Periprocedural Events Research Articles

Coronary dominance and predictors of adverse events during coronary interventional procedures: an observational study

Background: Coronary dominance is associated with adverse peri-procedural events during coronary interventions. There are limited data regarding events during coronary angiography in Nepal.Aims and methods: The aim of this article is to get information regarding events during invasive procedures of this region which has a large feeder population. All the cases undergone cardiac interventional procedures were included and analyzed.Results: Out of 200 cardiac interventional procedures, 160 cases underwent coronary angiography (CAG) and 20 percutaneous coronary intervention (PCI). 54% of the study populations were male. The mean age of study population was 61.2 years (range: 29-85 years). Most common indication for performing CAG was for post ACS (69%) followed by chronic stable angina (CSA) (16%). Most common finding in CAG was SVD (35%) LAD was the commonest (55% of SVD), DVD (19%), non-critical CAD (13%), TVD (14%) and left main (2%). Myocardial bridging was seen in 2% and 15% had normal coronaries. Commonest risk factor for CAD was Hypertension (45%) followed by smoking (35%) and diabetes (16%). CAG was most commonly performed from right radial (70%) followed by right femoral (24%), left radial (5%) and left femoral (1%). 78% of patients had right dominance, 16% had left dominance while 6% had co-dominance. Out of 40 non-right dominant (left or co-dominant) patient twenty three (57.5%) were female. There was no significant association of left dominance with the gender although the odds ratio was high (1.8) in female gender (P=0.12). Considering Left dominant patients only, the odds ratio of Tiger catheter versus Judkins Right (JR) is 8.33 but not statistically significant (P=0.17). Major complications encountered were ventricular tachycardia (VT) in 4 cases. The odds for VT with left dominance and right dominance was high with statistical significance [OR: 53.48, C.I :( 2.79-1023.4); P=0.002].Conclusion: Ventricular tachycardia which is among the major complication is found to be significantly associated with left dominance. Further studies are necessary to evaluate the evidence provided by this study.

Complete filter-based cerebral embolic protection with transcatheter aortic valve replacement.

To evaluate the value of left vertebral artery filter protection in addition to the current filter-based embolic protection technology to achieve complete cerebral protection during TAVR. The occurrence of cerebrovascular events after transcatheter aortic valve replacement (TAVR) has fueled concern for its potential application in younger patients with longer life expectancy. Transcatheter cerebral embolic protection (TCEP) devices may limit periprocedural cerebrovascular events by preventing macro and micro-embolization to the brain. Conventional filter-based TCEP devices cover three extracranial contributories to the brain, yet leave the left vertebral artery unprotected. Patients underwent TAVR with complete TCEP. A dual-filter system was deployed in the brachiocephalic trunk and left common carotid artery with an additional single filter in the left vertebral artery. After TAVR all filters were retrieved and sent for histopathological evaluation by an experienced pathologist. Eleven patients received a dual-filter system and nine of them received an additional left vertebral filter. In the remaining two patients, the left vertebral filter could not be deployed. No periprocedural strokes occurred. We found debris in all filters, consisting of thrombus, tissue derived debris, and foreign body material. The left vertebral filter contained debris in an equal amount of patients as the Sentinel filters. The size of the captured particles was similar between all filters. The left vertebral artery is an important entry route for embolic material to the brain during TAVR. Selective filter protection of the left vertebral artery revealed embolic debris in all patients. The clinical value of complete filter-based TCEP during TAVR warrants further research.

323 Comparison Between Balloon-Assisted and Stent-Assisted Technique for Treatment of Unruptured Internal Carotid Artery Aneurysms

