Percutaneous Coronary Intervention For Lesions Research Articles

Coronary orbital atherectomy using a five-French guiding catheter.

Recently, the efficacy was demonstratedof the Diamondback 360® Coronary Orbital Atherectomy System (OAS) (Cardiovascular Systems, Inc., St. Paul, MN, USA) for treating calcified coronary lesions in percutaneous coronary intervention (PCI). The safety and feasibility of OAS application through a 5-Fr guiding catheter (GC) which is less invasive and reduces access site complications were validated. This sequential, retrospective, observational study was conducted in a single center from September 2018 to May 2020. The primary endpoint was a successful PCI with the OAS. Secondary endpoints were major adverse complications related to PCI with the OAS, including coronary dissection, perforation, side branch loss, need for an unexpected cardiac assist device, access site complications, and major adverse cardiac and cerebrovascular events. 33 PCIs in 30 patients (mean age 72 ± 11years; male, 83.3%) were surveyed. All PCIs were successfully completed with OAS application through a 5-Fr GC. Coronary perforation after the OAS procedure occurred in one case (3.0%). Severe coronary dissection occurred in three cases (9.1%), and procedural myocardial infarction in two cases (6.1%). Regarding PCIs performed with the 5-Fr GC, the OAS is a safe and feasible strategy for calcified plaque modification.

Impact of intravascular ultrasound and final kissing balloon dilatation on long-term clinical outcome in percutaneous revascularization with 1-stent strategy for left main coronary artery stenosis in drug-eluting stent era.

It remains uncertain whether intravascular ultrasound (IVUS) use and final kissing balloon (FKB) dilatation would be standard care of percutaneous coronary intervention (PCI) with a simple 1-stent technique in unprotected left main coronary artery (LMCA) stenosis. This study sought to investigate the impact of IVUS use and FKB dilatation on long-term major adverse cardiac events (MACEs) in PCI with a simple 1-stent technique for unprotected LMCA stenosis. Between June 2006 and December 2012, 255 patients who underwent PCI with 1 drug-eluting stent for LMCA stenosis were analyzed. Mean follow-up duration was 1663 ± 946 days. Long-term MACEs were defined as death, nonfatal myocardial infarction (MI) and repeat revascularizations. During the follow-up, 72 (28.2%) MACEs occurred including 38 (14.9%) deaths, 21 (8.2%) nonfatal MIs and 13 (5.1%) revascularizations. The IVUS examination and FKB dilatation were done in 158 (62.0%) and 119 (46.7%), respectively. IVUS use (20.3 versus 41.2%; log-rank P < 0.001), not FKB dilatation (30.3 versus 26.5%; log-rank P = 0.614), significantly reduced MACEs. In multivariate analysis, IVUS use was a negative predictor of MACEs [hazards ratio 0.51; 95% confidence interval (CI) 0.29-0.88; P = 0.017], whereas FKB dilatation (hazard ratio 1.68; 95% CI, 1.01-2.80; P = 0.047) was a positive predictor of MACEs. In bifurcation LMCA stenosis, IVUS use (18.7 versus 48.0%; log-rank P < 0.001) significantly reduced MACEs. In nonbifurcation LMCA stenosis, FKB dilatation showed a trend of increased MACEs (P = 0.076). IVUS examination is helpful in reducing clinical events in PCI for LMCA bifurcation lesions, whereas mandatory FKB dilatation after the 1-stent technique might be harmful in nonbifurcation LMCA stenosis.

Ten-Year Trends in Coronary Bifurcation Percutaneous Coronary Intervention: Prognostic Effects of Patient and Lesion Characteristics, Devices, and Techniques.

