Percutaneous Intervention Strategy Research Articles

Advances in Diagnostic and Interventional Catheterization in Adults with Fontan Circulation.

Over the past five decades, the Fontan procedure has been developed to improve the life expectancy of patients with congenital heart defects characterized by a functionally single ventricle. The Fontan circulation aims at redirecting systemic venous return to the pulmonary circulation in the absence of an impelling subpulmonary ventricle, which makes this physiology quite fragile and leads to several long-term complications. Despite the importance of hemodynamic assessment through cardiac catheterization in the management and follow-up of these patients, a thorough understanding of the ultimate functioning of this type of circulation is lacking, and the interpretation of the hemodynamic data is often complex. In recent years, new tools such as combined catheterization with cardiopulmonary exercise testing have been incorporated to improve the understanding of the hemodynamic profile of these patients. Furthermore, extensive percutaneous treatment options have been developed, addressing issues ranging from obstructive problems in Fontan pathway and acquired shunts through compensatory collaterals to the percutaneous treatment of lymphatic circulation disorders and transcatheter edge-to-edge repair of atrioventricular valves. The aim of this review is to detail the various tools used in cardiac catheterization for patients with Fontan circulation, analyze different percutaneous treatment strategies, and discuss the latest advancements in this field.

Adult patients with univentricular physiology after Fontan palliation: prevalence and percutaneous closure of veno-venous collaterals

Abstract Background The Fontan operation resulted in improved survival of patients with congenital heart defects not equipped to sustain a biventricular circulation. Long-term complications are common. Veno-venous collaterals (VVC) can have both potentially beneficial and adverse physiological effects. The aim of this study was to evaluate the prevalence of VVC in adult Fontan patients and describe the percutaneous treatment strategy and the short term follow-up. Methods In this single-centre retrospective observational cohort study, consecutive adult Fontan patients under follow-up in the period between 2017-2023 were included. Results From a cohort of 51 Fontan patients, 14 (28%) underwent a percutaneous closure of VVC (71% female, mean age at intervention 24±4 years). Mean follow-up duration was 2.2±1.1 years. Indications were symptoms and/or significant exercise-related hypoxia. Ten patients (71%) had a systemic left ventricle, and 79% had an extracardiac tunnel (median conduit size 16[16-20]mm). Mean Fontan pressure was 10±4mmHg. Seven patients (50%) had Fontan-associated liver disease. A total of 24 VVC were occluded using coils and/or vascular plugs. No periprocedural complications occurred. The VVC originated from right-sided tributaries of the vena cava inferior (36%), superior vena cava (28%) or both (36%), with the majority draining directly into the pulmonary venous circulation. Eight patients (57%) reported a reduction of symptoms. Mean saturation in rest improved significantly, yet saturation during maximal exercise remained unchanged (94±3 to 97±3%, p=0.002 and 88±3 to 91±4%, p=0.103, respectively). Conclusions VVC are highly prevalent in the adult Fontan population and typically connect the right-sided tributaries of the vena cava inferior and/or superior with the pulmonary veins. Low Fontan pressures do not exclude the presence of VVC. Percutaneous closure of VVC is technically feasible and safe and is associated with reduction of symptoms and a significant rise in resting peripheral oxygen saturation. These results warrant further studies.

Percutaneous closure of veno-venous collaterals in adult patients with univentricular physiology after Fontan palliation: Single centre experience and systematic review

BackgroundThe Fontan operation resulted in improved survival of patients with congenital heart defects not equipped to sustain biventricular circulation. Long-term complications are common, such as veno-venous collaterals (VVC). The aim of this study was to evaluate patient characteristics, percutaneous treatment strategy and (short-term) outcomes in adult Fontan patients with VVC, and review literature to date. MethodsIn this single-centre retrospective observational cohort study, patients who underwent percutaneous VVC closure between 2017 and 2023 were identified. ResultsThirteen patients underwent percutaneous VVC closure (77 % female, age at intervention 24 ± 4 years, 77 % systemic left ventricle, 77 % extracardiac tunnel, median conduit size 16 [16–20]mm). Indications for closure were symptoms and/or significant exercise-related hypoxia. Mean Fontan pressure was 10±4 mmHg. The VVC originated from tributaries of the vena cava superior (VCS) and connected to pulmonary veins (8 VVC, 32 %), VCS to systemic atrium (3 VVC, 12 %), VCS to coronary sinus (3 VVC, 12 %) and tributaries of vena cava inferior to pulmonary veins (11 VVC, 44 %). Twenty-three VVC were occluded using coils and/or plugs. No periprocedural complications occurred. At first follow-up at least 6 months after closure (n = 11), 9 patients (82 %) reported symptom reduction. Saturation at rest and peak exercise increased significantly (96 ± 3 to 98 ± 1 %, p = 0.040; 89 ± 3 to 93 ± 5 %, p = 0.024, respectively). Exercise capacity remained unchanged. ConclusionsVVC typically connect the tributaries of the vena cava inferior and/or superior with the pulmonary veins. Low Fontan pressures do not exclude the presence of VVC. Percutaneous closure of VVC is technically feasible, safe, and associated with symptom reduction and a significant rise in resting and exercise oxygen saturation.