Abstract INTRODUCTION Balloon and stent are representative of assistant devices for wide-neck aneurysm coiling. To date, there were no studies comparing balloon-assisted (BAC) and stent-assisted coiling (SAC) for the treatment of internal carotid artery unruptured aneurysms (ICA-UA). METHODS We sought to characteristics of patients and aneurysms, and clinical and angiographic prognosis between groups. Total number of ICA-UA was 227 in 190 patients. Two groups were separted into BAC group (141 ICA-UA in 120 patients) and SAC group (86 ICA-UA in 70 patients). RESULTS >In SAC, aneurysm size and neck diameter tended to be larger than in BAC, but aneurysm volume and packed density of coil were not different between groups. Immediate angiographic occlusion grade was better for BAC than for SAC. Periprocedural thromboembolic events were more frequent during SAC (11.6%) than BAC (2.4%) per aneurysm, but hemorrhagic events were the opposite (2.4% for BAC and none for SAC per aneurysm) (P < 0.05). At discharge, treatment-related morbi-mortality rates were 1.6% for BAC and 1.4% per patient for SAC. At clinical follow-up (BAC, 118 patients [98.3%] for a mean of 48.4 months; SAC, 69 patients [98.6%], for a mean of 37.4 months), 1 additional treatment-related infarction occurred during SAC, resulting in a modified Rankin scale score of 4. Thus, overall treatment-related morbidity-mortality rates were 1.7% in BAC and 2.9% in SAC. At imaging follow-up (BAC, 135 aneurysms [95.7%] for 28.3 months; SAC, 81 aneurysms [94.1%] for 23.9 months), BAC and SAC showed stable or improved occlusion in 94.1% and 95.0%, minor recurrence in 4.4% and 2.5%, and major recurrence in 1.5% and 2.5%, respectively. CONCLUSION Both BAC and SAC were safe and effective techniques for ICA-UA. There were no differences in morbidity, mortality and recurrence rates between groups, despite their opposite trends.

Thrombo-embolic prevention after transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) has emerged as a valuable treatment alternative to surgical aortic valve replacement among patients with symptomatic aortic stenosis at increased surgical risk. The rapid technological evolution from early to current-generation TAVI systems with low-profile delivery catheters, bioprosthetic valves with proven midterm durability, and improved positioning and retrieval features have made important contributions to the widespread clinical use of this minimal invasive therapy. Although peri-procedural and long-term thrombotic and bleeding events after TAVI remain a relevant concern, the optimal antithrombotic strategy and duration to mitigate these risks remain unclear. This review provides an overview of recent insights in this field, and highlights current and future antithrombotic trials focusing on optimizing outcomes in patients undergoing TAVI.

Predictors of pre-procedural concentrations of direct oral anticoagulants: a prospective multicentre study.

Patients receiving direct oral anticoagulants (DOACs) frequently undergo elective invasive procedures. Their management is challenging. We aimed to determine the optimal duration of DOAC discontinuation that ensures a minimal anticoagulant effect during the procedure. This prospective multicentre study included 422 DOAC-treated patients requiring an invasive procedure. Pre-procedural DOAC concentration ([DOAC]) and routine haemostasis assays were performed to determine i/the proportion of patients who achieved a minimal pre-procedural [DOAC] (≤30 ng/mL) according to the duration of DOAC discontinuation, ii/the predictors of minimal [DOAC] and, iii/the ability of routine assays to predict minimal [DOAC]. Lastly, we assessed the predictors of peri-procedural bleeding events. The duration of DOAC discontinuation ranged from 1 to 218 h and pre-procedural [DOAC] from ≤30 to 527 ng/mL. After a 49-72-h discontinuation, 95% of the [DOAC] were ≤30 ng/mL. A 72-h discontinuation predicted concentrations ≤30 ng/mL with 91% specificity. In multivariable analysis, duration of DOAC discontinuation, creatinine clearance <50 mL/min and antiarrhythmics were independent predictors of minimal pre-procedural [DOAC] (concordance statistic 0.869; 95% confidence interval: 0.829-0.912). Conversely, routine haemostasis assays were poor predictors. Last, creatinine clearance <50 mL/min, antiplatelets and high-bleeding risk procedures were predictors of bleeding events. A last DOAC intake 3 days before a procedure resulted in minimal pre-procedural anticoagulant effect for almost all patients. Moderate renal impairment, especially in dabigatran-treated patients, and antiarrhythmics in anti-Xa-treated patients should result in a longer DOAC interruption. In situations requiring testing, routine assays should not replace DOAC concentration measurement.