BackgroundDespite advances in devices and techniques, coronary bifurcation lesion remains a challenging lesion subset in the field of percutaneous coronary intervention (PCI). We evaluate 10‐year trends in bifurcation PCI and their effects on patient outcomes.Methods and ResultsWe analyzed 10‐year trends in patient/lesion characteristics, devices, PCI strategy, stent optimization techniques, and clinical outcomes using data from 5498 patients who underwent bifurcation PCI from 2004 to 2015. Clinical outcomes 2 years after the index procedure were evaluated in terms of target vessel failure (a composite of cardiac death, myocardial infarction, and target vessel revascularization) and a patient‐oriented composite outcome (a composite of all‐cause death, myocardial infarction, and any revascularization). During the 10‐year study period, patient and lesion complexity, such as multivessel disease, diabetes mellitus, chronic kidney disease, and left main bifurcation, increased continuously (all P<0.001). The risk of target vessel failure or patient‐oriented composite outcome decreased continuously from 2004 to 2015 (target vessel failure: from 12.3% to 6.9%, log‐rank P<0.001; patient‐oriented composite outcome: from 13.6% to 9.3%, log‐rank P<0.001). The use of a second‐generation drug‐eluting stent and decreased target vessel failure risk in true bifurcation lesions were the major contributors to improved patient prognosis (interaction P values were <0.001 and 0.013, respectively).ConclusionsDuring the past decade of bifurcation PCI, patient and lesion characteristics, devices, PCI techniques, and patient prognosis have all significantly changed. Despite increased patient and lesion complexity, clinical outcomes after bifurcation PCI have improved, mainly because of better devices and more widespread adoption of procedural optimization techniques and appropriate treatment strategies.RegistrationURL: https://www.clinicaltrials.gov; Unique identifiers: NCT01642992 and NCT03068494.

Percutaneous coronary intervention in side branch coronary arteries: Insights from the Japanese nationwide registry.

BackgroundPerformance of percutaneous coronary intervention (PCI) in side-branch vessels (SB-PCI) has not been fully investigated despite the technical advancement of PCI.MethodsWe investigated 257,492 patients registered in the Japanese nationwide PCI registry from January to December 2018; 199,767 (78%) underwent PCI for major vessel PCI (MV-PCI), 21,555 (8.4%) underwent SB-PCI, and 24,862 (9.6%) underwent PCI for both vessels (SB + MV-PCI). The frequencies of primary composite adverse events, defined as in-hospital mortality and procedural complications (i.e., peri-procedural myocardial infarction, tamponade, new-onset cardiogenic shock, stent thrombosis, emergent surgery, and bleeding), and PCI for restenotic lesions were investigated. Their association with institutional frequency of each PCI was also investigated.ResultsFewer drug-eluting stents (66% vs. 86%) and more drug-coated balloons (23% vs. 9%) were used in SB-PCI than in MV-PCI (p < 0.001). Pre-procedure non-invasive testing was similarly performed in SB-PCI and MV-PCI (57% vs. 61%). The composite endpoint was observed in 0.7%, 1.9%, and 2.2% of the SB-PCI, SB + MV-PCI, and MV-PCI groups, respectively (p < 0.001). Institutional frequency of SB-PCI was inversely associated with the composite-endpoint risk for all PCI procedures (odds ratio 1.37, 95% confidence interval 1.04–1.81 in the lowest tertile, with reference to the middle tertile, p = 0.02). Frequency of PCI for restenotic lesions was also inversely associated with the institutional frequency of MV-PCI (p < 0.001).ConclusionSB-PCI was performed safely with a low frequency of acute complications, and higher SB-PCI frequency presented a lower risk of in-hospital adverse events, albeit with a cost of an increase in PCI for restenotic lesions.

Early effect of percutaneous coronary intervention of non-left anterior descending artery on coronary flow velocity reserve of left anterior descending artery assessed by transthoracic Doppler echocardiography.

