observed. The result calls for additional efforts to enhance their management.

Abstract 15027: Predicting Recurrence of Myocardial Infarction in Post-PCI Patients Using Machine Learning

Introduction: While prevention of recurrent myocardial infarction (MI) is important in the management of patients after percutaneous coronary intervention (PCI), risk stratification of MI remains a significant challenge with increasingly diverse and complex patient backgrounds. This retrospective observational study aimed to explore whether machine learning (ML) methods can predict recurrent MI after PCI using a variety of features extracted from electronic medical records (EMRs). Methods: Seven machine learning algorithms were retrospectively applied to predict recurrent MI within two years after PCI (124 cases, 4.2%) from a total of 2984 PCI cases. The imbalance in the proportion of positive and negative data was resolved by introducing misclassification costs. Basic patient information (e.g., age, sex, risk factors) and laboratory test results were used for the analysis. Feature importance was calculated to identify key factors for MI recurrence. Five-fold cross-validation was used to calculate accuracy, sensitivity, specificity, positive predictive value, and negative predictive value (NPV) for each model. Results: As shown in Figure 1a, several ML models showed excellent diagnostic accuracies in the prediction of recurrent MI, demonstrating high NPV. Although the weighting of feature importance for MI recurrence varied among ML models, infarct size (peak CK levels), increased inflammatory status, acute coronary syndrome, and traditional coronary risk factors were identified as important features for predicting recurrent MI within two years after PCI (Figure 1b). Conclusions: It is suggested that ML using EMR data is promising for predicting recurrent MI within two years after PCI. Further studies are warranted to address whether ML-based risk stratification could lead to improved clinical decision-making after PCI.

Rates of the Trans-radial Approach in Elective and Emergency Coronary Angiography in Iraq: A Cross-Sectional Study.

Background and aims The trans-radial access is becoming the default approach in many cardiac centers worldwide. Data from the Middle East, including Iraq, on the trends and rates of the use of trans-radial access are scarce. The aim of this study is to determine the rates of trans-radial approach (TRA) versus transfemoral approach (TFA) in patients with coronary artery syndromes undergoing coronary angiography and/or percutaneous coronary intervention (PCI) in Iraq. Methods In this multicenter prospective study, we collected 885 cases of coronary artery disease undergoing coronary angiography/PCI from three main cities of the Kurdistan Region in Iraq from 2022 to 2023. Results Of the total sample, 57.2% were diagnostic coronary angiography and 42.8% were PCI, 57.1% of all cases were TFA and 42.9% were TRA, and 64.3% of PCI cases were performed through TFA. Eghty-two percent of total emergency PCI included (primary PCI) cases underwent the procedure through the TFA, and only 18% of such cases were through the TRA. The overall crossover rate between both approaches happened in 14 (3.6%) cases. Conclusions Despite its main benefits, the radial access use in the Cath lab is yet underused in our region. Further steps in training programs are indicated to popularize the use of radial access among interventional cardiologists in addition to transfemoral access.

Zero Contrast and Ultra-Low Contrast Percutaneous Coronary Intervention

Contrast-induced acute kidney injury (AKI) is a common complication following percutaneous coronary intervention (PCI) in patients with a background of chronic kidney disease (CKD). This complication can lead to short- and long-term dialysis requirements. There has been some interest in recent years in performing PCI in high-risk patients with minimal use of contrast to avoid this complication. We reviewed a case series of eight cases where ultra-low-contrast PCI was performed and a further case of zero-contrast PCI, which were primarily performed under the guidance of intravascular imaging. Pre- and post-renal functions were recorded, and clinical outcomes were measured based on the survival rate and the need for revascularisation in the culprit vessel. A step-by-step description of how to perform the procedure safely and effectively is provided. There were no procedural complications encountered in this cohort. The renal function remained stable 1 week after the procedure. The procedure was technically successful in all cases based on intravascular and angiographic measures. Patients were followed up for a minimum of 6 months and no adverse clinical events were recorded. A description of the procedural steps is provided based on current experience and review of the literature. Ultra-low-contrast PCI is feasible and safe in a carefully selected group of patients in centres with experience in the use of intravascular imaging.