Outcomes after catheter ablation and cardioversion in patients with non-valvular atrial fibrillation: results from the prospective, observational XANTUS study.

In patients with atrial fibrillation, catheter ablation and cardioversion carry a risk of peri-procedural thromboembolic events; current guidelines recommend anticoagulation in these settings. This study aimed to report the baseline demographics and clinical characteristics of patients enrolled in the prospective, observational XANTUS study who underwent catheter ablation or cardioversion, and adverse outcomes with each of these procedures in patients treated with rivaroxaban. Data collected included information on catheter ablation and cardioversion, and adverse outcomes occurring within 30 days of these procedures: incidence of treatment-emergent adjudicated symptomatic thromboembolic events and major bleeding; and cardiovascular and all-cause death. Incidence of these adverse outcomes at 42 days after cardioversion was also analysed. Patients undergoing either procedure had significantly lower mean CHA2DS2-VASc and HAS-BLED scores than those who did not, and were more frequently hospitalized at study baseline. Within a period of 30 days after intervention, symptomatic thromboembolic events were reported in 1.2% and 0.6% of patients undergoing ablation or cardioversion, respectively; major bleeding events were reported in 2.9% and 0.4% of patients undergoing ablation or cardioversion, respectively. No patients died within 30 days of intervention. Incidence of symptomatic thromboembolic and major bleeding events remained low at 42 days after cardioversion. Similar to the results of prospective and non-interventional studies, the low rates of symptomatic thromboembolic events and major bleeding in patients with atrial fibrillation undergoing ablation or cardioversion and treated with rivaroxaban in XANTUS suggest that its use is associated with an acceptable benefit-risk profile in this setting. Clinicaltrials.gov: NCT01606995.

Transcatheter Mitral Valve Replacement for Native and Failed Bioprosthetic Mitral Valves.

Transcatheter mitral valve replacement (TMVR) is a novel approach for treatment of severe mitral regurgitation. A number of TMVR devices are currently undergoing feasibility trials using both transseptal and transapical routes for device delivery. Overall experience worldwide is limited to fewer than 200 cases. At present, the 30-day mortality exceeds 30% and is attributable to both patient- and device-related factors. TMVR has been successfully used to treat patients with degenerative mitral stenosis (DMS) as well as failed mitral bioprosthesis and mitral repair using transcatheter mitral valve-in-valve (TMViV)/valve-in-ring (ViR) repair. These patients are currently treated with devices designed for transcatheter aortic valve replacement. Multicenter registries have been initiated to collect outcomes data on patients currently undergoing TMViV/ViR and TMVR for DMS and have confirmed the feasibility of TMVR in these patients. However, the high periprocedural and 30-day event rates underscore the need for further improvements in device design and multicenter randomized studies to delineate the role of these technologies in patients with mitral valve disease.

Cerebral white matter lesion burden is associated with the degree of aortic valve calcification and predicts peri-procedural cerebrovascular events in patients undergoing transcatheter aortic valve implantation (TAVI).

To investigate the impact of aortic valve calcification and brain morphology on acute peri-procedural cerebrovascular events (CVEs) in patients undergoing transcatheter aortic valve implantation (TAVI). Aortic valve calcification and stenosis can be assessed with echocardiography. Cerebral magnetic resonance imaging (MRI) depicts and quantifies morphological signs of hypoperfusion and vascular embolism, which is of special interest in patients with severe aortic stenosis. Furthermore, subjects who undergo TAVI are prone to suffer of clinically silent peri-procedural CVEs. A total of 119 patients referred to TAVI were investigated for aortic valve calcification using trans-esophageal echocardiography. Cerebral MRI prior to and immediate after implantation was performed in all patients using a dedicated scan protocol. Prior to TAVI, brain morphology was characterized. Post TAVI, brains were investigated for the onset of acute peri-procedural CVEs using diffusion weighted imaging (DWI). Seventy-eight patients (65.5%) revealed acute peri-procedural CVEs on MRI after TAVI with a favor of the left hemisphere (57.5%). The degree of valve calcification was associated with peri-procedural CVEs. Patients with a high WML burden had an increased risk for CVEs ((OR) 2.36 (95% CI: 1.09-5.15; P = 0.037)), especially when distributed periventricular ((OR: 3.27; 95% CI: 1.47-7.26; P = 0.0038)). In patients undergoing TAVI, the degree of aortic valve calcification and periventricular WML burden were correlated with acute peri-procedural CVEs. Future studies are needed to evaluate their independent value for the long-term clinical outcome.