BackgroundLimited data are available regarding the influence of percutaneous coronary intervention (PCI) of non-totally occluded lesions (non-CTO) on the coronary flow of non-target vessels. We sought to investigate the short-term impact of the non-left anterior descending artery (non-LAD) PCI on the coronary flow physiology of LAD using transthoracic Doppler echocardiography (TDE).Methods and resultsWe consecutively studied 50 patients who underwent successful PCI of non-LAD and non-CTO lesions and a coronary flow velocity assessment of LAD at rest and maximal hyperemia before and at 2 days after the procedure by TDE. Coronary flow velocity reserve (CFVR) was calculated as the ratio of hyperemic to resting diastolic peak velocity (hDPV/bDPV). We evaluated the changes in LAD coronary flow characteristics after PCI of non-LAD and explored the determinants of the change in LAD-CFVR. The median fractional flow reserve (FFR) of the culprit lesion and the LAD quantitative flow ratio (QFR) were 0.67 and 0.88, respectively. After non-LAD PCI, LAD-CFVR was decreased in 33 patients (66.0%). LAD-CFVR significantly decreased (pre-PCI: 2.41, post-PCI: 2.03, p = 0.001) due to a significant decrease in LAD-hDPV (P = 0.007). The prevalence of impaired LAD-CFVR (≤2.0) significantly increased (pre: 30%, post: 48%, P = 0.027). Multivariable linear regression analysis showed that pre-PCI LAD-CFVR was independent predictor of the change in LAD-CFVR after PCI.ConclusionsLAD-CFVR significantly decreased after successful non-LAD PCI due to the postprocedural reduction of coronary flow assessed by LAD-hDPV.

1-Month Dual-Antiplatelet Therapy Followed by Aspirin Monotherapy AfterPolymer-Free Drug-Coated StentImplantation: One-Month DAPT Trial.

The aim of this study was to determine whether 1month of dual-antiplatelet therapy (DAPT) followed by aspirin monotherapy after polymer-free drug-coated stent (PF-DCS) implantation is noninferior to 6 to 12months of DAPT after biodegradable-polymer drug-eluting stent (BP-DES) implantation. It is necessary to determine the optimal minimal duration of DAPT followed by aspirin monotherapy after percutaneous coronary intervention (PCI). In this trial, 3,020 patients with coronary artery disease considered for PCI for noncomplex lesions were randomized to 1-month DAPT after PF-DCS (n=1,507) or 6- to 12-month DAPT after BP-DES (n=1,513). The primary endpoint was the 1-year composite of cardiac death, nonfatal myocardial infarction, target vessel revascularization, stroke, or major bleeding (noninferiority hypothesis margin of 3%). The primary endpoint occurred in 88 patients (5.9%) in the 1-month DAPT after PF-DCS group and 98 patients (6.5%) in the 6- to 12-month DAPT after BP-DES group (absolute difference-0.7%; upper limit of 1-sided 97.5% confidence interval: 1.33%; P< 0.001 for noninferiority). The occurrence of major bleeding was not different (1.7% vs 2.5%; P=0.136). There was no difference in the occurrence of stent thrombosis (0.7% vs 0.8%; P=0.842). Among patients who underwent PCI for noncomplex lesions, 1-month DAPT followed by aspirin monotherapy after PF-DCS implantation was noninferior to 6- to 12-month DAPT after BP-DES implantation for the 1-year composite of cardiovascular events or major bleeding. The present findings need to be interpreted in the setting of different types of stents according to antiplatelet strategy. (A Randomized Controlled Comparison Between One Versus More Than Six Months of Dual Antiplatelet Therapy After Biolimus A9-Eluting Stent Implantation; NCT02513810).

Long-term outcomes of percutaneous coronary intervention for in-stent restenosis among Medicare beneficiaries.

In-stent restenosis (ISR) is highly prevalent and leads to repeat revascularisation. Long-term implications of ISR are poorly understood. This study aimed to evaluate the long-term outcomes of patients undergoing percutaneous coronary intervention (PCI) for ISR. National Cardiovascular Data Registry CathPCI records for individuals aged ≥65 years undergoing PCI from July 2009 to December 2014 were linked to Medicare claims. Baseline characteristics and long-term rates of death, myocardial infarction (MI), repeat revascularisation including target vessel revascularisation (TVR), and major adverse cardiovascular and cerebrovascular events (MACCE) were compared between ISR PCI versus de novo lesion PCI. Of 653,304 individuals, 10.2% underwent ISR PCI and 89.8% underwent de novo lesion PCI. The median duration of follow-up was 825 days (quartile 1: 352 days-quartile 3: 1,379 days). The frequency of MACCE (55.6% vs 45.0%; p<0.001), all-cause mortality (27.8% vs 25.5%; p<0.001), MI (19.0% vs 12.3%; p<0.001), repeat revascularisation (31.9% vs 18.6%; p<0.001), TVR (22.4% vs 8.0%; p<0.001), and stroke (8.8% vs 8.3%; p=0.005) was higher after ISR PCI. After multivariable adjustment, ISR PCI remained associated with worse long-term outcomes than after de novo lesion PCI (hazard ratio [HR] for MACCE 1.24 [95% CI: 1.22, 1.26], mortality 1.07 [95% CI: 1.05, 1.09], MI 1.44 [95% CI: 1.40, 1.48], repeat revascularisation 1.55 [95% CI: 1.51, 1.59], and TVR 2.50 [95% CI: 2.42, 2.58]). ISR PCI was common and was associated with a significantly higher risk of recurrent long-term major ischaemic events compared to patients undergoing de novo lesion PCI. There remains a need for new strategies to minimise ISR.