Strategy of delayed intervention without stent implantation in myocardial infarction with ST segment elevation caused by massive thrombosis of the infarct-related artery

Aim. TIntroduction. To evaluate in-hospital angiographic and five-year posthospital clinical outcomes of percutaneous intervention strategy without stent implantation with immediate coronary artery stenting technique in STEMI patients with massive coronary thrombosis.Material and methods. The study enrolled 116 patients with primary STEMI myocardial infarction with the signs of massive thrombosis in the lumen of the main epicardial coronary artery with TIMI thrombus grade greater than 3 after antegrade blood flow restoration. In the 1st group of delayed intervention at the primary stage the blood flow was restored by small diameter balloon inflation and/ or manual vacuum thrombus aspiration until stable TIMI grade 3 blood flow was achieved, at control CAG on day 5-6 in 36 people the stent was not implanted due to insignificance of infarct-related coronary artery stenosis (stenosis less than 50% according to QCA). Immediate stent implantation was performed in 78 patients (group 2). The primary endpoint was the incidence of adverse cardiovascular events, including total mortality, recurrent myocardial infarction, repeated revascularization of the infarct-responsive artery. Secondary endpoint: frequency of achieving optimal myocardial perfusion as measured by angiography – TIMI blood flow and Myocardial Blush Grade.Results. The median follow-up period was 47 months. The incidence of the primary end point (MACE) was 15,8% in group 1 and 23,1% in group 2, with no statistically significant difference (p=0,408). Overall mortality (10,5% and 11,7%), the rate of repeat myocardial infarction (2,6% and 5,1%), and the rate of repeat target vessel revascularization (2,6% and 6,4%) were without significant advantage between subgroups. Optimal reperfusion (TIMI-3 and Myocardial Blush Grade 2-3 after primary procedure was achieved in significantly (p=0,02) more patients in group 1 (89%) than in group 2 (69,2%) ST segment resolution ≥70% after intervention was achieved in 87% of cases in group 1 and in 64,1% of cases in group 2 (p=0,011).Conclusion. In STEMI patients with massive coronary thrombosis, the method of delayed percutaneous intervention increases the rate of achieving optimal blood flow and allows avoiding stent implantation in the infarct-related artery in 50% of cases as compared to the method of immediate stenting. Both methods have comparable hospital and five-year clinical risks.

Thirty-day outcomes of in-hospital multi-vessel versus culprit-only revascularization strategy for ST-segment elevation myocardial infarction with multivessel coronary disease.

Many studies have demonstrated the benefit of complete multivessel revascularization versus culprit-only intervention in patients of ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease. However, only a few single-center retrospective studies were performed on small Chinese cohorts. Our study aims to demonstrate the advantage of multivessel percutaneous intervention (PCI) strategy on 30-day in-hospital outcomes to patients with STEMI and multivessel disease in larger Chinese population. From the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS) project, 5935 patients with STEMI and multivessel disease undergoing PCI and hospitalized for fewer than 30 days were analyzed. After 5: 1 propensity score matching, 3577 patients with culprit-only PCI and 877 with in-hospital multivessel PCI were included. The primary outcome was major adverse cardiovascular and cerebrovascular event (MACCE), defined as a composite of myocardial infarction, all-cause death, stent thrombosis, heart failure, and stroke. Multivariable logistic regression analysis revealed that in-hospital multivessel PCI was associated with lower risk of 30-day MACCE (adjusted OR = 0.75, 95% CI: 0.57-0.98, P = 0.032) than culprit-only PCI and conferred no increased risk of all-cause death, myocardial infarction, stent thrombosis, stroke, or bleeding. Subgroup analysis showed that MACCE reduction was observed more often from patients with trans-femoral access (OR = 0.34, 95% CI: 0.15-0.74) than with trans-radial access (OR = 0.87, 95% CI: 0.66-1.16, P for interaction = 0.017). The in-hospital multivessel PCI strategy was associated with a lower risk of 30-day MACCE than culprit-only PCI in patients with STEMI and multivessel coronary artery disease.

