Complication Of Percutaneous Coronary Intervention Research Articles

Thrombose de stent : quoi de neuf en 2017 ?

Stent thrombosis (ST) is still a dreadful and threatening complication of percutaneous coronary intervention (PCI) with a high risk of morbi-mortality. Nevertheless, it becomes exceptional (0.6% at 1 year and 0.15%/year later) thanks to improvement of stents and use of new P2Y12 inhibitors. Endo-coronary imaging and especially Optical Coherence Tomography (OCT) change radically its understanding with revealing quiet systematic morphologic endoluminal abnormalities (97% of the cases). OCT becomes an essential tool in practice (ESC recommendation class IIa) and allows a therapeutic strategy optimization. Its prevention is based on mechanical causes correction and a personalized adaptation of anti-platelet treatment.

Right coronary artery perforation extending to the coronary sinus of Valsalva during percutaneous intervention successfully sealed with polytetrafluoroethylene-covered stent: a case report

BackgroundRight coronary artery perforation extending to the sinus of Valsalva is a rare and potentially fatal complication of percutaneous coronary intervention. There are no definite guidelines on the management strategies for such complications. Treatment modality depends on the patient’s haemodynamic stability and the extent of aortic involvement. Polytetrafluoroethylene-covered stents have emerged as a revolutionary strategy, enabling efficient endovascular repair of the entry port of such dissections, particularly the coronary ostia, and obviating the need for high-risk emergent surgical intervention.Case presentationA 60 year old Bangladeshi gentleman underwent a coronary angiogram following a prior inferior ST elevation myocardial infarction (MI), 1 month previously. Coronary angiography done via right radial approach using 5 FR TIG catheter showed diffuse mid RCA disease with maximum 90% stenosis. Angioplasty of the RCA was planned. The RCA was cannulated with a 6-French JR 3.5 guiding catheter (USA). The lesion was crossed by a 0.014 inch guide wire and stented with a 2.75 × 38 mm novolimus-eluting DESyne stent, after predilatation. Immediately after stenting, a Type II perforation was observed in the ostial RCA, which progressed into the right coronary sinus of Valsalva. As the patient was haemodynamically stable with no ischaemia on ECG, we attempted to seal the ostial RCA with bare metal stents. Two successive bare metal stents failed to seal the aorto-coronary dissection. Ultimately, a 3.0 × 19 mm polytetrafluoroethylene-covered stent was deployed to seal the entry port in the ostial RCA, yielding a satisfactory angiographic result with only minimal contrast staining limited to the right sinus of Valsalva. The patient was closely monitored and discharged on dual antiplatelet therapy comprising of aspirin and prasugrel. He remained asymptomatic and with follow up echocardiograms showing no pericardial effusion nor extension of the dissection.ConclusionsThe polytetrafluoroethylene-covered stent provides a safe and effective means of sealing iatrogenic aorto-coronary dissections complicated by Ellis type II or II perforations, thus avoiding emergency surgery. However, as they are associated with increased incidence of stent thrombosis, an efficient and prolonged post-PCI antiplatelet regimen is recommended.

Percutaneous Coronary Intervention of Chronic Total Occlusions in Patients With Low Left Ventricular Ejection Fraction

ObjectivesThe study sought to assess the outcome of percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) in patients with low left ventricular ejection fraction (LVEF) (≤35%). BackgroundData regarding the outcome of PCI in patients with low LVEF affected by CTO are scarcely reported. MethodsThe authors performed a prospective longitudinal multicenter study including consecutive patients undergoing elective PCI of CTOs. Patients were subdivided into 3 groups: group 1 (LVEF ≥50%), group 2 (LVEF 35% to 50%), and group 3 (LVEF ≤35%). ResultsA total of 839 patients (mean 64.6 ± 10.5 years of age, 87.7% men) underwent CTO PCI attempts. Baseline LVEF ≤35% was present in 72 (8.6%) patients. The angiographic success was high (overall 93.6%) and similar among the 3 groups (93.5% vs. 94.4% vs. 91.7%, respectively; all p = NS). In group 3, no periprocedural complications of CTO PCI were observed. Mean clinical follow-up of 16.3 ± 8.2 months duration was available in 781 (93.1%) patients including those with LVEF ≤35%. At 2 years, major cardiac and cerebrovascular events (MACCE) free survival was similar in the 3 groups (86% vs. 82.8% vs. 75.2%; all p = NS). In patients with LVEF ≤35%, LVEF improved significantly in the presence of a successful CTO PCI from 29.1 ± 3.4% to 41.6 ± 7.9% (p < 0.001). ConclusionsIn CTO patients with low LVEF, PCI could represent a safe and effective revascularization strategy achieving good midterm outcome and LVEF improvement.