Complete Revascularization in Patients Undergoing a Pharmacoinvasive Strategy for ST-Segment–Elevation Myocardial Infarction: Insights From the COMPLETE Trial

[Figure: see text].

Comparison of clinical outcomes between percutaneous coronary intervention for de novo lesions versus in-stent restenosis lesions.

In-stent restenosis (ISR) remains the primary concern after a percutaneous coronary intervention (PCI) and is considered to be associated with worse clinical outcomes. However, comparative data on ISR and de novo lesions are rare. Therefore, we aimed to compare PCI-related clinical outcomes between patients with de novo lesions and those with ISR lesions. We undertook a retrospective analysis of patients who had undergone a PCI between 2013 and 2020. The incidences of major adverse cardiac and cerebrovascular events (MACCE) and all-cause death over a 2-year follow-up period were evaluated. In total, 1538 patients were enrolled and divided into two groups: a de novo lesions group (n = 1258, 81.8%) and an ISR lesions group (n = 280, 18.2%). Patients in the ISR lesions group were significantly older, with a higher prevalence of hypertension, diabetes mellitus, dyslipidemia, and chronic kidney disease than those in the de novo lesions group. Kaplan-Meier curves showed no significant between-group differences in the incidence of MACCE (log-rank, p = 0.93) and all-cause death (p = 0.09). After adjustment for other covariates, PCIs for ISR lesions were not found to be significantly associated with MACCE (hazard ratio [HR], 1.10; 95% confidential interval [CI] 0.49-2.49; p = 0.81) and all-cause death (HR, 0.58; 95% CI 0.26-1.31; p = 0.19). PCIs for ISR lesions were not associated with worse clinical outcomes compared with PCIs for de novo lesions.

Clinical outcomes of Fractional Flow Reserve-Guided Percutaneous Coronary Intervention By Coronary Flow Capacity Status in Stable Lesions.

Coronary flow capacity (CFC) provides integrated information about coronary flow reserve (CFR) and hyperaemic coronary flow and is useful for identifying coronary flow limitation. The aim of this study was to investigate the effect of percutaneous coronary intervention (PCI) on vessel-related major adverse cardiovascular events (MACE) according to CFC status in stable coronary lesions. From a global, multicentre registry of comprehensive physiological assessment, a total of 1,397 patients (1,694 vessels) were analysed. Low CFC was defined for lesions with reduced CFR and inverse of hyperaemic mean transit time (1/hTmn). A predefined definition of CFC (CFR <2.0 and 1/hTmn less than the corresponding percentile) was assessed first in a multivariable marginal Cox proportional model with the interaction term between CFC status and PCI (performed or not), and then the optimal definition of CFC was explored. We observed a significant interaction between predefined low CFC and PCI (p=0.067). With the optimal definition of CFC (CFR ≤3.2 and 1/hTmn ≤2.8), the HR (95% CI) of PCI was 0.278 (0.103-0.751) and 1.393 (0.783-2.478) in lesions with low and normal CFC, respectively. If lesions with fractional flow reserve (FFR) ≤0.8 and normal CFC had been deferred, the number of PCI would have decreased by 64%. FFR-guided PCI for low CFC lesions was associated with reduced incidence of MACE in low CFC but not in normal CFC lesions. Our results suggest the potential use of CFC in combination with FFR for optimising the indication for PCI by reducing potentially unbeneficial PCI. https://clinicaltrials.gov/ct2/show/NCT03690713.