Congenital heart disease: addressing the need for novel lower-risk percutaneous interventional strategies

ABSTRACT Introduction With the advent of improved neonatal care, increasingly vulnerable higher-risk patients with complex congenital heart anomalies are presenting for intervention. This group of patients will always have a higher risk of an adverse event during a procedure but by recognizing this risk and with the introduction of risk scoring systems and thus the development of novel lower risk procedures, the rate of adverse events can be reduced. Area covered This article reviews risk scoring systems for congenital catheterization and demonstrates how they can be used to reduce the rate of adverse events. Then, novel low risk strategies are discussed for low-weight infants e.g. patent ductus arteriosus (PDA) stent insertion; premature infants e.g. PDA device closure; and transcatheter pulmonary valve replacement. Finally, how risk is assessed and managed within the inherent bias of an institution is discussed. Expert opinion There has been a remarkable improvement in the rate of adverse events in congenital cardiac interventions, but now, as the benchmark of mortality rate is switched to morbidity and quality of life, continued innovation into lower risk strategies and understanding the inherent bias when assessing risk will be key to continuing this improvement.

Diagnosis and Management of Failed Surgical Tricuspid Valve Annuloplasty

Annular-based strategies for treating tricuspid valve (TV) regurgitation do not always have satisfactory long-term outcomes. Management of failed TV annuloplasty can be challenging and requires a dedicated heart team approach. This review explores the treatment options available for failed TV annuloplasty. Recent developments and novel percutaneous treatment options have emerged as promising alternatives for patients with failed TV annuloplasty. Leaflet-based interventions, valve-in-valve procedures, transcatheter tricuspid valves and new-generation trans-caval valves are all feasible options, which can assure good results whilst minimizing risks for the patient. Failure of tricuspid annuloplasty is not uncommon amongst patients treated with either a tricuspid ring or suture-based device. The complex anatomy, physiology and clinical risk profile should be carefully evaluated on an individual patient-by-patient basis in order to select the most appropriate clinical and percutaneous treatment strategy. Different transcatheter tricuspid valve repair or replacement techniques may provide an attractive alternative treatment option for managing this challenging patient cohort.

Catheter Induced Left Main Coronary Artery Dissection: Incidence, Management and Medium-term Outcome ?? A Study of Contemporary Practice

Background: Catheter-induced left main (LM) coronary artery dissection is rare but requires immediate intervention. In this situation, the results of emergency percutaneous intervention (PCI) using DES to restore the flow in the left coronary artery are poorly known. Aims of the Study: To examine the incidence, clinical and angiographic features as well as the longer-term outcomes of iatrogenic LM dissection. The strategy for coronary revascularization was emergency PCI using DES. Methods: A study of all 24,995 coronary procedures performed in our institution (comprising 2 catheter-laboratories) during eight years in succession (1 April 2009- 1 April 2017). Cases of iatrogenic LM dissection were identified and studied in detail and clinical follow-up was obtained in all patients in whom iatrogenic LM dissection occurred. Results: Catheter-induced dissection of the LM occurred in 20 patients, representing 0.08 % of the all procedures: 16/8,019 PCI (0.2%) and 4/16,976 diagnostic angiograms (0.02%). Significant LM stenosis was present in 7/20 patients. No specific causal catheter was identified. LM coronary artery dissection was obstructive in 5 patients and involved the distal LM in 70%. Hemodynamic status was immediately impaired in 11/20 patients. The strategy for LM PCI was provisional stenting of the side branch after LM and main vessel stenting with final kissing inflation. Angiographic success was obtained in 18/20 and in these patients in-hospital outcome was free of events or re-intervention. PCI failed to restore blood flow in 2 patients who died during PCI attempt. During follow-up repeat revascularization was required in 2 patients (1 CABG 1 re-PCI) but there were no other adverse events. Conclusion: Catheter-induced LM coronary artery dissection is a rare complication with an incidence of less than 1 in 1000 coronary procedures overall, but with a mortality rate in this study of 10%. Emergency PCI with DES is an effective and appropriate treatment associated with a favourable midterm outcome.

