Prior Coronary Artery Bypass Grafting Research Articles

Orbital Atherectomy for Treatment of Complex Severely Calcified Coronary Artery Lesions: Insights from a Veterans Affairs Cohort

BackgroundCoronary artery calcification remains a significant challenge to successful percutaneous coronary intervention (PCI). Orbital atherectomy (OA) is an effective treatment for severely calcified coronary artery lesions during PCI, but few data are available in the Veterans Affairs (VA) system which has an increasingly complex subset of patients. MethodsData were obtained from retrospective analysis of patients with severe coronary artery calcification who underwent OA followed by stent implantation from February of 2015 to July of 2018 at a single VA Medical Center. Kaplan-Meier analysis was utilized to assess the primary endpoints of 30-day and 1-year freedom from major adverse cardiac events [MACE: Cardiac Death, myocardial infarction (MI), or target vessel revascularization (TVR)]. ResultsAmong 151 patients, baseline comorbidities included diabetes (57%), prior PCI (51%), congestive heart failure (36.4%), and prior coronary artery bypass grafting (23.2%). The most common indication for intervention was stable angina (54.3%). Seventeen percent of cases required hemodynamic support. Angiographic complication rates were low. Overall freedom from MACE was 96% at 30 days and 87.7% at 1 year. ConclusionThis single-center VA cohort demonstrates that patients with severely calcified and anatomically complex coronary artery lesions treated with OA had a low rate of angiographic complications and a high rate of one-year freedom from MACE. Moreover, this study included demographics underrepresented in clinical trials, including those with acute myocardial infarction, left main coronary artery disease, and bifurcation lesions.

Pericardial complications and postcardiac injury syndrome after cardiovascular implantable electronic device placement : Ameta-analysis and systematic review.

Postcardiac injury syndrome (PCIS) is an emerging condition including pericarditis with or without pericardial effusion after an injury to cardiac tissue. Data are lacking on its incidence and clinical predictors after cardiovascular implantable electronic device (CIED) placement. We therefore performed this meta-analysis to determine the incidence of PCIS. Medline, Embase, and Cochrane CENTRAL databases were searchedaccording to PRISMA guidelines from February 2007 to February 2017 for studies evaluating pericardial complications subsequent to CIED implantation. Primary outcome was the total number of cases of pericarditis, pericardial effusion, and cardiac tamponade documented. Of 2931 references, 22articles (enrolling 188,944 patients) were included. Pooled estimates from random-effects analysis showed an overall incidence of 5.82 per 1000 patients (95% confidence interval [CI], 4.33-8.17) at 30days, and 1.60 per 1000 (95% CI: 0.13-3.07) at 1year. Advanced age and prior coronary artery bypass graft (CABG) surgery were associated with increased rates of pericardial complications. Our analysis revealed that CIED implantations are associated with alow incidence (0.6%) of pericardial complications at 30days. Patients with advanced age and prior CABG are high-risk patients for pericardial complications.

Diffuse ST-segment depression despite prior coronary bypass grafting: An electrocardiographic-angiographic correlation

The standard 12‑lead electrocardiogram (ECG) has become a mainstay diagnostic tool in patients suspected to have myocardial ischemia. The identification of hallmark electrocardiographic abnormalities, such as ST-segment deviation or serial T wave changes, not only helps identify the presence of myocardial ischemia but also may help localize myocardial territories with an ongoing injury. Widespread ST-segment depression is commonly attributed to diffuse subendocardial ischemia precipitated by severe multivessel or left main coronary artery disease. However, among patients with prior coronary revascularization, clear electrocardiographic-angiographic relationships responsible for widespread ST-segment depressions have not been well defined. We report a case in which diffuse ST-segment depression emerged from a patient with prior coronary artery bypass grafting. In this report, we examine the patient's presenting ECG pattern as to (1) establish causal inferences which align with the distribution of myocardial ischemia supported by angiography and (2) provide an accompanying analysis of the relevant scientific literature.