Case Report: Role of Rotational Atherectomy in Complex PCI

Background : One in three patients undergoing percutaneous coronary intervention (PCI) exhibits moderate or severe coronary artery calcification. Coronary calcification remains a major independent predictor of PCI failure and adverse outcomes. PCI of calcified coronary lesions remains challenging, despite significant improvements in the available tools and techniques. Rotational Atherectomy (RA) is a critical component to improve PCI success in these situations by producing lumen enlargement by physical removal of plaque and reduction in plaque rigidity, thus facilitating dilation Case Illustration: A 73-year-old man with exertional angina was referred to our hospital, with a history of hypertension, diabetes mellitus, ex-smoker and dyslipidemia. Physical exam, electrocardiogram, chest x-rays, and laboratory findings were unremarkable, but transthoracic echocardiogram revealed anterior wall hypokinesis. History of cardiac catheterization outside of our center with angiographic result of left anterior descending (LAD) lesion, highly calcified, non-dilatable on first several POBA attempts. Coronary angiography at our center, revealed diffuse calcification from proximal to distal of the LAD artery with about 90% maximum stenosis in mid LAD. RA (Rotablator, Boston) was then performed with A 1.50 mm burr gradually advanced at 150,000 rpm to passed the lesion. After deployments of stents, final angiogram showed well positioned stents with good distal run-off flow. The patient was uneventful during the procedure and was discharged following day. Discussion: In experienced hands, RA is as safe as standard PCI. RA is as a tool to make PCI possible in complex lesions with moderate or severe calcification when clinical variables make PCI appropriate. Rotablator is a catheter-based interventional cardiology procedure using a high-speed rotational device designed to ablate atherosclerotic plaque and restore luminal patency. This help to facilitate stent delivery, avoiding the barotrauma caused by repeated high-pressure balloon inflations that can lead to vessel dissection or perforation. Atherectomy can be performed safely with optimal burr selection and proper ablation techniques, and as a result, complication rates have been significantly minimized, with few changes in the acute complications reported in contemporary studies.

Randomized Comparison Between Radialand Femoral Large-Bore Accessfor Complex Percutaneous Coronary Intervention.

The aim of this study was to investigate whether transradial (TR) percutaneous coronary intervention (PCI) is superior to transfemoral (TF) PCI in complex coronary lesions with large-bore guiding catheters with respect to clinically relevant access site-related bleeding or vascular complications. The femoral artery is currently the most applied access site for PCI of complex coronary lesions, especially when large-bore guiding catheters are required. With downsizing of TR equipment, TR PCI may be increasingly applied in these patients and might be a safer alternative compared with the TF approach. An international prospective multicenter trial was conducted, randomizing 388 patients with planned PCI for complex coronary lesions, including chronic total occlusion, left main, heavy calcification, or complex bifurcation, to either 7-F TR access (TRA) or 7-F TF access (TFA). The primary endpoint was defined as access site-related clinically significant bleeding or vascular complications requiring intervention at discharge. The secondary endpoint was procedural success. The primary endpoint event rate was 3.6% for TRA and 19.1% for TFA (p<0.001). The crossover rate from radial to femoral access was 3.6% and from femoral to radial access was 2.6% (p=0.558). The procedural success rate was 89.2% for TFA and 86.0% for TRA (p=0.285). There was no difference between TFA and TRA with regard to procedural duration, contrast volume, or radiation dose. In patients undergoing PCI of complex coronary lesions with large-bore access, radial compared withfemoral access is associated with a significant reduction in clinically relevant access-site bleeding or vascular complications, without affecting procedural success. (Complex Large-Bore Radial Percutaneous Coronary Intervention [PCI] Trial [Color]; NCT03846752).

A Clinical Analysis of the Treatment of Chronic Coronary Artery Occlusion With Antegrade Dissection Reentry.