Left Atrial Appendage Occlusion in Patients With Atrial Fibrillation and Previous Major Gastrointestinal Bleeding (from the Amplatzer Cardiac Plug Multicenter Registry)

History of major gastrointestinal (GI) bleeding may represent a frequent clinical indication for left atrial appendage occlusion (LAAO) in patients with non-valvular atrial fibrillation (AF). This study aims to investigate the procedural safety and long-term outcome of patients with previous major GI bleeding (MGIB) who underwent LAAO. Data from the Amplatzer Cardiac Plug multicenter registry on 1,047 patients were analyzed. Patients with previous MGIB as indication for LAAO were compared with patients without previous MGIB. A total of 151 patients (14.4%) with previous MGIB were identified. Periprocedural major bleeding events were more frequent in patients with previous MGIB (4.0% vs 0.8%, p= 0.001). With an average follow-up of 1.3years, the observed annual rate of stroke/transient ischemic attack and major bleeding for patients with previous MGIB were 2.1% (61.4% relative reduction according to the Congestive Heart failure, Hypertension, Age ≥75 (doubled), Diabetes, Stroke (doubled), Vascular disease, Age 65-74, and Sex (female) [CHA2DS2-VASc] score) and 4.6% (20.1% relative reduction according to the expected rate based on the Hypertension, Abnormal renal/liver function (1 point each), Stroke, Bleeding history or predisposition, Labile INR, Elderly (>65 years), Drugs/alcohol concomitantly (1 point each) [HAS-BLED] score), respectively. In conclusion, in patients with non-valvular atrial fibrillation and previous MGIB, LAAO was associated with a low annual rate of stroke/transient ischemic attack. Periprocedural major bleeding events were more frequent in this specific population although the annual major bleeding rate showed a 20.1% relative risk reduction according to the HAS-BLED score.

Total Thrombus-formation Analysis System Predicts Periprocedural Bleeding Events in Patients With Coronary Artery Disease Undergoing Percutaneous Coronary Intervention.

BackgroundPeriprocedural bleeding events are common after percutaneous coronary intervention. We evaluated the association of periprocedural bleeding events with thrombogenicity, which was measured quantitatively by the Total Thrombus‐formation Analysis System equipped with microchips and thrombogenic surfaces (collagen, platelet chip [PL]; collagen plus tissue factor, atheroma chip [AR]).Methods and ResultsBetween August 2013 and March 2016, 313 consecutive patients with coronary artery disease undergoing elective percutaneous coronary intervention were enrolled. They were divided into those with or without periprocedural bleeding events. We determined the bleeding events as composites of major bleeding events defined by the International Society on Thrombosis and Hemostasis and minor bleeding events (eg, minor hematoma, arteriovenous shunt and pseudoaneurysm). Blood samples obtained at percutaneous coronary intervention were analyzed for thrombus formation area under the curve (PL24‐AUC10 for PL chip; AR10‐AUC30 for AR chip) by the Total Thrombus‐formation Analysis System and P2Y12 reaction unit by the VerifyNow system. Periprocedural bleeding events occurred in 37 patients. PL24‐AUC10 levels were significantly lower in patients with such events than those without (P=0.002). Multiple logistic regression analyses showed association between low PL24‐AUC10 levels and periprocedural bleeding events (odds ratio, 2.71 [1.22–5.99]; P=0.01) and association between PL24‐AUC10 and periprocedural bleeding events in 176 patients of the femoral approach group (odds ratio, 2.88 [1.11–7.49]; P=0.03). However, PL24‐AUC10 levels in 127 patients of the radial approach group were not significantly different in patients with or without periprocedural bleeding events.ConclusionsPL24‐AUC10 measured by the Total Thrombus‐formation Analysis System is a potentially useful predictor of periprocedural bleeding events in coronary artery disease patients undergoing elective percutaneous coronary intervention.