Incidence and predictors of target lesion failure in patients undergoing contemporary DES implantation—Individual patient data pooled analysis from 6 randomized controlled trials

Drug-eluting stents (DESs) have improved clinical outcomes of patients undergoing percutaneous coronary intervention (PCI). Nevertheless, adverse events related to previously treated lesion still occur. We sought to evaluate the incidence and predictors of target lesion failure (TLF) in patients undergoing contemporary DES implantation. Patient-level data from 6 prospective, randomized trials were pooled, and DES treatment outcomes were analyzed at up to 5 years. Primary outcome was TLF (cardiac death, target lesion revascularization, or target vessel myocardial infarction). Cox proportional-hazards model was used to identify predictors of TLF. Overall, 10,072 patients were included in the analysis. TLF rate was 1.7%, 4.3%, and 11.9% at 30 days, 1 year, and 5 years, respectively. The only independent predictor of TLF at 30 days was stent length (hazard ratio [HR] 1.017, 95% CI 1.011-1.024, P < .0001). Moderate/severe calcification, stent length and post procedural diameter sthenosis were predictors between 30 days to 1 year but not at 1 to 5 years. Reference vessel diameter was the only lesion-related predictor at 5 years (P = .003). Clinical predictors of TLF between 30 days and 1 year were diabetes and hypertension (P < .01 for both), and between 1 and 5 years, diabetes (HR 1.40, 95% CI 1.13-1.73, P = .002), prior coronary artery bypass grafting (HR 2.52, 95% CI 1.92-3.30, P < .0001), and prior PCI (HR 1.29, 95% CI 1.02-1.64, P = .04) predicted TLF. Predictors of TLF vary in the early, late, and very late postprocedural periods. Reference vessel diameter was the only lesion-related predictor of long-term TLF; clinical predictors were diabetes, prior coronary artery bypass grafting, and prior PCI.

Outcomes of Isolated Tricuspid Valve Surgery Have Improved in the Modern Era

Surgery for isolated tricuspid valve (TV) disease remains relatively infrequent because of significant patient comorbidities and poor surgical outcomes. This study reviewed the experience with isolated TV surgery in the current era to determine whether outcomes have improved. From 2007 through 2017, 685 TV operations were performed in a single institution, of which 95 (13.9%) operations were isolated TV surgery. Patients were analyzed for disease origin, risk factors, operative mortality and morbidity, and long-term survival. A total of 95 patients underwent isolated TV surgery, an average of 9 patients per year increasing from an average of 5 per year to 15 per year during the study period. Surgery was reoperative in 41% (38 of 95) of patients, including 11.6% (11 of 95) with prior coronary artery bypass grafting and 29.4% (28 of 95) with prior valve surgery (9 TV, 11 mitral, 2 aortic, 5 mitral and aortic, and 1 mitral and TV). Repair was performed in 71.6% (68 of 95) of patients, and replacement was performed in 28.4% (27 of 95). Operative mortality was 3.2% (3 of 95), with no mortality in the most recent 73 patients over the last 6 years. Stroke occurred in 2.1% (2 of 95) of patients, acute kidney injury requiring dialysis in 5.3% (5 of 95), and the need for new permanent pacemaker in 16.8% (16 of 95). In the current era with careful patient selection and periprocedural management, isolated TV surgery can be performed with lower morbidity and mortality than has traditionally been reported with good long-term survival. These outcomes can also serve as a benchmark for catheter-based TV intervention outcomes.

TCTAP A-071 Safety and Feasibility of Transradial Approach for Coronary Artery Bypass Graft Intervention

PCI in patients with prior coronary artery bypass graft (CABG) surgery is becoming increasingly common in recent times, even via the trans-radial route. There is insufficient data comparing the safety and feasibility of radial versus femoral access in graft intervention. This study was done to