Baseline hemoglobin and bleeding risk in patients with myocardial infarction treated with PCI

Abstract Background Bleeding is one of the major complications of the modern treatment of myocardial infarction (MI). The data on admission hemoglobin (aHb) and bleeding in patients with MI who underwent percutaneous intervention (PCI) are scarce. Purpose We aimed to investigate the association between the graded aHb level and hospital bleeding in patients with MI who underwent PCI. Methods A single-center retrospective study was performed at our university, a tertiary referral hospital with a 24/7 PCI service. We analyzed 7315 MI patients. The patients were treated according to the published guidelines for the management of MI. The PCI strategy and concomitant medication were left to the discretion of the operator and the attending physician. The groups, stratified at 10g/L intervals according to the Hb level on admission, were compared. The criteria of the Bleeding Academic Research Consortium (BARC) 3a bleeding (an aHb drop of 30–50 g/L or any transfusion) were used. Data were analyzed using descriptive statistics. The interval with the most patients (130–139 g/L) was used as the reference group. The aHb value was used not only as a categorical variable but also as a continuous variable. Results The rates of bleeding were significantly higher in the groups with lower baseline aHb compared to the groups with higher aHb levels (p<0.0001). A nonlinear inverse relationship was observed between the aHb and bleeding (Figure 1). Higher values of aHb were associated with a lower risk of bleeding (adjusted OR 0.76; 95% CI 0.72 to 0.81; p<0.0001). We observed that there was an ∼7.5-fold and an ∼2-fold lower odds of bleeding in the lowest aHb level groups (<100g/L and 100–109 g/L) compared to the reference group, respectively (adjusted OR 7.54; 95% CI 5.38 to 10.56; p<0.0001 and 2.01; 95% CI 1.38 to 2.92) after adjustment for potential confounders. Patients with aHb levels equal to or greater than 110 g/L had a similar bleeding risk to the reference group. Conclusion We found that a graded decrease in the aHb level is associated with a progressively increased risk of hospital bleeding. Patients with aHbs lower than 110 g/L are particularly prone to bleed. Up to now, no consensus has been reached as to whether interventions aimed at correcting anemia could improve the outcome in these patients. Therefore, preventive measures to minimize additional bleeding (radial access, thinner sheaths, the use of selective GPIIb/IIIa receptor antagonists, proton-pump inhibitors) should be used. Even bare-metal stents may be selected, based on the evaluation of the bleeding/thrombosis risk for each patient. In general, the lower the aHb, the greater the bleeding risk. Admission Hb and bleeding Funding Acknowledgement Type of funding source: None

Outflow Graft Obstruction Causing Recurrent Heart Failure after Left Ventricular Assist Device Implantation

Outflow graft obstruction is a poorly described complication following continuous flow-left ventricular assist device (CF-LVAD) surgery. We sought to define the incidence of CF-LVAD outflow graft obstruction and assess clinical outcomes with a percutaneous treatment strategy. From January 2012 to June 2019, 252 CF-LVAD patients were managed at our institution. Patients with suspected LVAD outflow graft obstruction underwent comprehensive evaluation with Doppler echocardiography, cardiac computed tomography with angiography and invasive hemodynamic assessment followed by percutaneous intervention. Fourteen patients (5.6%) developed hemodynamically significant LVAD outflow graft obstruction at a rate of 0.03 events per patient-year. Outflow graft obstruction presented a mean of 34±18 months after surgery. Patients presented with heart failure (HF; 86%), low LVAD pump flow (93%), or both (79%). LVAD flow declined by an average of 2.1±0.8L/min (p<0.001). Outflow graft obstruction was caused by external graft compression (77%), stenosis of the aortic anastomosis (46%) and discrete kinking of the outflow cannula (46%); most patients presented with 2 or more lesions (69%). There were no cases of outflow graft thrombosis. External graft compression was uniformly due to build-up of fibrinous material between the outflow cannula and the protective external GoreTex graft. Outflow graft stenting was 100% successful and reduced the gradient from 80mmHg (IQR 58-100mmHg) to 13mmHg (IQR 10-20mmHg, Figure). There was no in-hospital mortality and few complications. Outflow graft stenting was durable; over a mean follow-up of 13±7 months, no patients had recurrent outflow graft obstruction. LVAD outflow graft obstruction is a relatively common and underappreciated cause of recurrent HF and LVAD dysfunction. Outflow graft stenting can be achieved with low morbidity and provides a long-term solution to this complication.