Pretreatment with and ongoing use of omega-3 fatty acid ethyl esters reduce the slow-flow phenomenon and prevent in-stent restenosis in patients undergoing carotid artery stenting

ObjectiveCarotid artery stenting (CAS) is a less invasive alternative to carotid endarterectomy, but it is essential to prevent thromboembolic complications during CAS and to suppress in-stent restenosis (ISR) after CAS because of the relatively high risk of periprocedural and follow-up stroke events. Clinical trials have demonstrated the strong relationship of carotid plaque vulnerability with the subsequent risk of ipsilateral ischemic stroke and thromboembolic complications during CAS. Recent studies demonstrated that both low eicosapentaenoic acid (EPA) and low docosahexaenoic acid (DHA) levels were significantly associated with lipid-rich coronary and carotid plaques, but little is known about the effect of administration of omega-3 fatty acids (O-3FAs) containing EPA and DHA before and after CAS for stabilizing carotid plaque, preventing thromboembolic complications, and suppressing ISR. In this study, the efficacy of pretreatment with and ongoing daily use of O-3FA in addition to statin treatment was evaluated in patients undergoing CAS. MethodsThis study was a nonrandomized prospective trial with retrospective analysis of historical control data. From 2012 to 2015, there were 100 consecutive patients with hyperlipidemia undergoing CAS for carotid artery stenosis who were divided into two groups. Between 2012 and 2013 (control period), 47 patients were treated with standard statin therapy. Between 2014 and 2015 (O-3FA period), patients were treated with statin therapy and add-on oral O-3FA ethyl esters containing 750 mg/d DHA and 1860 mg/d EPA from 4 weeks before CAS, followed by ongoing daily use for at least 12 months. In all patients, the plaque morphology by virtual histology intravascular ultrasound, the incidence of new ipsilateral ischemic lesions on the day after CAS, the slow-flow phenomenon during CAS, and ISR within 12 months after CAS were compared between the periods. ResultsThe slow-flow phenomenon during CAS with filter-type embolic protection devices decreased in the O-3FA period (1 of 53 patients [2%]) compared with the control period (7 of 47 patients [15%]; P = .02). Furthermore, ISR for 12 months after CAS was significantly decreased in the O-3FA period (1 of 53 patients [2%]) compared with the control period (10 of 47 patients [21%]; P = .01). On virtual histology intravascular ultrasound analysis, the fibrofatty area was significantly smaller and the fibrous area was significantly greater in the O-3FA period. On multivariate logistic regression analysis, a low EPA/arachidonic acid ratio and a symptomatic lesion were the factors related to vulnerable plaque (P = .01 [odds ratio, 5.24; 95% confidence interval, 1.65-16.63] and P = .01 [odds ratio, 11.72; 95% confidence interval, 2.93-46.86], respectively). ConclusionsPretreatment with O-3FA reduces the slow-flow phenomenon generated by plaque vulnerability during CAS, and on-going daily use of O-3FA suppresses ISR after CAS.

A comparison of results of carotid endarterectomy in octogenarians and nonagenarians to younger patients from the Mid-America Vascular Study Group and the Society for Vascular Surgery Vascular Quality Initiative