Abstract 259: Impact of Valvular Heart Disease on 1-Year Mortality in Veterans

Background: The impact of valvular heart disease (VHD) on outcomes in the Veteran population has not been well studied, especially in the contemporary era. Methods: The study population included 244 Veterans who were seen in Cardiology Clinic in January 2015 - of which 190 had a recent echocardiogram at the time of visit. Veterans with evidence of VHD (defined as any evidence of aortic stenosis (AS), &gt; 2+ moderate mitral regurgitation (MR), and/or &gt; 2+ tricuspid regurgitation(TR)) were identified and characteristics of Veterans with and without VHD were evaluated. Differences in one-year rates of major adverse cardiac events (MACE) (a composite of all-cause mortality or cardiovascular hospitalization) were compared for Veterans with VHD versus those without. Results: Of these 190 Veterans, 39 (20.5%) had evidence of valvular heart disease - 19 (10.0%) has any grade of AS, 15 (7.4%) has &gt; 2+ MR, and 18 (9.5%) has &gt; 2+ TR. Veterans with VHD were older (77 vs 68 years, p&lt;0.001), had higher rates of prior coronary artery bypass graft surgery (41.0% vs 21.9%, p=0.015), had higher serum creatinine (1.8 vs 1.2 mg/dl, p=0.002) and lower hemoglobin (12.5 mg/dl vs 13.4mg/dl, p=0.003), higher right ventricular systolic pressure (47 vs 32mmHg, p&lt;0.001) and higher left atrial volume (107 vs 79ml, p&lt;0.001). Rates of MACE and all-cause mortality at 1 year were significantly higher for Veterans with VHD than those without (See Figure). VHD was associated with 1-year mortality [odds ratio (OR) 8.04, 95% confidence interval (CI) 2.22-29.11.35) in Veterans. Conclusions: In Veterans with cardiovascular disease, presence of VHD is associated with higher rates of MACE and all-cause mortality at 1 year. Further research on VHD specifically in the Veteran population is warranted.

Predictors of Failure of Retrograde Approach for Percutaneous Intervention of Coronary Chronic Total Occlusion: A Single-Center Experience

Objective: The aim of the study is to assess the predictors of failure of percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) lesions using a retrograde approach. Methods: The present study retrospectively enrolled all 211 patients who underwent retrograde CTO PCI from January 2009 to December 2015 at Shanghai Institute of Cardiovascular Disease. Multivariate Cox regression analysis was used to assess potential predictors of retrograde CTO PCI failure including sex, vascular access site, sheath size, prior PCI, prior coronary artery bypass grafting, history of myocardial infarction, target vessel of CTO, J-CTO score, retrograde wire crossing collaterals, and reverse controlled antegrade and retrograde subintimal tracking (CART) use. Results: Of the 211 patients studied, retrograde CTO PCI was successful in 115 (54.5%) patients, and in an additional 46 (21.8%) with an antegrade approach after retrograde failure. For the 50 (23.7%) patients who failed both retrograde and antegrade approaches, the most common (50% [25/50]) reason was inability to cross collaterals with the retrograde wire. This group of patients had fewer instances of a prior PCI (P

In-Hospital Outcomes of Chronic Total Occlusion Percutaneous Coronary Interventions in Patients With Prior Coronary Artery Bypass Graft Surgery

We examined the procedural outcomes of chronic total occlusions (CTO) percutaneous coronary interventions in patients with prior coronary artery bypass graft surgery (CABG). We compared the clinical, angiographic characteristics and outcomes of 3486 CTO interventions performed in patients with (n=1101) and without (n=2317) prior CABG at 21 centers. Prior CABG patients (32% of total cohort) were older (67±9 versus 63±10 years; P<0.001) and had more comorbidities and lower left ventricular ejection fraction (50% [40-58] versus 55% [45-60]; P<0.001). The CTO target vessel in prior CABG patients was the right coronary artery (56%), circumflex (26%), and left anterior descending artery (17%). The mean J-CTO (2.9±1.2 versus 2.2±1.3; P<0.001) and PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention; 1.5±1.1 versus 1.2±1.0; P<0.001) score was higher in prior CABG patients. Retrograde (53% versus 30%, P<0.001) and antegrade dissection reentry (35% versus 28%; P<0.001) techniques were used more frequently in prior CABG patients. Prior CABG patients had lower technical (84% versus 89%; P<0.001) and procedural (82% versus 87%, P<0.001) success, but similar incidence of in-hospital major complications (3.1% versus 2.5%; P=0.287). In-hospital mortality (1% versus 0.4%; P=0.016) and coronary perforation (7.1% versus 3.1%; P<0.001) occurred more frequently in prior CABG patients, however, CABG patients had a lower incidence of pericardial tamponade (0.1% versus 1.0%; P=0.002) and pericardiocentesis (0% versus 1.3%; P<0.001). In a large multicenter CTO percutaneous coronary interventions registry, prior CABG patients had lower success rate but similar overall risk for complications, although mortality was higher and the incidence of tamponade was lower. URL: https://www.clinicaltrials.gov . Unique identifier: NCT02061436.