Successful percutaneous occlusion of a large left circumflex coronary artery fistula draining into the coronary sinus using a ventricular septal defect occluder: a case report

BackgroundCoronary artery fistula (CAF) is a congenital anomaly of the coronaries that can lead to significant intracardiac shunting and myocardial ischaemia.Case summaryWe describe the case of a 15-year-old male with an incidentally documented precordial cardiac murmur. An evidently dilated coronary sinus (CS) on transthoracic echocardiography prompted further investigation. A computed tomography (CT) revealed the presence of a large CAF from the left circumflex coronary artery to the CS. No other structural heart defects were detected. A haemodynamically significant intracardiac shunt was confirmed during cardiac catheterization, and it was decided to close the fistula. This was successfully performed using a ventricular septal defect (VSD) occluder (Konar 10-8, Lifetech Scientific) that was deployed through a 6 Fr right coronary guiding catheter. A partial thrombotic occlusion of the CS behind the closure device was noted during follow-up which led to anticoagulation in a higher target INR range and concomitant start of low dose carbasalate calcium to reduce further retrograde thrombus extension. Patient is doing well at over 1 year of follow-up, and no further thrombotic extension into the CS was seen on a recent CT.DiscussionThis report illustrates the diagnostic workup and a percutaneous treatment strategy of a CAF using a VSD occluder. We also describe a not previously reported complication, thrombotic CS occlusion. Improving transcatheter techniques and marketing of novel devices with a broad spectrum of applications can offer new opportunities for treating CAF and avoiding surgical correction often involving cardiopulmonary bypass, reserving this option for patients with complex anatomy or failed transcatheter closure.

Percutaneous Treatment of Superficial Femoral Artery Total Occlusions: Single Center Experience

Objectives &#x0D; Superficial femoral artery (SFA) is the most commonly effected vessel in peripheral arterial disease (PAD) and SFA total occlusions constitute the 50% of PAD patients presenting with symptoms. In this study, we investigated our patients with SFA total occlusions who were treated with percutaneous treatment strategy.&#x0D; &#x0D; Methods&#x0D; In this study, we included ambulatory patients who were admitted to our clinics due to symptomatic severe SFA total occlusion and underwent PTA or PTA + stenting procedure.The demographic findings of the patients, procedure details, complications and follow-up results were noted.&#x0D; Results&#x0D; Out of 67 patients, 62 (92.5%) underwent PTA or PTA + stenting procedure successfully for SFA total occlusions. Only one serious complication, acute renal failure resulting in death developed during hospitalization. The mean follow-up time after the procedure was 11.1±7.2 months. During this follow-up time 36 (58.1%) were asymptomatic. Out of 26 patients who were symptomatic, only 6 of them underwent reintervention and 3 were recommended surgical intervention.&#x0D; &#x0D; Conclusion&#x0D; Peripheral interventions for SFA total occlusions are being performed successfully in experienced centers with low complication rates as the first treatment strategy in PAD. Herein,we have presented our patients who underwent successful PTA and/or stenting procedure with high success and low complication rates. Peripheral interventions should be the first choice for SFA total occlusions in experienced centers.&#x0D;

Animal chronic total occlusion models: A review of the current literature and future goals

Coronary chronic total occlusions (CTOs) are commonly found in patients undergoing coronary angiography and is associated with poorer prognosis than in those patients with other forms of stable coronary artery disease. As such, with an increasing appreciation of this clinical entity, there is a need to identify, firstly the pathophysiological process driving its formation, as well as new percutaneous strategies for revascularisation with long term durability and improved outcomes. An appropriate, reliable and reproducible animal model is vital for both of these objectives.We review the prevalence of spontaneous collaterals in different species, as well as review the current literature with respect to animal models of CTOs, and compare and contrast the advantages and disadvantages of these differing models. Whilst both extrinsic compression models and endoluminal procedures may create situations analogous to a CTO in a human, the ideal animal model of a CTO will include an occluded artery, functional collaterals and a viable myocardium. This would allow study of the process driving collateral formation and arteriogenesis as well as percutaneous intervention strategies for both acute and long term benefits.

Fulminant cytomegalovirus myocarditis in an infant with concomitant large atrial and ventricular septal defects: medical intervention strategy for functional cardiac regeneration.

A cytomegalovirus-associated heart failure in a young infant with atrial and ventricular septal defects is reported in this case report. The patient recovered by an anti-congestive and anti-viral therapy with an extra percutaneous transcatheter treatment strategy. In the context of bi-ventricular predominant right heart failure associated with supra-systemic pulmonary hypertension, the already closed arterial duct was re-opened and stented to unload the right ventricle and thereby augment the systemic blood flow. Either the left-to-right shunting atrial septal defect or bi-directional shunting ventricular septal defect was involved in the disease process and was not able to avoid global heart failure. After clinical improvement, the stented duct was shunted left-to-right and was occluded with an ADO-II-AS. During the same procedure the atrial septal defect was closed with an Amplatzer-ASD occluder, while the peri-membranous ventricular septal defect was closed with an ADO-II occluder 2 months later.