ObjectiveCarotid endarterectomy (CEA) reduces stroke risk in selected patients. However, CEA risk profile may be different in older patients. We compared characteristics and outcomes of octogenarians and nonagenarians with those of younger patients. MethodsDeidentified data from CEA patients were obtained from the Society for Vascular Surgery Vascular Quality Initiative (VQI) database. Prior CEA, carotid artery stent, or combined CEA and coronary artery bypass were excluded, yielding 7390 CEAs in octogenarians and nonagenarians (≥80 years of age) and 35,303 CEAs in younger patients (<80 years of age). We compared post-CEA outcomes, including periprocedural cerebral ischemic events and death, and details such as operative time, bleeding, and return to surgery. ResultsOctogenarians and nonagenarians were more likely to have pre-CEA neurologic symptoms (51.4% vs 45.6%; P < .001) and to have never smoked (37.8% vs 22.0%; P < .001), and they were slightly more likely to have required urgent CEA (16.1% vs 13.4%; P < .001). Stenosis ≥70% was similar (octogenarians and nonagenarians, 94.2%; younger patients, 94.4%; P = .45). Perioperative ipsilateral neurologic events and ipsilateral stroke were slightly more common among octogenarians and nonagenarians (1.6% vs 1.1% [P < .001] and 1.2% vs 0.8% [P = .002]). Multivariate modeling (logistic regression) showed that pre-CEA neurologic symptoms (odds ratios, 1.35 [P = .005] and 1.42 [P = .007]), pre-CEA ipsilateral cortical ischemic event (odds ratios, 1.18 [P < .001] and 1.20 [P < .001]), and urgency (odds ratios, 1.75 [P < .001] and 1.67 [P < .001]) remained strong predictors of any ipsilateral neurologic event and any ipsilateral stroke, respectively. However, age ≥80 years remained a significant predictor of these outcomes (odds ratios, 1.37 [P = .003] and 1.44 [P = .004]). Kaplan-Meier estimated survival was lower for octogenarians and nonagenarians at 30 days and 1 year (98.6% vs 99.4% and 93.7% vs 97.0%; log-rank, P < .001). Age ≥80 years was also associated with a greater rate of discharge to other than home after CEA, a difference that was only partially explained by comorbidities in multivariate modeling. ConclusionsCEA was performed with low rates of perioperative neurologic events and mortality. Multivariate testing showed that the higher rate of neurologic complications in octogenarians and nonagenarians appeared partially related to symptomatic status and urgent surgery; but after adjusting for these factors, age ≥80 years still predicted a slightly higher rate. Periprocedural CEA outcomes appear similar in comparing older and younger patients, although longer term survival is lower for older patients, and older patients are at greater risk of discharge to other than home. CEA was associated with slightly higher risk of neurologic complications in older patients but may be considered appropriate for selected octogenarians and nonagenarians.

CRT-800.28 The CIN-IT Study: - Contrast Induced Nephropathy In Patients Undergoing Transcatheter Aortic Valve Replacement

Patients with chronic kidney disease have worse outcomes following TAVR (Transcatheter Aortic Valve Replacement). They are older, have more comorbidities and are exposed to significant volumes of contrast and risk for peri-procedural thromboembolic events. Identifying patients we can provide the

Abstract 6: Interim Report of the Weave Trial: First 102 Consecutive on Label Patients

Purpose: The initial FDA approval trial of the self-expanding Wingspan stent for symptomatic intracranial atherosclerotic disease demonstrated a 4.5% periprocedural complication rate. Subsequently, similar on-label registry data was reported. The WEAVE Trial is a prospective, consecutive enrollment, single-arm, post-market surveillance trial evaluating periprocedural outcomes in patients with the revised FDA indications for use. Methods: Data for the first 102 on-label patients for which completed data is available are included in this report. The primary analysis endpoints included periprocedural stroke, death, or symptomatic bleed within 72 hours of the stenting procedure in patients who were treated on label. A subgroup of the participating sites included anti-platelet therapy resistance testing and correction, if needed, in their treatment of the patient. All patient outcomes were separately adjudicated by a stroke Neurologist by 72 to 96 hours post procedure. Results: In the initial 122 consecutive patients enrolled with completed data, 102 patients were treated on label and are included in the primary analysis, and 20 patients were treated off label and were part of secondary analyses. The mean stenosis in the primary analysis group was 83% with target artery break down as follows: 40.2% MCA, 25.5% ICA, 19.6% Basilar, 14.7% Vertebral or VB junction. Of the 102 patients in the primary analysis, 3 patients (2.9%) reached a primary endpoint of stroke, symptomatic bleed, or death within 72 hours. In the off label group, 4 of the 20 patients (20%) reached a primary endpoint within that period. Conclusions: The early interim analysis of the first 102 patients of WEAVE trial has demonstrated a very low periprocedural morbidity and mortality of 2.9%. This is lower than the high periprocedural event rate in the SAMMPRIS trial, and statistically better than the outcomes in the off label group (Fisher’s Exact test p value 0.014). This early data provides impetus to continue to collect data in this trial, and lends support to the concept that refined patient selection criteria and establishment of best practice techniques and management for these patients can substantially decrease the peri-procedural risk of intracranial stenting.