LIMA TO THE RESCUE: CHALLENGES OF MANAGING INTRACTABLE ANGINA

Recurrent angina pectoris following coronary artery bypass grafting can present a variety of treatment challenges specifically when it is unresponsive to standard medical therapy. 68-year-old male with prior coronary artery bypass grafting in 1980s was referred for a coronary angiogram due to Class

Coronary CT angiography radiation dose trends: A 10-year analysis to develop institutional diagnostic reference levels

Purpose: To develop institutional diagnostic reference levels (IDRL) for coronary CT angiography (CCTA) according to patient size by analyzing radiation dose changes over the past 10 years.Materials and methods: This IRB approved retrospective investigation analyzed radiation dose data from CCTA between 2007 and 2016 at our institution. Annual trends in radiation dose were described for each scanner type and scanning mode. Radiation levels were analyzed for normorhythmic patients, patients with prior coronary artery bypass grafting (CABG), arrhythmia, and according to patient size and tube voltage. Median, and quartile values for volume CT dose index (CTDIvol), dose-length product (DLP), and size-specific dose estimate (SSDE) were calculated. Wilcoxon rank-sum test and Kruskal Wallis test were performed to assess the significance of quantitative data.Results: 35,375 examinations from 33,317 patients (median age, 58 [50–66] years; male patients, 21,087 [58.7%]) were analyzed. CTDIvol, DLP, and SSDE significantly decreased by 9.0%, 30.8%, and 40.1% (all P < 0.05) for all examinations, respectively. All radiation dose metrics progressively decreased across scanning modes (especially retrospectively ECG-gated spiral and prospectively ECG-triggered high-pitch spiral acquisition mode), but did not significantly change across scanners in the last 6 years. CTDIvol and DLP increased with patient size when water-equivalent diameters were >19 cm for normorhythmic and CABG patients. In arrhythmic patients, CTDIvol increased progressively with water-equivalent diameters across all groups.Conclusion: CCTA radiation dose has progressively decreased in the past decade except in patients with prior CABG and arrhythmia. Size-specific IDRLs may optimize radiation utilization in these patients going forward.

Procedural Outcomes of Percutaneous Coronary Interventions for Chronic Total Occlusions Via the Radial Approach: Insights From an International Chronic Total Occlusion Registry