TCT-638 Non-pharmaco, Non-invasive approach in treatment of coronary No-reflow phenomenon

No-reflow is a common complication of percutaneous coronary intervention (PCI) (primary, acute coronary syndrome, stable coronary disease and graft vessel disease) with adverse outcomes. Microvascular obstruction of downstream bed is the culprit. Intracoronary administration of various calcium

Clinical Characteristics and Management of Coronary Artery Perforations: A Single-Center 11-Year Experience and Practical Overview.

BackgroundCoronary artery perforation (CAP) is a potentially lethal complication of percutaneous coronary intervention. We report on the incidence, clinical characteristics, and management of iatrogenic coronary perforations based on an 11‐year single‐center experience.Methods and ResultsFrom February 9, 2005, through November 20, 2016, 150 CAP cases were identified from our percutaneous coronary intervention database of 21 212 procedures (0.71%). Mean age of CAP patients was 66±11 years, and 62.7% were male. Treated lesion type was B2/C in 94.6%, and 31.3% were chronic total occlusions. Nonworkhorse guidewires were applied in 74.3%. CAP types were Ellis type I in 2.9%, Ellis type II in 40.4%, Ellis type III in 54.8%, and Ellis type III cavity spilling in 1.9%. CAP treatment was conservative (including prolonged balloon inflation) in 73.3%. Covered stents, coiling, and fat embolization were used in 24.0%, 0.7%, and 2.0%, respectively. Pericardiocentesis for tamponade was required for 72 patients (48.0%), of whom 28 were initially unrecognized. Twelve patients (12.7%) required emergency cardiac surgery to alleviate tamponade. Periprocedural myocardial infarction occurred in 34.0%, and in‐hospital all‐cause mortality was 8.0%. All‐cause mortality accrued to 10.7% at 30 days and 17.8% at 1 year.ConclusionsCAP is a rare complication of percutaneous coronary intervention, but morbidity and mortality are considerable. Early recognition and adequate management are of paramount importance.

Plasma big endothelin-1 and stent thrombosis: An observational study in patients undergoing percutaneous coronary intervention in China

IntroductionStent thrombosis (ST) is a rare but catastrophic complication of percutaneous coronary intervention, leading to poor prognosis. Endothelin-1 (ET-1) plays an important role in endothelial dysfunction and thrombogenesis. However, the impact of big ET-1 level on ST in patients with coronary stenting is unknown. We aimed to evaluate big ET-1 level as a potential predictor of ST in patients undergoing percutaneous coronary intervention. Materials and methodsFrom January 2013 to December 2013, 8106 consecutive patients underwent successful coronary stent implantation and were prospectively enrolled in this study. Patients were stratified into three groups based on plasma big ET-1 level at admission. ResultsThe incidence of definite and probable ST at 2years postoperatively was 0.84%; ST incidence was lowest in the low big ET-1 group (0.56%), highest in the high big ET-1 group (1.48%), and intermediate in the medium big ET-1 group (0.74%, log-rank p=0.001). Compared with the low big ET-1 group, the multivariate-adjusted hazard ratio (HR) for ST in the high big ET-1 group was 2.06 (95% confidence interval (CI) 1.14–3.73, p=0.017). In subgroup analyses, high big ET-1 level was independently associated with ST in patients with acute coronary syndrome (HR 2.29, 95% CI 1.03–5.06, p=0.041), but not in those with stable coronary artery disease (p=0.331), and tended to be associated with older age. ConclusionsPlasma big ET-1 level is a valuable independent predictor of ST in patients with coronary stents, especially in the acute coronary syndrome population.