Objective: This study aimed to investigate the efficacy and safety of antegrade dissection re-entry (ADR) technique in the percutaneous coronary intervention (PCI) to open chronic total occlusion (CTO) lesions.Methods: The baseline, angiographic results, PCI success rate, and major adverse cardiac events (MACE) during the 12 months of follow-up were compared between 48 patients who did not use ADR in the treatment of CTO lesions (control group) and 50 patients who used ADR (treatment group).Results: The control group comprised 48 patients who had 52 CTO lesions, and the treatment group comprised 50 patients who had 58 CTO lesions. The success rate of PCI in the treatment group (89.7 vs. 71.2%, P = 0.047) was significantly higher than in the control group, where six patients had in-stent restenosis (ISR, ISR-CTO) that were all recanalized. The mean PCI time (71 ± 25 min vs. 95 ± 33 min, P = 0.041), X-ray exposure time (42 ± 17 min vs. 71 ± 22 min, P = 0.032), contrast agent dosage (98 ± 26 ml vs. 178 ± 63 ml, P = 0.029), MACE incidence during the 12 months of follow-up (22.0 vs. 41.7%, P = 0.046) and recurrent myocardial infarction incidence (10.0 vs. 27.1%, P = 0.047) were significantly lower in the treatment group than in the control group. The differences were all statistically significant.Conclusion: It is safe and effective to use the ADR technique in PCI for coronary artery CTO lesions. The technique shortens the operation time, reduces the radiation dose of doctors and patients and the use dose of contrast agents, and improves patients' prognoses.

Feasibility and Safety of the Left Distal Radial Approach in Percutaneous Coronary Intervention for Bifurcation Lesions.

Recently, the left distal radial approach (DRA) for percutaneous coronary intervention (PCI) has been shown to be a feasible option, but there are limited data regarding the feasibility of performing bifurcation PCI via the left DRA. Therefore, this study aimed to describe our experience with the contemporary left DRA to perform PCI of bifurcation lesions. Between December 2017 and December 2019, we identified 106 patients treated with bifurcation PCI via the left DRA. We evaluated the success rate of PCI, access-site complications including major bleeding requiring surgery or transfusion, hematoma, distal and forearm radial artery occlusion, and 30-day mortality. Eleven patients (10.4%) treated with left main bifurcation and true bifurcations accounted for 39.6% of cases, with the left anterior descending artery/diagonal branch being the most frequent bifurcation site (57.5%, 61/106). PCI was performed using a 6-French guiding catheter in 101 (95.3%) cases. Successful PCI for bifurcation lesions via the left DRA was achieved in all 106 patients without access-site cross-over. There was no major bleeding, distal and forearm radial artery occlusion, forearm hematoma, or mortality at 30 days. The left DRA is a safe and feasible alternative access site for bifurcation PCI in selected patients.

Association of changes of pulse wave velocity and augmentation index after isometric handgrip exercise with coronary lesion extent and revascularization

BackgroundArterial stiffness is associated with myocardial ischemia and incident coronary artery disease (CAD), and indexes of arterial stiffness are usually increased in patients with CAD. However, these indexes are often increased in elderly without CAD. Arterial stiffness in patients with CAD may become more evident after isometric handgrip exercise which increases systolic pressure and ventricular afterload. We investigated the association of the change of stiffness indexes after isometric handgrip exercise with the lesion extent of CAD and the necessity for coronary revascularization.MethodsPatients who were scheduled a routine coronary angiography via a femoral artery were enrolled. Arterial waveforms were traced at aortic root and external iliac artery using coronary catheters at baseline and 3 min after handgrip exercise. Augmentation index (AIx) was measured on the recorded aortic pressure waveform, and pulse wave velocity (PWV) was calculated using the ECG-gated time difference of the upstroke of arterial waveforms and distance between aortic root and external iliac artery.ResultsTotal 37 patients were evaluated. Both PWV and AIx increased after handgrip exercise. ΔPWV was significantly correlated with ΔAIx (r = 0.344, P = 0.037). Patients were divided into higher and lower ΔPWV or ΔAIx groups based on the median values of 0.4 m/sec and 3.3%, respectively. Patients with higher PWV had more 2- or 3-vessel CAD (69% vs. 27%, P = 0.034), and underwent percutaneous coronary intervention (PCI) more frequently (84% vs. 50%, P = 0.038), but higher ΔAIx was not associated with either the lesion extent or PCI. Area under curve (AUC) of ΔPWV in association with PCI by C-statistics was 0.70 (95% confidence interval [CI] 0.51–0.88; P = 0.056). In multiple logistic regression analysis, ΔPWV was significantly associated with PCI (odds ratio 7.78; 95% CI 1.26–48.02; P = 0.027).ConclusionsHigher ΔPWV after isometric handgrip exercise was associated with the lesion extent of CAD and the necessity for coronary revascularization, but higher ΔAIx was not.