ObjectivesThis study examined the frequency and outcomes of radial access for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BackgroundRadial access improves the safety of PCI, but its role in CTO PCI remains controversial. MethodsWe compared the clinical, angiographic, and procedural characteristics of 3,790 CTO interventions performed between 2012 and 2018 via radial-only access (RA) (n = 747) radial-femoral access (RFA) (n = 844) and femoral-only access (n = 2,199) access at 23 centers in the United States, Europe, and Russia. ResultsPatients’ mean age was 65 ± 10 years, and 85% were men. Transradial access (RA and RFA) was used in 42% of CTO interventions and significantly increased over time from 11% in 2012 to 67% in 2018 (p < 0.001). RA patients were younger (age 62 ± 10 years vs. 64 ± 10 years and 65 ± 10 years; p < 0.001), less likely to have undergone prior coronary artery bypass graft surgery (18% vs. 39% and 35%; p < 0.001), and less likely to have undergone prior PCI (60% vs. 63% and 66%; p = 0.005) compared with those who underwent RFA and femoral-only access PCI. RA CTO PCI lesions had lower J-CTO (Multicenter CTO Registry in Japan) (2.1 ± 1.4 vs. 2.6 ± 1.3 and 2.5 ± 1.3; p < 0.001) and PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) complication (2.3 ± 1.9 vs. 3.2 ± 2.0 and 3.2 ± 1.9; p < 0.001) scores. The mean sheath size was significantly smaller in the RA group (6.6 ± 0.7 vs. 7.0 ± 0.6 and 7.3 ± 0.8; p < 0.0001), although it increased with lesion complexity. Antegrade dissection re-entry (20% vs. 33% and 32%; p < 0.001) was less commonly used with RA, whereas use of retrograde techniques was highest with RFA (47%). The overall rates of technical success (89% vs. 88% vs. 86%; p = 0.061), procedural success (86% vs. 85% vs. 85%; p = 0.528), and in-hospital major complication (2.47% vs. 3.40% vs. 2.18%; p = 0.830) were similar in all 3 groups, whereas major bleeding was lower in the RA group (0.55% vs. 1.94% and 0.88%; p = 0.013). ConclusionsTransradial access is increasingly being used for CTO PCI and is associated with similar technical and procedural success and lower major bleeding rates compared with femoral-only access interventions. (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention [PROGRESS CTO]; NCT02061436)

Percutaneous Coronary Intervention of Chronic Total Occlusions in Patients with Diabetes Mellitus: a Treatment-Risk Paradox.

Diabetes mellitus (DM) is highly prevalent among patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs). This review aims to summarize the available evidence on CTO recanalization in patients with DM. Coronary artery bypass grafting (CABG) surgery is the recommended revascularization modality for patients with DM and multivessel coronary artery disease (CAD). However, the optimal management strategy in diabetic patients with CTO and single-vessel disease or prior CABG remains a clinical dilemma. Contemporary, large-scale, observational registries support the notion that CTO PCI, if performed at high-volume CTO PCI centers by highly experienced operators, conveys similar high procedural success and low complication rates in patients with and without DM. Although DM patients have more frequently CTOs and may derive greater benefit from complete revascularization, they are less frequently exposed to CTO PCI than non-DM patients (treatment-risk paradox). CTO PCI performed by highly experienced operators constitutes a safe and effective treatment option for selected diabetic CTO patients who are not candidates for CABG. Randomized studies are warranted to compare long-term outcomes of CTO PCI and medical therapy in this high-risk subset.

Predictors of mortality in patients with non-anterior ST-segment elevation myocardial infarction: Analysis from the HORIZONS-AMI trial.

We sought to identify clinical, electrocardiographic (ECG), and angiographic characteristics that are predictive of 3-year mortality after primary percutaneous coronary intervention (PCI) in patients with non-anterior ST-elevation myocardial infarction (NA-STEMI) from the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial. Which patients with NA-STEMI undergoing PCI have a poor prognosis is uncertain. NA-STEMI was defined as ST-segment elevation in lateral (V5, V6, I, aVL), inferior (II, III, aVF), or inferolateral (I, II, III, aVF, and V5-V6) ECG leads or posterior myocardial infarction with ST-segment depression of ≥1 mm in ≥2 contiguous anterior leads. Cox regression was used to identify independent predictors of 3-year mortality. Missing data were imputed using multiple imputation. In HORIZONS-AMI, 2,578/3,602 patients had no prior coronary artery bypass grafting, underwent single-vessel PCI, and had baseline ECG data assessed in an independent core laboratory. Among them, 1,495 (58.0%) had NA-STEMI. Patients with NA-STEMI had lower 3-year mortality risk than those with anterior STEMI (4.5% versus 7.1%, P = 0.004). The independent predictors of increased 3-year mortality in NA-STEMI were older age (median > 59.0 years), diabetes, reduced LVEF (≤50%), Killip class ≥2, post-procedure TIMI flow 0-2 versus 3, renal insufficiency, and ST-resolution <30% at 60 min post-PCI. Patients with 0, 1, 2, 3, and ≥4 of these risk factors had 3-year mortality rates of 1.8%, 2.3%, 3.1%, 6.1%, and 36.3%, respectively (P < 0.0001). Although NA-STEMI carries a better prognosis than anterior STEMI, high-risk patient cohorts with NA-STEMI may be identified who have substantial 3-year mortality.