Coronary angiography and percutaneous coronary intervention after transcatheter aortic valve replacement: Feasibility in clinical practice

Introduction and ObjectiveCoronary artery disease is highly prevalent among patients with severe aortic stenosis who undergo transcatheter aortic valve replacement (TAVR). As indications for TAVR are now expanding to younger and lower-risk patients, the need for coronary angiography (CA) and percutaneous coronary intervention (PCI) during their lifetime is expected to increase. The objective of our study was to assess the need for CA and the feasibility of re-engaging the coronary ostia after TAVR. MethodsWe performed a retrospective analysis of 853 consecutive patients undergoing TAVR between August 2007 and December 2020. Patients who needed CA after TAVR were selected. The primary endpoint was the rate of successful coronary ostia cannulation after TAVR. ResultsOf a total of 31 CAs in 28 patients (3.5% of 810 patients analyzed: 57% male, age 77.8±7.0 years) performed after TAVR, 28 (90%) met the primary endpoint and in three cannulation was semi-selective. All failed selective coronary ostia cannulations occurred in patients with a self-expanding valve. Sixteen (52%) also had indication for PCI, which was successfully performed in all. The main indication for CA was non-ST-elevation acute coronary syndrome (35%, n=11). Two cases of primary PCI occurred without delay. There were no complications reported during or after the procedure. ConclusionAlthough CA was rarely needed in patients after TAVR, selective diagnostic CA was possible in the overwhelming majority of patients. PCI was performed successfully in all cases, without complications.

Effects of Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting on Clinical Outcomes in Patients with Reduced Ejection Fraction Heart Failure and Coronary Heart Disease: A Meta-Analysis.

To clarify the effects of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) on the clinical outcomes of patients with coronary heart disease (CHD) complicated with reduced ejection fraction heart failure (HFrEF) through meta-analysis. Three major literature databases - PubMed, Web of Science, and Cochrane - were searched by search terms and the literature retrieval time was publications dating from January 2007 to December 2021. To search for observational studies and randomized controlled trials (RCT) comparing the efficacy of PCI and CABG in patients with CHD and HFrEF, the abstract or full text of the literature was read and the final included literature was determined, according to inclusion and exclusion criteria. The quality of the included literature was evaluated using the Ottawa scale and data extraction was further completed. Data analysis was made using RevMan5.4 and R4.1 software; relevant forest plots and funnel plots were made, according to the extracted data. Egger's test was used to evaluate whether the data had publication bias. Outcomes were the major adverse cardiovascular events (MACE). A total of 10 studies were included and 11,032 subjects were included, made up of 5,521 cases of PCI and 5,511 cases of CABG. The results showed no significant difference between the two groups in cardiac mortality (CM) (RR=1.13, 95% CI 0.98-1.30, P = 0.10) and in overall all-cause mortality (ACM) (RR=1.12, 95% CI 0.92-1.37, P = 0.25). In the subgroup analysis of ACM, in the subgroups with left ventricular ejection fraction (LVEF) less than 35% and exceeding 35% and less than 50% (RR=1.12, 95% CI 0.92-1.37, P = 0.25) between the two groups, there was no statistical difference. However, among other MACE, compared with the PCI group, the CABG group had a lower risk of MACE (RR=1.58, 95%CI 1.49-1.70, P < 0.00001), myocardial infarction (MI) (RR=1.99, 95% CI 1.02-3.88, P = 0.04), heart failure (HF) (RR=1.29, 95% CI 1.17-1.43, P < 0.00001) and revascularization (RR=2.74, 95% CI 1.93-3.90, P < 0.00001). Finally in the CABG group, the risk of stroke or transient ischemic attack (TIA) was higher (RR=0.71, 95% CI 0.58-0.86, P = 0.0006) than the PCI group. The mortality rates of PCI and CABG were similar in patients with CHD complicated with HFrEF. Compared with PCI, CABG had a lower incidence of MACE, MI, HF, and revascularization, and a higher incidence of stroke or TIA.

Comparative analysis of percutaneous revascularization practice in the United States and the United Kingdom: Insights from the BMC2 and BCIS databases.