Impact of sex on outcomes of bifurcation lesion percutaneous coronary intervention: results from a single-centre prospective registry.

Coronary bifurcation lesions are technically and clinically more challenging compared to nonbifurcation lesions. Sex-related differences in diagnostic and invasive therapeutic coronary procedures have been described in the literature. Our objective was to assess the impact of sex on outcomes of bifurcation lesion percutaneous coronary intervention (PCI). Our data were taken from a prospective registry of consecutive patients undergoing PCI for bifurcation lesions at our medical centre between 2004 and 2019. We compared rates of death and major adverse cardiac events (MACE) between men and women at 1 year and 3 years. MACE comprised cardiac death, myocardial infarction, target vessel revascularization or stroke. A total of 1209 patients were included, 948 (78.4%) were male and 261 (21.6%) were female. Women were older (mean age 69.7 ± 11 years vs. 63.1 ± 11 years, P < 0.01), and had more comorbidities than men. Female patients had more angiographically calcified (38.1% vs. 30.1%, P = 0.017) lesions. At 1-year follow up, there was no significant difference of MACE (18.8 vs. 15.2%, P = 0.183) or all-cause mortality (5.7% vs. 3.9%, P = 0.242) between sexes. At 3-year follow up, there was a significantly higher rate of MACE in women (29.1% vs. 22.5%, P = 0.026), this was driven by a significantly higher all-cause mortality (13.8% vs. 6.5%, P < 0.01). Women undergoing bifurcation PCI are older and have more comorbidities than their male counterparts. Intermediate term follow-up outcomes are similar between sexes. Poorer long-term outcomes of women are likely due to baseline higher risk profile.

Pericardial Tamponade Caused by Rotational Atherectomy Ablation Grinding Through a Barrier Stent Protruding From the Diagonal Artery: A Case Report

Rotational atherectomy (RA) has been described in case reports to be effective in ablating under-expanded stents. We present a case of calcified bifurcation lesion percutaneous coronary intervention (PCI), in which the branch stent protruding into main branch blocked the balloon getting through, and the following RA led to pericardial tamponade. The first stent was deployed from the proximal of left anterior descending artery (LAD) to the proximal of diagonal for an 80-year-old man who suffered from non-ST-elevation myocardial infarction to make a Culotte dual stent PCI. The operator failed to make balloon get through the struts protruding into LAD lumen anyway. After RA drill through the LAD lumen, it showed an excellent angiographic outcome. Stent deployment in LAD was successful, but pericardial tamponade occurred in a short time. After pericardiocentesis was performed under fluoroscopic guidance, the patient was uneventful. After 1 year, the follow-up coronary computed tomography (CT) angiography showed no in-stent restenosis, stent fracture or disrupted struts protruding outside of the vessel’s outline of LAD and the first diagonal (D1). This case shows stents’ RA could be dangerous in grinding across the stents’ lateral hole in an unsymmetrical lumen. Although RA could be a useful remedy in the situation of under-expansion of implanted stents, the debulking should be performed for longitudinal stent ablation and cautiously performed for bifurcation lesion in which the protruding stents from side branch were unsymmetrically blocking the path. J Med Cases. 2021;12(6):230-232 doi: https://doi.org/10.14740/jmc3678