Evidence-based medical oncology and interventional radiology paradigms for liver-dominant colorectal cancer metastases.

Colorectal cancer metastasizes predictably, with liver predominance in most cases. Because liver involvement has been shown to be a major determinant of survival in this population, liver-directed therapies are increasingly considered even in cases where there is (limited) extrahepatic disease. Unfortunately, these patients carry a known risk of recurrence in the liver regardless of initial therapy choice. Therefore, there is a demand for minimally invasive, non-surgical, personalized cancer treatments to preserve quality of life in the induction, consolidation, and maintenance phases of cancer therapy. This report aims to review evidence-based conceptual, pharmacological, and technological paradigm shifts in parenteral and percutaneous treatment strategies as well as forthcoming evidence regarding next-generation systemic, locoregional, and local treatment approaches for this patient population.

Effects of a percutaneous coronary intervention or conservative treatment strategy on treatment outcomes in elderly female patients with acute coronary syndrome

Aim. To determine the difference in hospi-tal outcomes between percutaneous coro-nary intervention (PCI) and conservative treatment of elderly female patients hos-pitalized for acute coronary syndrome (ACS).Material and Methods. This controlled study included 123 female patients admit-ted to the Clinic for heart and cardiovas-cular diseases University Hospital of Split with a diagnosis of ACS and multiple car-diovascular risk factors. We recorded their habits, history, demographics, presenting symptoms, electrocardiograms, ultra-sound results, laboratory tests, diagnostic tests and treatment. We compared these data between the two groups, i.e., those treated with conservative therapy and those treated with PCI.Results. There were fewer arrhythmias (P<0.001) and episodes of heart failure (P<0.001) during hospitalization in the PCI group than in the conservative ther-apy group. There was no significant differ-ence in complications between the groups (P=0.887).Conclusion. Elderly female patients with ACS treated with PCI had less arrhythmias and heart failure during hospitalization than those treated with conservative ther-apy and there was no difference in com-plications. These results suggest that even high risk patients have better outcomes af-ter treatment with PCI, and therefore PCI is suggested as first-line treatment in these patients, regardless of risk factors.

Percutaneous coronary interventional strategies for treatment of in-stent restenosis: a network meta-analysis

Percutaneous coronary intervention (PCI) with drug-eluting stents is the standard of care for treatment of native coronary artery stenoses, but optimum treatment strategies for bare metal stent and drug-eluting stent in-stent restenosis (ISR) have not been established. We aimed to compare and rank percutaneous treatment strategies for ISR. We did a network meta-analysis to synthesise both direct and indirect evidence from relevant trials. We searched PubMed, the Cochrane Library Central Register of Controlled Trials, and Embase for randomised controlled trials published up to Oct 31, 2014, of different PCI strategies for treatment of any type of coronary ISR. The primary outcome was percent diameter stenosis at angiographic follow-up. This study is registered with PROSPERO, number CRD42014014191. We deemed 27 trials eligible, including 5923 patients, with follow-up ranging from 6 months to 60 months after the index intervention. Angiographic follow-up was available for 4975 (84%) of 5923 patients 6-12 months after the intervention. PCI with everolimus-eluting stents was the most effective treatment for percent diameter stenosis, with a difference of -9·0% (95% CI -15·8 to -2·2) versus drug-coated balloons (DCB), -9·4% (-17·4 to -1·4) versus sirolimus-eluting stents, -10·2% (-18·4 to -2·0) versus paclitaxel-eluting stents, -19·2% (-28·2 to -10·4) versus vascular brachytherapy, -23·4% (-36·2 to -10·8) versus bare metal stents, -24·2% (-32·2 to -16·4) versus balloon angioplasty, and -31·8% (-44·8 to -18·6) versus rotablation. DCB were ranked as the second most effective treatment, but without significant differences from sirolimus-eluting (-0·2% [95% CI -6·2 to 5·6]) or paclitaxel-eluting (-1·2% [-6·4 to 4·2]) stents. These findings suggest that two strategies should be considered for treatment of any type of coronary ISR: PCI with everolimus-eluting stents because of the best angiographic and clinical outcomes, and DCB because of its ability to provide favourable results without adding a new stent layer. None.