Abstract TP123: Efficacy of Staged Angioplasty to Prevent Cerebral Hyperperfusion Syndrome After Endovascular Revascularization for Carotid Artery Stenosis

Background and aim: Cerebral hyperperfusion syndrome (CHS) including intracranial hemorrhage (ICH) is a serious complication after carotid artery stenting (CAS). Staged angioplasty (SAP), undersized-balloon angioplasty followed by delayed CAS, was reported to be a potential preventable method against CHS. The aim of this study was to clarify the efficacy of SAP to prevent CHS after endovascular carotid revascularization for high-risk patients of CHS. Methods: The STOP CHS study is a multicenter, retrospective study which registered 535 high-risk patients of CHS from 45 Japanese centers, who underwent regular CAS, SAP or angioplasty performed by board-certified neurointerventionists between October 2007 and March 2014. Selection of high-risk patients of CHS was based on imaging tests, such as single-photon emission computed tomography with acetazolamide. We investigated the cumulative periprocedural rates of CHS, ICH and major adverse event (MAE: stroke, myocardial infarction and death) of patients scheduled for regular CAS or SAP (intention-to-treat [ITT] population) and the relationship between SAP and the cumulative incidence of CHS in ITT and as-treated (AT) populations (patients who underwent regular CAS or SAP). Results: A total of 525 patients (532 lesions, 74 women, 72.5±7.5 years old) was included. Angiographic stenosis was 86.2±9.2% and 337 lesions were symptomatic. Scheduled procedures were regular CAS in 419 lesions and SAP in 113 lesions, and final procedures were regular CAS in 428 lesions, SAP in 102 lesions and angioplasty in 2 lesions. The cumulative event rates were CHS in 9.2%, ICH in 4.3% and MAE in 11.5%, and these were higher in patients scheduled for regular CAS than in patients scheduled for SAP(10.5 % vs 4.4%, 5.3% vs 0.9% and 12.9% vs 6.2% with each p-value &lt;0.05, respectively). After multivariate adjustment, schedule for SAP was negatively related to the cumulative incidence of CHS (OR, 0.25; 95%CI, 0.09-0.73). Same applied to implementation of SAP in AT population (OR, 0.28; 95%CI, 0.10-0.82). Conclusion: The cumulative periprocedural event rates of high-risk patients of CHS scheduled for regular CAS or SAP were actually high. SAP was a negative predictor of CHS in both ITT and AT populations.

Is Complete Revascularisation Mandated for all Patients with Multivessel Coronary Artery Disease?

In multivessel coronary artery disease (MVCAD), myocardial revascularisation can be achieved by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), with complete revascularisation on all diseased coronary segments or with incomplete revascularisation on selectively targeted lesions. Complete revascularisation confers a long-term prognostic benefit, but is associated with a higher rate of periprocedural events compared with incomplete revascularisation. In most patients with MVCAD, the main advantage of CABG over PCI is conferred by the achievement of more extensive revascularisation. According to current international guidelines, PCI is generally preferred in single-vessel disease, low-risk MVCAD or isolated left main disease; whereas CABG is usually recommended in patients with complex two-vessel disease, most patients with three-vessel disease and/or non-isolated left main disease. In patients with MVCAD, the choice on revascularisation modality should depend on a multifactorial evaluation, taking into account not only coronary anatomy, the ischaemic burden, myocardial function, age and the presence of comorbidities, but also the adequacy of myocardial revascularisation.