International registry comparisons provide insight into regional differences in clinical practice patterns, procedural outcomes, and general trends in population health and resource utilization in percutaneous coronary intervention (PCI). We sought to compare data from a state-wide PCI registry in the United States with a national registry from the United Kingdom (UK). We analyzed all PCI cases from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium and the British Cardiovascular Intervention Society registries from 2010 to 2017. Procedural characteristics and in-hospital outcomes were stratified by PCI indication. A total of 248,283 cases were performed in Michigan and 773,083 in the United Kingdom during the study period. The proportion of patients with a prior diagnosis of diabetes in Michigan was nearly double that in the United Kingdom (38.9% vs. 21.0%). PCI for ST-elevation myocardial infarction was more frequent in the UK (25% UK vs. 14.3% Michigan). Radial access increased in both registries, reaching 86.8% in the UnitedKingdom versus 45.1% in Michigan during the final study year. Mechanical support utilization was divergent, falling to 0.9% of cases in the United Kingdom and rising to 3.95% of cases in Michigan in 2017. Unadjusted crude mortality rates were similar in the two cohorts, with higher rates of post-PCI transfusion and other complications in the Michigan population. In a real-world comparison using PCI registries from the US and UK, notable findings include marked differences in the prevalence of diabetes and other comorbidities, a greater proportion of primary PCI with more robust adoption of transradial PCI in the United Kingdom, and divergent trends in mechanical support with increasing use in Michigan.

Meta-Analysis on the Safety and Efficacy of Transradial Approach in Chronic Total Occlusion Percutaneous Coronary Intervention

The aim of this study was to compare the efficacy and safety of transradial approach (TRA) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) with the efficacy and safety of transfemoral approach (TFA). We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies (OS) reporting the outcomes of TRA versus TFA in CTO PCI. The primary end point was procedural success. Secondary end points included access-site complications, in-hospital adverse events, procedural efficacy outcomes, and 30-day all-cause mortality. A total of 28,754 CTO PCI cases from 19 studies were included (2 RCTs and 17 OS). The pooled mean J-CTO score is 2.3. The main analysis showed a trend toward a higher success rate for TRA (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.00 to 1.38), but this was not the case in the secondary analysis, which included only RCTs and OS with moderate risk of bias (OR 0.99, 95% CI 0.81 to 1.22). TRA was associated with significant reductions in access-site complications (OR 0.33, 95% CI 0.24 to 0.45) and major bleeding (OR 0.34, 95% CI 0.20 to 0.59), and a similar risk of other in-hospital adverse events and 30-day mortality (p >0.05) to that of TFA. Moreover, there was less fluoroscopy time (minutes) and contrast volume use (ml) in the transradial CTO PCI (mean difference: -6.19 [-10.98 to -1.40] and -22.14[-34.56 to -9.72], respectively). In conclusion, the transradial PCI in appropriate CTO lesions was associated with a lower incidence of access-site complications/major bleeding than was TFA and a similar other periprocedural complications rate, without compromising procedural success.

Transformation of the Cardiovascular Clinics in Japan - How to Overcome Crisis Due to Changes in the External Environment.

The first percutaneous coronary intervention (PCI) was performed in September 1977, and after 1980 this minimally invasive treatment was established in Japan. To deliver this treatment to a larger population, a number of cardiovascular clinics emerged across the country in the 2000s, and the number of PCI cases performed has been steadily increasing, to >250,000 cases per year. In the early 2000s, a single catheterization unit was profitable, if it performed a certain number of treatments and was adequately staffed without excessive capital investment. In the late 1990s, the price of a balloon catheter medical device used for PCI was approximately JPY300,000, although the price was reduced to JPY32,000, almost one-tenth in price, in the April 2022 revision of the National Health Insurance. The reimbursement of the mainstream drug-eluting stent has also decreased from JPY421,000, when it was first introduced, to JPY136,000 currently. In addition, the consumption tax and reforms in working hours will have a major impact on clinic management. We present a history of cardiovascular clinics in Japan and their present and future positions under the variable external environment.

Role of the retrograde Carlino technique for chronic total occlusion percutaneous coronary intervention.

There is scarce data on the outcomes of the Carlino technique for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We aimed to investigate the indications and outcomes of the Carlino technique as performed in the context of the retrograde approach. We pooled CTO PCI cases where a retrograde Carlino technique was performed from high-volume operators at four centers. The Carlino technique was characterized according to its indication (achieving plaque/cap modification, clarifying microcatheter location within the vessel, resolving distal cap ambiguity) and was considered successful when it led to the desired outcome. A total of 43 patients were included. Occlusion complexity was very high (mean J-CTO score 3.3 ± 0.8). The two most common indications were understanding the anatomy of the occlusion and clarifying gear location (37.2%) and impenetrable distal cap (34.9%). The Carlino technique was successful in 88.4% of cases. Overall technical and procedural success was 86.0%. The most common successful crossing technique was reverse controlled antegrade and retrograde subintimal tracking (70.3%). No complications were attributed to the Carlino technique. We observed a high success rate of the retrograde Carlino technique, as well as overall technical and procedural success rates. No Carlino technique-related complications were observed. Additional data from larger registries are warranted to further confirm the safety and efficacy of this technique.