PP.14.31] RISK FACTORS AND PROGNOSIS OF CONTRAST-INDUCED ACUTE KIDNEY INJURY IN PATIENTS UNDERGOING PERCUTANEOUS CORONARY INTERVENTION

Objective: Contrast-induced acute kidney injury (CI-AKI) is a serious potentially preventable complication of percutaneous coronary interventions (PCI). It remains a challenge as use of PCI is growing, patient population is aging, diabetes and chronic kidney disease are coming more common. The risk factors and prognosis of CI-AKI are not well defined. The aim of the study was to evaluate the risk factors and prognosis of CI-AKI in patients undergoing PCI. Design and method: 502 patients (346 male, 64 ± 12 years (M ± SD), arterial hypertension 92%, previous myocardial infarction 38%, diabetes mellitus (DM) 22%, known chronic kidney disease 19%, anemia 16%, heart failure 62%, left ventricular ejection fraction 40 ± 16%) who underwent PCI (stable angina pectoris (SAP), n = 50; unstable AP/non-ST-segment elevation myocardial infarction (UAP/NSTEMI), n = 236; STEMI, n = 216) were examined. CI-AKI was defined using 2012 KDIGO Guidelines. Mann-Whitney test and multivariate logistic regression analysis were performed. P < 0.05 was considered statistically significant. Results: 18% of total population, in SAP patients 12%; UAP/NSTEMI, 15%; STEMI, 20%, developed CI-AKI (p < 0.01). Patients with versus without CI-AKI in total population were older (68 ± 13 vs 63 ± 12 years, p < 0.05), had higher baseline SCr (114 ± 31 vs 92 ± 23 μmol/l, p < 0.05), white blood cells (WBC) (11.08 ± 2.41 vs 9.62 ± 3.86, p < 0.05), higher rate of DM (25 vs 15%, p < 0.05),), anemia (30 vs 15%, p < 0.05) and higher rate of main left coronary artery disease (29 vs 15%, p < 0.01), higher contrast media volume/estimated glomerular filtration rate ratio (CV/eGFR) (4.32 ± 2.35 vs 2.47 ± 1.02, p < 0.05). Main independent predictors of CI-AKI were anemia (OR 2.42; 95% CI 1.43–4.09; p < 0.05), main left coronary artery disease (OR 2.29; 95% CI 1.35–3.89; p < 0.001), DM (OR 1.82; 95% CI 1.05–3.17; p < 0.05). Patients with CI-AKI had higher risk of 30-days mortality (11 vs 4%, p < 0.05) and similar rate of 6 months rehospitalizations (63 vs 48%, p < 0.05). Conclusions: CI-AKI was associated with higher rate of comorbidities (DM, anemia), higher baseline serum creatinine and WBC, main left coronary artery disease. CI-AKI had negative impact on 30-days mortality and 6 months rehospitalizations.

Editor's Choice- What do small serum creatinine changes tell us about outcomes after acute myocardial infarction?

Acute kidney injury (AKI), mostly defined as a rise in serum creatinine concentration of more than 0.5 mg/dl, is a common, serious, and potentially preventable complication of percutaneous coronary intervention and is associated with adverse outcomes including an increased risk of inhospital mortality. Recent data from the National Cardiovascular Data Registry/Cath-PCI registry including 985,737 consecutive patients undergoing percutaneous coronary intervention suggest that approximately 7% experienced AKI with a reported incidence of 3-19%. In patients undergoing primary percutaneous coronary intervention for acute myocardial infarction (AMI), AKI occurs more frequently with rates up to 20% depending on patient and procedural characteristics. However, varying definitions of AKI limit comparisons of AKI rates across different studies. Recently, most studies have adopted the Acute Kidney Injury Network (AKIN) criteria for definition and classification of AKI. Beyond the AKIN criteria for AKI, other classifications such as the risk, injury, failure, loss and end-stage kidney disease (RIFLE) and kidney disease: improving global outcomes (KDIGO) criteria are used to define AKI. Notably, even small increases in serum creatinine beyond AKI may be associated with adverse outcomes including increased hospital length of stay and excess. Acute kidney injury (AKI) is a serious and potentially preventable complication of percutaneous coronary intervention (PCI). Worsening renal function is associated with adverse outcomes including a higher rate of in-hospital mortality. In patients undergoing primary PCI for acute myocardial infarction (AMI), AKI occurs up to 20% of such individuals. Varying definitions of AKI limit comparisons of AKI rates across different studies. Additionally, even small increases in serum creatinine beyond lavels meeting AKI definitions may be associated with adverse outcomes including increased hospital length of stay.