Managing Calcified Coronaries: the Bugaboo of Percutaneous Coronary Intervention

Background Percutaneous coronary intervention (PCI) of lesions with heavily coronary artery calcium (CAC) still represents a challenge for interventionists, with increased risk of immediate complications, late failure due to stent underexpansion and malapposition, and consequently poor clinical outcome. In this focused review, we provide the summary of principles, technique and contemporary evidence for various existing and emergent plaque modifying strategies. Main text PCI of lesions with heavy CAC still poses a challenge for the interventionists due to an increased risk of incomplete lesion preparation with subsequent suboptimal stent deployment and higher rates of acute and chronic stent failure. With the emergence of many novel devices and technologies, the treatment of lesions with heavy CAC has become increasingly feasible, safe and predictable. It seems likely that combining enhanced intravascular imaging modalities with traditional or new dedicated tools for the treatment of such lesions grant better lesion preparation. This optimizes delivery and deployment of drug-eluting stents translating into improved patient outcome. Conclusion The lesions with significant CAC are likely to surge due to aging population and increased rates of diabetes and chronic renal disease. The optimal therapy for such lesions is multi-adjunctive and requires the availability of several modalities including intracoronary imaging which could impact the clinical outcome favourably.

Multi-modality intravascular imaging for guiding coronary intervention and assessing coronary atheroma: the Novasight Hybrid IVUS-OCT system.

Intravascular imaging has evolved alongside interventional cardiology as an adjunctive tool for assessing plaque pathology and for guiding and optimizing percutaneous coronary intervention (PCI) in challenging lesions. The two modalities which have dominated the field are intravascular ultrasound (IVUS), which relies on sound waves and optical coherence tomography (OCT), relying on light waves. These approaches however have limited efficacy in assessing plaque morphology and vulnerability that are essential for guiding PCI in complex lesions and identifying patient at risk that will benefit from emerging therapies targeting plaque evolution. These limitations are complementary and, in this context, it has been recognized and demonstrated in multi-modality studies that the concurrent use of IVUS and OCT can help overcome these deficits enabling a more complete and accurate plaque assessment. The Conavi Novasight Hybrid IVUS-OCT catheter is the first commercially available device that is capable of invasive clinical coronary assessment with simultaneously acquired and co-registered IVUS and OCT imaging. It represents a significant evolution in the field and is expected to have broad application in clinical practice and research. In this review article we present the limitations of standalone intravascular imaging techniques, summarize the data supporting the value of multimodality imaging in clinical practice and research, describe the Novasight Hybrid IVUS-OCT system and highlight the potential utility of this technology in coronary intervention and in the study of atherosclerosis.

One Year Outcomes After Percutaneous Coronary Intervention in Diabetics With Stable Ischemic Heart Disease: A Single-Center Comparative Study.

IntroductionCoronary artery disease is the leading cause of death not only in Pakistan but also worldwide. Coronary artery disease is prevalent in diabetes and is the major cause of morbidity and mortality. This study aims at comparing the long-term outcomes of patients with and without diabetes undergoing percutaneous coronary interventions (PCI) in in a tertiary care hospital.MethodsThis is a prospective study including 200 patients undergoing PCI for stable ischemic heart disease. All the patients were followed up over three, six months, and then over one year for major outcomes, including death, nonfatal myocardial infarction, and revascularization, including target vessel revascularization (TVR), and target lesion revascularization (TLR), as well as the outcome of a major adverse cardiovascular event (MACE).ResultsThe mean age (standard deviation) of the non-diabetic with stable ischemic heart disease (SIHD) patients was higher (57.4±8.9 years) than diabetes mellitus (DM) patients. All baseline characteristics were not statistically significant between the two groups. Triple vessel disease prevalence was more in DM than in the non-DM patients with SIHD, although it was not statistically significant. The number of stents implanted per patient (2.8±0.7 vs 1.9±0.8) was more in DM patients than in non-DM patients with SIHD. In-hospital adverse outcomes, including death due to cardiovascular causes, periprocedural myocardial infarction, hyperacute stent thrombosis, and bleeding complications, were insignificant between the two groups. Contrast-induced nephropathy was more prevalent in diabetics with SIHD. Although one-year major adverse cardiovascular outcomes were common in the diabetic group, these were statistically insignificant.ConclusionPCI for complex lesions in stable ischemic heart disease, both with and without diabetes, is associated with favorable in-hospital and long-term outcomes with regards to MACE and ischemia-driven revascularization.