Biosensing of periprocedural events in acute ST-segment elevation myocardial infarction patients with the erythrocyte-derived microparticles

Biosensing of periprocedural events in acute ST-segment elevation myocardial infarction patients with the erythrocyte-derived microparticles

Deferred versus conventional stent implantation in patients with acute ST-segment elevation myocardial infarction: An updated meta-analysis of 10 studies

BackgroundWe sought to evaluate safety and efficacy of the deferred stenting versus immediate stent implantation of infarct-related arteries in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). MethodsA meta-analysis using random-effects models were conducted. The primary outcome, major adverse cardiac events (MACE), was a composite of all-cause mortality, myocardial infarction (MI), any unplanned target vessel revascularization (TVR), and hospitalization due to cardiac cause. Periprocedural composite events were composed of acute re-occlusion, no-reflow/slow flow, or distal embolization. ResultsSeven non-randomized registries and three randomized trials comparing outcomes of deferred versus immediate stenting in infarct-related arteries of 2281 STEMI patients were selected. Risk of MACE between deferred or immediate stenting did not differ significantly (rates, 12.8% vs 15.0%; pooled RR=0.68, 95% CI: 0.43–1.06; p=0.087; I2=26.8%). Deferred stenting was associated with significantly reduced risk of periprocedural composite events (rates, 5.3% vs 10.2%; pooled RR=0.36, 95% CI: 0.18–0.69; p=0.002; I2=68.0%) and flow abnormality in infarct-related arteries (rates, 3.8% vs 8.4%; pooled RR=0.29, 95% CI: 0.14–0.61; p=0.001; I2=58.1%). However, clinical outcomes including all-cause mortality, MI, or any unplanned TVR, were unaffected. Meta-regression indicated a significant relationship between prolonged total ischemic and reduced risk of MACE after deferred stenting (OR=0.994, 95% CI: 0.990–0.998; p=0.027; I2 residual 0.0%, adjusted R2=100.0%). ConclusionsAlthough deferred stenting carried significantly lower risk of periprocedural composite events and abnormal flow in patients undergoing primary PCI for STEMI, such benefits had no impact on MACE, which did not differ significantly by timing of stent placement.

Update on new stents and protection devices for carotid artery stenting: what we know, what we learnt recently and what we need to know.

Carotid artery stenting (CAS) is considered an alternative option to carotid endarterectomy (CEA) for significant carotid stenosis, in both symptomatic and asymptomatic patients. Comparing to CEA, CAS offers significant advantages. The most important arise from the minimally invasive nature of the procedure, which reduces the surgical complications and adds significant comfort to the patient, without compromising the efficacy. Nowadays, CAS can achieve acute and long-term outcome results comparable to CEA, maintaining low rates of periprocedural embolic events. Evolution of the stent design and routine application of protection devices, played an important role to CAS performance. In this review, we aim to present all available new data on stent design and protection devices while we pose a set of unanswered questions that need to be addressed in the future.

Incidence and risk factors of embolized particles in carotid artery stenting and association with clinical outcome

BackgroundOne of the mechanisms for periprocedural neurologic events in carotid artery stenting (CAS) is catheter manipulation within the aorta and supraaortic arteries causing plaque embolization. Therefore, the present analysis sought to determine risk factors for embolic particle dimensions and their relationship with adverse clinical events after CAS. MethodsBetween 1999 and 2015 embolic protection devices (EPD) of a total of 944 CAS procedures were evaluated regarding the occurrence and size of captured particles. ResultsParticles were found in 819 of 944 (87%) EPDs. Larger particles were detected in procedures using open cell stents (150±282μm vs. 107±177μm; p=0.005) and longer stents (≥40mm) (165±315μm vs. 122±215μm; p=0.026). With increasing learning curve, particle size was continually reduced (168±282μm in the first third of the cohort vs. 127±309μm in the second third vs. 108±114μm in the last third; p=0.009). Longer stents and use of Acculink stent were found to be independent predictors for particle diameter. In patients who died or sustained a stroke during long-term follow-up (median 5.5years [IQR 2.6–7.9]) significantly larger particles were captured during CAS compared to those patients with an uneventful follow-up (160±330μm vs. 121±195μm; p=0.047). ConclusionsIn the vast majority of CAS procedures particles could be retrieved from the EPDs used. Procedural characteristics such as stent type and stent length were associated with larger particles.