Risk Factors For Radiation-Induced Skin Ulceration in Percutaneous Coronary Interventions of Chronic Total Occluded Lesions: A 2-Year Observational Study

Relationship between radiation-induced skin ulceration (RSU) and variables in percutaneous coronary interventions (PCI) was rarely reported. RSU is a severe complication in PCIs, especially for chronic total occlusion (CTO) lesions. We investigated the RSUs and their risk factors in patients receiving CTO PCIs over a 2-year period. Data were analyzed using chi-square tests, t-tests and receiver operating characteristic (ROC) curve. Of 238 patients, 11 patients (4.6%) had RSUs all at right upper back. RSUs were significantly associated with use of left anterior oblique (LAO) views (100% vs. 47.1%, p < 0.001), retrograde techniques (36.3% vs. 7.9%, p = 0.012), or a procedure time (PT) defined as a time duration between the first and last angiograms of > 120, 180, or 240 minutes (p < 0.05). ROC analysis showed a long PT was an accurate predictor of RSUs (AUC = 0.88; p < 0.001) at a cut-off of 130 minutes (sensitivity = 0.91, specificity = 0.81). The results showed risk factors for RSUs containing use of large LAO views, retrograde techniques, and prolonged PTs. This study suggests that, to minimize RSU, interventionalists should limit PT to roughly 2 hours in fixed LAO views.

Effects of nicorandil on PI3K/Akt signaling pathway and its anti-apoptotic mechanisms in coronary microembolization in rats.

Coronary microembolization (CME) is a common complication of percutaneous coronary intervention (PCI) for acute coronary syndrome. It leads to myocardial apoptosis and cardiac dysfunction. Nicorandil pretreatment can prevent PCI-related myocardial injury and reduce the incidence of no- or slow-reflow phenomena. This cardioprotective effect is probably attributable to the suppression of CME-induced cardiomyocyte apoptosis, but the specific mechanisms have not been clarified. We aimed to investigate the protective effects of nicorandil pretreatment on CME-induced myocardial injury and clarify the underlying mechanisms. In vivo studies, we used echocardiography, cardiac-enzymes measurement, hematoxylin–basic fuchsin–picric acid staining, TUNEL assay, and western blot, and found that CME significantly increased apoptotic cardiomyocytes in the infarct and peri-infarct areas in rats. The PI3K/Akt signaling pathway was involved in cardiomyocyte apoptosis. Nicorandil pretreatment given 7 days before CME effectively reduced cardiomyocyte apoptosis and myocardial injuries in rats, mainly through the activation of PI3K/Akt signaling. In vitro studies further showed that nicorandil reduced hypoxia-induced cardiomyocyte apoptosis and improved cardiomyocyte-survival rate. The PI3K-specific inhibitor LY294002 reduced these cardioprotective effects, indicating that they were attributable to the activation of the PI3K/Akt signaling pathway. In conclusion, nicorandil has significant cardioprotective effects in CME mainly through the activation of the PI3K/Akt signaling pathway and reduction of CME-induced cardiomyocyte apoptosis. Our findings may provide important support for the pre-PCI use of nicorandil to reduce post-PCI myocardial injuries.