A COMPARISON OF LONG TERM OUTCOMES OF CROSS-OVER SINGLE STENTING AND TWO STENTS IN LEFT MAIN BIFURCATION VIA TRANSRADIAL APPROACH

The outcome of different percutaneous intervention strategy for distal left main (LM) bifurcation via transradial approach (TRA) was not clear. This study aims to compare the long-term outcomes of two stents with that of cross-over single stenting using the drug-eluting stent (DES) on LM bifurcation

Educational ExhibitAbstract No. 374 - Vascular compression syndromes for the interventional radiologist

No. 373 Detection of small hepatocellular carcinoma less than three centimeters by dual phase cone beam computed tomography hepatic arterial angiography (CBCTHA) during conventional transcatheter arterial chemoembolization X. Wang, G. Cao, X. Zhu, P. Liu, R. Yang, S.B. Solomon; Peking University Cancer Hospital, Beijing Cancer Hospital & Institute, Beijing, China; Sloan-Kettering Cancer Center, New York, NY Purpose: The objective of this study was to compare the sensitivity of identify small hepatocellular carcinoma tumor less than 30 millimeters in diameter by dual phase cone beam computed tomography hepatic arterial angiography (CBCTHA) during conventional transcatheter arterial chemoembolization with non-selective hepatic arterial digital substraction angiogram (DSA) and pre-TACE conventional contrast enhanced tri-phase CT or MR. Materials and Methods: Thirty five consecutive patients with newly diagnosed unresectable hepatocellular carcinoma were referred to receive TACE. Pre CE-CT or CE-MR were performed within 1 months. Dual phase CBCTHA were performed following conventional hepatic arterial angiography (DSA-HA) before TACE. Lipiodol CBCT were performed just after TACE procedure. The detectability of small hepatocellular carcinoma tumor less than 30 millimeters in diameter by dual phase CBCTHA were compared with that by DSA common hepatic angiograms and pre-TACE tri-phase CECT or MR. Results: Sixty-six small hepatic carcinoma tumors were detected in twenty patients. Dual phase CBCTHA can depict all small tumors either on arterial or venous phase, with sensitivity of 100%, compared with 46/66(69.7%) and 43/66 (65.2%) on pre-TACE CT or MR and DSA-HA. Sensitivity of single arterial phase (97%) of CBCTHA is higher than that of venous phase (71.2%). Of these 66 small tumors, only two were detected just on venous phase rather than on arterial phase. On the venous phase, the corona enhancement were shown in 46 (68.2%) of all 66 lesions, and 46 (95.7%) of 47 venous phase visualized tumors. 8 wedge shape or irregular stained nodules depicted on arterial phase which were not shown on venous phase and on lipiodol CBCT were deemed as portal venous fistula. For sensitivity of these 33 tiny tumors less than 10mm, pre-TACE CT or MR and DSA-HA were more limited, only depicted 18 (54.5%) and 16 (48.5%) tumors. Conclusion: Dual phase CBCTHA is superior than CE-CT or MR and DSA-HA for detection the small lesion less than 30 mm, especially of that less than 10mm, and is helpful in making accurate planning of TACE. Educational Exhibit Abstract No. 374 Vascular compression syndromes for the interventional radiologist S. Cornejo, S.G. Naidu, E. Huettl, S. Money, W. Stone, R. Fowl; Radiology, Mayo Clinic Arizona, Scottsdale, AZ; Vascular Surgery, Mayo Clinic Arizona, Scottsdale, AZ Learning Objectives: Review the vascular compression syndromes and their clinical presentation, imaging findings and percutaneous treatment strategies via a case based approach. Background: Anatomic variants can result in compression of vascular structures with resultant intimal damage, ischemia, thrombosis and/or embolic disease. Aortosternal venous compression, Paget-Schroetter syndrome, Nutcracker compression, May-Thurner, quadrilateral space syndrome, median arcuate ligament compression, and popliteal artery entrapment comprise the majority of vascular compression syndromes. Distinguishing normal from variant anatomy is an important first step when one is entertaining such a diagnosis. As many asymptomatic patients may have imaging findings of a compression syndrome, correlation with clinical presentation and in some cases, reproducibility of symptoms triggered by maneuvers to induce compression is often a key piece of information in the diagnostic algorithm. The interventional radiologist provides useful diagnostic information and in some cases, potential treatment options. Clinical Findings/Procedure Details: In compliance with the IRB, the radiology database was retrospectively searched to identify cases of vascular compression syndromes. The clinical course, cross sectional and angiographic images are presented highlighting normal and variant anatomy resulting in these pathological states as well as percutaneous treatment strategies. Conclusion and/or Teaching Points: 1. Understand the most common presenting clinical symptoms with each vascular compression disorder. 2. The union of imaging findings with clinical symptoms is often the most reliable method for diagnosis. 3. The interventional radiologist is well suited to play a diagnostic role in these patients, but when appropriate, provide initial management.