Ministernotomy aortic valve surgery in patients with prior patent mammary artery grafts after coronary artery bypass grafting.

Patients with patent internal thoracic artery (ITA) grafts after prior coronary artery bypass grafting surgery who require aortic valve replacement (AVR) pose unique technical challenges for safe and optimal myocardial protection. The purpose of this study is to review our short- and long-term outcomes with redo minimally invasive AVR in patients with patent in situ ITA grafts. From 2008 to 2016, 48 patients with at least 1 patent in situ mammary artery graft underwent minimally invasive AVR. Preoperative computed tomography was performed in all patients to evaluate the relationship of patent grafts to the sternum. Retrograde coronary sinus and pulmonary vent catheters were placed via the right internal jugular vein. The in situ ITA grafts were not clamped during AVR. Transverse aortotomy, taking care to avoid the grafts arising from the aorta, was performed to expose the aortic valve. The median age of the patients was 78 years [Quartile 1 (Q1)-Quartile 3 (Q3): 71-81]. Thirty-nine (81%) patients were men, and 46 (96%) patients had aortic stenosis. The median cardiopulmonary bypass and cross-clamp times were 124 (Q1-Q3: 108-164) and 92 (Q1-Q3: 83-116) min, respectively. Moderate hypothermia at 28-30°C was used in all patients. Most patients received cold blood cardioplegia with antegrade induction and continuous retrograde delivery. Four patients received only retrograde delivery due to some degree of aortic insufficiency. Thirty-day mortality was 4% (2 of 48 patients). There was no conversion to full sternotomy, and no reoperations were performed for postoperative bleeding or sternal wound infection. Excluding the 2 patients who died in the hospital, the median postoperative length of stay was 7 days (Q1-Q3: 5-8). Overall survival at 1, 5 and 10 years was 94%, 87% and 44%, respectively. Percutaneous retrograde cardioplegia combined with antegrade cardioplegia and moderate hypothermia, without interruption of ITA flow, is a safe and reliable strategy in patients with patent ITA grafts undergoing aortic valve replacement. This strategy combined with a minimally invasive approach may reduce surgical trauma, and is a safe and effective technique in these challenging patients.

High-risk NSTEMI due to Subclavian Artery Atherothrombosis in a Prior Coronary Artery Bypass Graft Patient.

High-risk NSTEMI due to Subclavian Artery Atherothrombosis in a Prior Coronary Artery Bypass Graft Patient.

Differences in patients and lesion and procedure characteristics depending on the age of the coronary chronic total occlusion.

IntroductionWhether duration of chronic total occlusion (CTO) affects lesion and procedural characteristics remains largely unknown.AimTo investigate whether CTO duration influences lesion characteristics and revascularization success.Material and methodsEuroCTO Registry data on patients who had CTO percutaneous coronary intervention between January 2015 and April 2017 were analyzed. Three groups were created based on occlusion age: 3 to 6 months (n = 1415), 7 to 12 months (n = 973), > 12 months (n = 1656).ResultsPatients with greater CTO duration were older (63.0 (56.0–70.0); 63.0 (56.0–71.0); 66.0 (59.0–73.0) years respectively; p < 0.001), had more 3-vessel disease (32.2%; 30.9%; 46.1% respectively; p < 0.001) and more frequent prior coronary artery bypass grafting (8.2%; 9.9%; 29.4% respectively; p < 0.001). In multivariate analysis, occlusion duration was associated with moderate/severe calcification (OR = 1.52; 95% CI: 1.28–1.80; p < 0.001), lesion length > 20 mm (OR 1.77; 95% CI 1.49–2.10; p < 0.001), and collateral circulation Werner type 2 (OR = 1.20; 95% CI: 1.01–1.43; p = 0.041). The CTO duration was associated with lower procedural success (OR for success 0.60; 95% CI: 0.46–0.79; p < 0.001). In multivariate analysis in-hospital adverse events did not differ according to duration of CTO.ConclusionsCoronary artery CTO duration is associated with greater extent of calcification, lesion length, development of collateral circulation and, most importantly, with lower procedural success.