Minor Myocardial Injury: An Early Post Intervention Complication

Percutaneous Coronary Intervention (PCI) is the most commonly performed invasive therapeutic cardiac procedure and plays an important role in the treatment of ischemic heart disease. Complications of Percutaneous Coronary Intervention (PCI) are relatively infrequent. The most common complications include discomfort and bleeding at the puncture site where the catheter was inserted. Major complications include death, MI, or stroke and other infrequent complications include transient ischemic attacks (minor myocardial injury), vascular complication and contrast induced nephropathy, transient ischemia, or minor myocardial injury (MMI), myocardial necrosis due to compromisation of threatened coronary circulation during balloon inflation. Cardiac Troponin I (cTnI) assays for the assessment of myocardial injury has been demonstrated for the diagnosis of MMI and long term prognosis after PCI.Delta Med Col J. Jul 2017 5(2): 94-98

Predictors of Impaired Reperfusion after Percutaneous Coronary Intervention in Patients with In-Hospital Acute Stent Thrombosis: A Retrospective Analyses of 5 Years of Data.

Acute stent thrombosis (STh) is a rare complication of percutaneous coronary intervention (PCI) and is associated with a high-risk of reperfusion failure. However, data focusing on risk factors of reperfusion failure in patients undergoing repeat PCI for treatment of STh remains inadequate. A total of 8815 patients who underwent PCI with stent implantation from January 2009 to December 2013 were retrospectively reviewed. Among those cases, patients that presented with acute STh and underwent a repeat PCI for acute STh were identified. There were 108 patients who underwent repeat PCI for the treatment of in-hospital acute STh that were retrospectively analyzed. Of these study subjects, 21 (25%) had thrombolysis in myocardial infarction (TIMI) flow < 3 after repeat PCI. The median value of pain-to-balloon time was 40 minutes in the TIMI < 3 group, 35 minutes in the TIMI = 3 group (p < 0.001), and the first PCI-to-stent thrombosis time was also longer in the TIMI < 3 group (10 hours vs. 2.5 hours, p = 0.001). When patients were evaluated according to PCI time, the percentage of patients with TIMI < 3 was significantly higher in the night period compared to the daytime period (46.4% vs. 17.5 %, p = 0.002). In the multivariable logistic regression analysis, stent length [odds ratio (OR) = 1.18, 95% confidence interval (CI) 1.008-1.38] and pain-to- balloon time (OR = 1.28, 95% CI, 1.06-1.54) were the only independent predictors of failed reperfusion. Baseline stent length and pain-to-balloon time were associated with reperfusion failure in PCI for STh. Moreover, TIMI flow grade showed a circadian variation.

Coronary Perforation of Distal Diagonal Branch Followed by Prolonged Recurrent Cardiac Tamponade Finally Resolved with Pericardiotomy - the Potential Risk of Hydrophilic Guide-Wires.

Purpose:Coronary artery perforation (CAP) is a complication of percutaneous coronary interventions (PCIs). Hydrophilic guide-wires have been shown to increase the probability of CAP. Depending on the size of perforations we adopt different treatments.Case:We present the case of a 73-year old male with coronary artery disease and severe aortic valve stenosis. The patient was in the process of qualifying for a transcatheter aortic valve implantation. Unfortunately, CAP of the first diagonal branch of the LAD occurred during PCI. Initially, abrupt bleeding to the pericardial sac was primarily restrained. However, in the following days, pericardial bleeding became silent, prolonged and finally resulted in surgical pericardiotomy and surgical aortic valve replacement.Conclusion:This case depicts that in some cases, more aggressive endovascular treatment of CAP during the acute phase could decrease the probability of future radical surgical treatment. Although, in other cases, avoiding radical endovascular treatment of CAP and secondary necrosis along the distribution of the artery culminates in a higher risk for conversion to a surgical cardiac procedure. Accurate primary assessment of CAP seriousness and careful observation after PCI could improve results and lead to avoiding severe complications.