Book Review Manual of Chronic Total Occlusion Percutaneous Coronary Interventions: A Step-by-Step Approach

The Manual of Chronic Total Occlusion Percutaneous Coronary Interventions: A Step-by-Step Approach, Third Edition is a useful reference for percutaneous coronary intervention (PCI) with chronic total occlusion (CTO). Written by national and international experts in the field of CTO and edited by Emmanuel Brilakis, this book gives the steps necessary to do CTO PCI, the pitfalls to watch out for, and how to modify tactics if we face CTO complications. This manual book is dedicated and made for interventional cardiologists, interventional cardiology fellows, general cardiology residents, also cardiac catheterization laboratory staff. This book will give you the latest state of the art in the field of CTO PCI. In this new edition, new numbers, images, and algorithms have been developed and shared to reflect the CTO PCI updates. Additionally, this update includes links to nearly 200 of his CTO PCI cases. The structure of the book has been completely revised to align with the recently published Manual of Percutaneous Coronary Intervention.

647 COMPLEX PERCUTANEOUS CORONARY INTERVENTION IN HIGHT BLEEDING AND THROMBOTIC RISK PATIENT: WHICH ANTITHROMBOTIC THERAPY?

Abstract Background Antiplatelet therapy is required in patients with atherosclerotic coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES). Current European and American guidelines recommend 6 months of DAPT in CCS and 12 months after ACS. However, a shorter duration of DAPT may be considered in high bleeding risk (HBR) patients, and a longer duration in those at higher thrombotic risk (HTR). To minimize the risk of thrombotic and bleeding events of an individual patient and therefore improve the overall outcomes of PCI, risk stratification is essential. In particular, bleeding and thrombotic characteristics must be weighed on a case-by-case basis to tailor antiplatelet therapy strategies and decisions over a patient's individual risk profile. We describe an illustrative case of complex PCI in patient with ACS in which defining the appropriate duration of DAPT is a clinical challenge. Clinical case A 68-year-old man with ACS-NSTEMI and anemia was hospitalized in intensive care unit. His medical history was notable for hypertension, dyslipidemia, diabetes mellitus, diabetic retinopathy, chronic kidney disease (CKD) and paroxysmal atrial fibrillation. A transthoracic echocardiogram showed left ventricular ejection fraction of 30% with diffuse hypokinesia, without relevant valvular disease. He was conducted to the cath-lab for a diagnostic coronary angiogram which showed a three-vessel critical CAD. After Heart Team evaluation coronary artery bypass surgery (CABG) was indicated. However, during the hospitalization in intensive care unit there was a worsening of clinical conditions with cognitive impairment due to mesencephalic stroke leading to a new Heart Team assessment that indicated PCI after stabilization of clinical scenario. After two weeks patient was conducted to the cath-lab to undergoing an IVUS guided PCI. PCI of the right coronary artery was performed with implantation of 1 DES (3.0/30 mm) on the middle segment and 1 DES (4.0/15 mm) on the ostial segment. PCI of the left main bifurcation was performed with implantation of 2 DES (4.0/28 mm) with culotte technique. Patients have both HBR and HTR, therefore, after procedure, the new trade off model score introduced by the Academic Research Consoritum (ARC) was applied. Based on his risk factor, the predicted 1-y risk of BARC type 3 to 5 bleeding (51.41%) was greater than the predicted 1-y risk of myocardial infarction or stroke (25.00%). Based on this result we decided to prescribe Triple antithrombotic therapy for 1 week, dual antithrombotic therapy for 12 months and after only oral anticoagulation. Conclusion In the context of patient with several risk factor undergoing complex PCI the stratification of bleeding and thrombotic individual risk is mandatory to define the appropriate duration of DAPT. The new trade-off model score is an important useful tool to identify patients who might benefit from individualized DAPT durations depending on the balance between HBR and HTR characteristics.