Radial Percutaneous Coronary Intervention in Complex Arm and Chest Vasculature: Tips and Tricks.

The purpose of this review is to identify the anatomical difficulties an operator may encounter during the transradial approach for cardiac catheterization and to offer tips and tricks to overcome those challenges. With increasing implementation of the transradial approach for cardiac catheterization, many new techniques have been utilized to overcome anatomical challenges. This article also discusses the difficulties faced during transradial approach in patients with prior coronary artery bypass grafting (CABG). Numerous large randomized trials have demonstrated the value of the transradial approach over the transfemoral approach during cardiac catheterization. However, this technique is routinely avoided or aborted due to anatomical variations in the upper arm and chest. These obstacles have delayed adoption of transradial access by operators despite the apparent benefits. This article reviews some of the available tips and tricks described in the literature to overcome anatomical obstacles. By implementing some of these tools into practice, an operator may realize improved procedural success, decreased procedure time, and improved patient comfort with the transradial approach.

Conservative Management and 1-Year Follow-Up of a Huge Left Atrial Intramural Hematoma Related to an Epicardial Collateral Perforation During a Chronic Total Occlusion Percutaneous Coronary Intervention

A 68 year-old man, with multiple cardiovascular risk factors, prior stroke, moderate aortic stenosis, prior coronary artery bypass grafts and percutaneous coronary intervention (PCI) on the mid-circumflex coronary artery, was admitted to our hospital because of severe angina (Canadian Cardiovascular

Outcomes Following Percutaneous Coronary Intervention in Non-ST-Segment-Elevation Myocardial Infarction Patients With Coronary Artery Bypass Grafts.

Background There are limited data on outcomes of patients with previous coronary artery bypass graft (CABG) presenting with non-ST-segment-elevation myocardial infarction undergoing percutaneous coronary intervention (PCI). We compare clinical characteristics and outcomes in non-ST-segment-elevation myocardial infarction patients undergoing PCI with or without prior CABG surgery in a national cohort. Methods and Results We identified 205 039 patients with non-ST-segment-elevation myocardial infarction who underwent PCI between 2007 and 2014 in the British Cardiovascular Intervention Society database. Clinical, demographic, procedural, and outcome data were analyzed by dividing into 3 groups: group 1, PCI in native coronary arteries and no prior CABG (n=186 670); group 2, PCI in native arteries with prior CABG (n=8825); group 3, PCI in grafts (n=9544). Patients in group 2 and 3 were older and had more comorbidities and higher mortality at 30 days (group 2, 2.6% and group 3, 1.9%) and 1 year (group 2, 8.29% and group 3, 7.08%) as compared with group 1 (1.7% and 4.87%). After multivariable analysis, no significant difference in outcomes was observed in 30-days mortality (odds ratio; group 2=0.87 [CI, 0.69-1.80; P=0.20], group 3=0.91 [CI, 0.71-1.17; P=0.46]), in-hospital major adverse cardiovascular event (odds ratio: group 2=1.08 [CI, 0.88-1.34; P=0.45], group 3=0.97 [CI=0.77-1.23; P=0.82]), and in-hospital stroke (odds ratio: group 2=1.37 [CI, 0.71-2.69; P=0.35], group 3=1.13 [CI, 0.55-2.34; P=0.73]; group 1=reference). Conclusions Patients with prior CABG are presenting with non-ST-segment-elevation myocardial infarction and treated with PCI had more comorbid illnesses, but once these differences were adjusted for, prior CABG did not independently confer additional risk of mortality and major adverse cardiovascular event.