Abstract No. 373 - Detection of small hepatocellular carcinoma less than three centimeters by dual phase cone beam computed tomography hepatic arterial angiography (CBCTHA) during conventional transcatheter arterial chemoembolization

No. 373 Detection of small hepatocellular carcinoma less than three centimeters by dual phase cone beam computed tomography hepatic arterial angiography (CBCTHA) during conventional transcatheter arterial chemoembolization X. Wang, G. Cao, X. Zhu, P. Liu, R. Yang, S.B. Solomon; Peking University Cancer Hospital, Beijing Cancer Hospital & Institute, Beijing, China; Sloan-Kettering Cancer Center, New York, NY Purpose: The objective of this study was to compare the sensitivity of identify small hepatocellular carcinoma tumor less than 30 millimeters in diameter by dual phase cone beam computed tomography hepatic arterial angiography (CBCTHA) during conventional transcatheter arterial chemoembolization with non-selective hepatic arterial digital substraction angiogram (DSA) and pre-TACE conventional contrast enhanced tri-phase CT or MR. Materials and Methods: Thirty five consecutive patients with newly diagnosed unresectable hepatocellular carcinoma were referred to receive TACE. Pre CE-CT or CE-MR were performed within 1 months. Dual phase CBCTHA were performed following conventional hepatic arterial angiography (DSA-HA) before TACE. Lipiodol CBCT were performed just after TACE procedure. The detectability of small hepatocellular carcinoma tumor less than 30 millimeters in diameter by dual phase CBCTHA were compared with that by DSA common hepatic angiograms and pre-TACE tri-phase CECT or MR. Results: Sixty-six small hepatic carcinoma tumors were detected in twenty patients. Dual phase CBCTHA can depict all small tumors either on arterial or venous phase, with sensitivity of 100%, compared with 46/66(69.7%) and 43/66 (65.2%) on pre-TACE CT or MR and DSA-HA. Sensitivity of single arterial phase (97%) of CBCTHA is higher than that of venous phase (71.2%). Of these 66 small tumors, only two were detected just on venous phase rather than on arterial phase. On the venous phase, the corona enhancement were shown in 46 (68.2%) of all 66 lesions, and 46 (95.7%) of 47 venous phase visualized tumors. 8 wedge shape or irregular stained nodules depicted on arterial phase which were not shown on venous phase and on lipiodol CBCT were deemed as portal venous fistula. For sensitivity of these 33 tiny tumors less than 10mm, pre-TACE CT or MR and DSA-HA were more limited, only depicted 18 (54.5%) and 16 (48.5%) tumors. Conclusion: Dual phase CBCTHA is superior than CE-CT or MR and DSA-HA for detection the small lesion less than 30 mm, especially of that less than 10mm, and is helpful in making accurate planning of TACE. Educational Exhibit Abstract No. 374 Vascular compression syndromes for the interventional radiologist S. Cornejo, S.G. Naidu, E. Huettl, S. Money, W. Stone, R. Fowl; Radiology, Mayo Clinic Arizona, Scottsdale, AZ; Vascular Surgery, Mayo Clinic Arizona, Scottsdale, AZ Learning Objectives: Review the vascular compression syndromes and their clinical presentation, imaging findings and percutaneous treatment strategies via a case based approach. Background: Anatomic variants can result in compression of vascular structures with resultant intimal damage, ischemia, thrombosis and/or embolic disease. Aortosternal venous compression, Paget-Schroetter syndrome, Nutcracker compression, May-Thurner, quadrilateral space syndrome, median arcuate ligament compression, and popliteal artery entrapment comprise the majority of vascular compression syndromes. Distinguishing normal from variant anatomy is an important first step when one is entertaining such a diagnosis. As many asymptomatic patients may have imaging findings of a compression syndrome, correlation with clinical presentation and in some cases, reproducibility of symptoms triggered by maneuvers to induce compression is often a key piece of information in the diagnostic algorithm. The interventional radiologist provides useful diagnostic information and in some cases, potential treatment options. Clinical Findings/Procedure Details: In compliance with the IRB, the radiology database was retrospectively searched to identify cases of vascular compression syndromes. The clinical course, cross sectional and angiographic images are presented highlighting normal and variant anatomy resulting in these pathological states as well as percutaneous treatment strategies. Conclusion and/or Teaching Points: 1. Understand the most common presenting clinical symptoms with each vascular compression disorder. 2. The union of imaging findings with clinical symptoms is often the most reliable method for diagnosis. 3. The interventional radiologist is well suited to play a diagnostic role in these patients, but when appropriate, provide initial management.