Pre-Procedural Blood Glucose Level and Contrast-Induced Nephropathy after Percutaneous Coronary Intervention in Non Diabetic Patients with Acute Coronary Syndrome

Background: Contrast induced nephropathy (CIN) is not an uncommon complication of percutaneous coronary intervention (PCI) and it is more in diabetic patients. But we do not know the incidence and consequences of CIN of patients with high blood sugar but not known diabetic. We planned to find the relationship between level of admission blood glucose and contrast induced nephropathy after PCI in Acute Coronary Syndrome (ACS) in non-diabetic patients.Methods: This prospective observational study was conducted in National Institute of Cardiovascular Diseases, Dhaka from January 2012 to June 2012. Total 120 patients were observed in two groups, group-I non-diabetic with normal blood glucose (?7.8 mmol/L) and group-II non-diabetic with high blood glucose (?7.8 mmol/L).Results: Results show increase in serum creatinine (0.1mg/dl vs. 0.3 mg/dl) and decrease in creatinine clearance rate (12.9 ml/min vs. 6.0ml/min) was more in hyperglycemic than normoglycemic. When most common definition of contrast induced nephropathy was used, the incidence of CIN was 24% in high blood glucose group and 4% in normal blood glucose group (p=0.004). The higher the admission blood glucose level there is more incidence of contrast induced nephropathy. Multivariate analysis of factors associated with CIN shows that patients with high blood glucose (&gt;7.8 mmol/l) and &gt; 150 ml of contrast exposure are independent predictors of contrast induced nephropathy. The patients subjected to PCI having high blood glucose were at 6 times higher risk of developing CIN than normal blood glucose and use of contrast &gt;150 ml were more than 2 times higher risk of developing CIN.Conclusion: Patients with high blood sugar on admission of ACS patients have more chance of developing CIN after PCI.Cardiovasc. j. 2017; 9(2): 106-115

Effect of transcatheter embolization by tissue adhesive Histoacryl in treatment of coronary artery perforation during percutaneous coronary intervention

Aim. Coronary artery perforation (CAP) is a rare but severe complication of percutaneous coronary intervention (PCI). The aim of our study was to evaluate the effect and safety of transcatheter embolization by tissue adhesive Histoacryl when treating CAP.Methods. As CAP was confirmed, the final composition of the tissue adhesive histoacryl and radiopaque agent Lipiodol was prepared. The perforated vessel was embolized by tissue adhesive Histoacryl via a micro-catheter. There were eleven patients undergoing transcatheter embolization by Histoacryl in treatment of CAP during PCI at Academician Ye. Meshalkin Novosibirsk Research Institute of Circulation Pathology from March 2013 to February 2016, and the clinical data of these patients were collected and analyzed retrospectively.Results. The lesion morphology of the patients was classified by using the American College of Cardiology/American Heart Association Task Force classification, there were four patients with Class B2 lesions and seven patients with Class C lesions (there also were four patients with chronic total occlusion lesions). According to the Ellis classification of CAP, there were five patients with Class II perforations and six patients with Class III perforations. The causes of perforation were a guide wire (ten patients) and balloon predilation (one patient). Three patients had pericardial effusion. All of the eight patients with CAP underwent transcatheter embolization by Histoacryl. Coronary angiography confirmed that all of them had been embolized successfully. There were no severe postoperative complications. Conclusion. Transcatheter embolization by Histoacryl is an effective, safe, cheap, and easy way to treat perforation of small vessels during PCI.Received 14 September 2016. Accepted 2 February 2017.Financing: The study did not have sponsorship.Conflict of interest: Conflict of interest: Evgeny I. Kretov served as guest editor on this issue on vascular surgery. The other authors declare no conflict of interest.Author contributionsData collection and analysis: Shermuk A.A., Naryshkin I.A., Grankin D.S., Zubarev D.D., Ibragimov R.U., Baystrukov V.I. Drafting the article: Shermuk A.A., Khelimskiy D.A., Krestyaninov O.V. Critical revision: Shermuk A.A., Khelimskiy D.A., Krestyaninov O.V., Kretov E.I.

Analysis of percutaneous coronary interventions in a 10-year period (2005-2015) - a single center experience.

Background: Medicor was established as the third cardiovascular center in Slovenia and started with percutaneous cardiovascular interventions in 2005. The purpose of our study was to describe the features and results of percutaneous coronary intervention (PCI) performed between 2005 and 2015. Methods: Our retrospective descriptive study included consecutive patients undergoing PCI, who were enrolled in the PCI Registry. Patient characteristics, coronary anatomy, PCI features, use of coronary stents, procedural success and complications were investigated. Special emphasis was put on patients undergoing unprotected left main PCI. Results: During the study period, 1981 PCI procedures were performed. PCI patients were mainly men (73 %), their average age was 65+10 years and a majority (94 %) had stable coronary disease with mutivessel involvement (62 %). PCI was performed on 2978 lesions (1.50 lesion/patient) with an average diameter stenosis of 85+10 %. Target lesion was located either in the left anterior descending artery (42.9 %), right coronary artery (32.4 %), left circumflex artery (18.4 %), left main (3 %), surgical grafs (2.3 %) or in the intermediate artery (1 %). Balloon angioplasty alone was used in 9.6 % while other patients received 1 to 7 stents (1.44+0.86 per patient). Until 2009, drug eluting stents (DES) penetration ranged between 20 % and 30 %. It then increased to 80 % in 2012 and 100 % in 2015. PCI was angiographically successful in 95.2 %. Because of PCI complications, 4 patients (0.2 %) required immediate open-heart surgery and 4 patients (0.2 %) a surgical intervention at the femoral access site. Hospital mortality was 0 %. Stent thrombosis within 30 days was documented in 6 patients (0.3 %). In a subgroup of 58 patients undergoing unprotected lef main PCI, provisional stenting was used in 88 %. DES penetration was 94 %. PCI was angiografcally successful in all patients. Hospital and 30-day mortality rates were 0 %, 1-year mortality 1.7 % (95 % confidence interval 0–11 %) and 5-year mortality 13.8 % (95 % confidence interval 7–33 %). Target vessel revascularization at 5 years was 3.5 % (95 % confidence interval 0–23 %). Conclusion: PCI in patients with predominantly stable coronary artery disease in the Medicor Cardiovascular Center appears to be an effective and safe method of revascularization, which is also true for an intervention in unprotected left main.

Analiza izvajanja perkutanih koronarnih posegov v 10-letnem obdobju (2005–2015) – izkušnje enega centra

Background: Medicor was established as the third cardiovascular center in Slovenia and started with percutaneous cardiovascular interventions in 2005. The purpose of our study was to describe the features and results of percutaneous coronary intervention (PCI) performed between 2005 and 2015.Methods: Our retrospective descriptive study included consecutive patients undergoing PCI, who were enrolled in the PCI Registry. Patient characteristics, coronary anatomy, PCI features, use of coronary stents, procedural success and complications were investigated. Special emphasis was put on patients undergoing unprotected left main PCI.Results: During the study period, 1981 PCI procedures were performed. PCI patients were mainly men (73 %), their average age was 65+10 years and a majority (94 %) had stable coronary disease with mutivessel involvement (62 %). PCI was performed on 2978 lesions (1.50 lesion/patient) with an average diameter stenosis of 85+10 %. Target lesion was located either in the left anterior descending artery (42.9 %), right coronary artery (32.4 %), left circumflex artery (18.4 %), left main (3 %), surgical grafs (2.3 %) or in the intermediate artery (1 %). Balloon angioplasty alone was used in 9.6 % while other patients received 1 to 7 stents (1.44+0.86 per patient). Until 2009, drug eluting stents (DES) penetration ranged between 20 % and 30 %. It then increased to 80 % in 2012 and 100 % in 2015. PCI was angiographically successful in 95.2 %. Because of PCI complications, 4 patients (0.2 %) required immediate open-heart surgery and 4 patients (0.2 %) a surgical intervention at the femoral access site. Hospital mortality was 0 %. Stent thrombosis within 30 days was documented in 6 patients (0.3 %). In a subgroup of 58 patients undergoing unprotected lef main PCI, provisional stenting was used in 88 %. DES penetration was 94 %. PCI was angiografcally successful in all patients. Hospital and 30-day mortality rates were 0 %, 1-year mortality 1.7 % (95 % confidence interval 0–11 %) and 5-year mortality 13.8 % (95 % confidence interval 7–33 %). Target vessel revascularization at 5 years was 3.5 % (95 % confidence interval 0–23 %).Conclusion: PCI in patients with predominantly stable coronary artery disease in the Medicor Cardiovascular Center appears to be an effective and safe method of revascularization, which is also true for an intervention in unprotected left main.

Anti-platelet drugs, pharmacogenomics and stent thrombosis: What’s new?

Stent thrombosis is a catastrophic complication of percutaneous coronary intervention (PCI) and is associated with a mortality of 25 to 40%. The perception that stent thrombosis is very low in all patients has resulted in a lack of adherence to professional guidelines. New data to identify patients at increased risk for stent thrombosis are emerging. Clopidogrel is a prodrug and the activation of clopidogrel is dependent on CY2C19. Numerous alleles of CYP2C19 exist. The allele CYP2CP*2 has been associated with a marked decrease in platelet responsiveness to clopidogrel. Heterozygote carriers of the CYP2C19*2 have a 2.7 fold increased risk and homozygotes a 4.8 fold increased risk of stent thrombosis. Prospective randomised clinical trials will be necessary to determine the efficacy of CYP2C19 genotype directed therapy in evidence-based clinical decision making. Point-of-care platelet-function tests are becoming available and some centres are now performing such tests on their PCI patients. The most recent AHA/ACC /SCAI guidelines recommend testing for clopidogrel responsiveness in patients at high risk of subacute stent thrombosis and recommend increasing the dose of clopidogrel in non-responders.

Management of Percutaneous Coronary Intervention Complications.

With the recent increase in complex coronary interventions including percutaneous coronary intervention (PCI) for chronic total occlusions and complex higher risk (and indicated) patients, the spectrum of potential periprocedural complications and their prompt management has become even more relevant. Vascular access-related problems remain the most prevalent of all PCI complications and with randomized controlled trial data from over 20,000 patients supporting the superiority of radial over femoral access in reducing bleeding and vascular complications, a default radial strategy should be promoted. The European Society of Cardiology guidelines have acknowledged this by giving a class 1 (level of evidence: A) recommendation for a radial approach for PCI. The US society guidelines, however, have thus far lagged behind. Each individual patient undergoing a PCI should be risk-stratified objectively using available risk prediction models based on patient comorbidities and anatomical and procedural complexities. Customized informed consent should therefore be provided to all patients and should include the potential risks from radiation injury. Here, we review the current data related to common periprocedural complications related to PCI.

Update on the Management of Chronic Total Occlusions in Coronary Artery Disease.

Chronic total occlusions (CTOs) are found in about a third of patients with coronary artery disease (CAD) and can pose a significant challenge during percutaneous revascularization. However, advances in CTO percutaneous coronary intervention (PCI) strategies, devices, and algorithms have led to significant improvements in successful treatment of CTOs. This review summarizes current management of CTOs in the context of modern PCI techniques and current evidence. The hybrid algorithm now provides a standardized, teachable approach to CTO PCI, and success rates are approximately 90% in experienced hands. The first randomized controlled trial in patients with CTOs recently reported that patients with ST elevation myocardial infarction (STEMI) and a CTO in the non-culprit vessel showed an improvement in ejection fraction in patients undergoing CTO PCI of the LAD, but not other vessels. Updated data from the SYNTAX trial showed a benefit with complete revascularization in patients with coronary artery disease (CAD). Incomplete revascularization of CTOs in the PCI group may explain some of the benefit seen with CABG over PCI in patients with complex coronary disease. Contemporary CTO registries have reported success rates of approximately 90%, and the OPEN-CTO registry updates our understanding of CTO PCI complication rates and outcomes. The available evidence highlights the potential benefits of CTO PCI in patients with an indication for revascularization. Technological advancements have paved the way for success rates approaching 90% at high-volume centers, but further studies evaluating outcomes following CTO PCI are needed, with several currently underway.