Revascularization Rates Research Articles

Clinical Outcomes in Diabetic Females Presenting with STEMI: A Cohort Study

Introduction: Although the incidence of Acute Coronary Syndrome (ACS) is lower in women, outcomes are worse, particularly in diabetic females. Despite advances in revascularisation and treatment, mortality rates among diabetic females remain higher, with poorer postpercutaneous coronary intervention outcomes. Studies have rarely addressed the differences in the course of myocardial infarction in diabetic females and this underrepresentation has influenced the formulation of guidelines. Aim: To evaluate the in-hospital composite outcomes of death, non fatal myocardial infarction, emergency revascularisation, heart failure and cerebrovascular accident in diabetic women presenting with ST Elevation Myocardial Infarction (STEMI), as well as the individual in-hospital outcomes and outcomes at one and three months follow-up. Materials and Methods: This was a prospective single-centre cohort study conducted between November 2017 and October 2018 on 204 patients with STEMI and followed-up for three months. Data were collected from patients using a semistructured questionnaire-based interview, clinical examination, laboratory investigations, echocardiography and angiography. In-hospital outcomes—death, non fatal MI, emergency revascularisation, heart failure and cerebrovascular accident—were studied. Telephonic follow-up was conducted at one and three months. The comparison of variables was carried out using the Independent Student’s t-test or Chi-square test, and regression analysis was performed to identify predictors of mortality. Results: The mean age was 64±11 years; 60.3% were hypertensive and 26% had dyslipidaemia. A total of 12.3% were newly diagnosed diabetics. The mean prehospital delay was 201.9±156.8 minutes. Primary angioplasty was performed in 77%, while thrombolysis was done in 16.7%. The composite outcome was observed in 26.3% of the patients, with heart failure occurring in 19%, cardiogenic shock in 27.9% and death in 16.2%. Cerebrovascular accidents were noted in 0.5% and renal dysfunction was present in 13.2%. At one and three months, heart failure occurred in 7.6% and 5.8%, respectively. Among those with in-hospital mortality, a higher proportion had Anterior Wall Myocardial Infarction (AWMI) (p=0.043), were in Killip class>II (p-value <0.0001), and had qRBBB (Right Bundle Branch Block) (p-value <0.0001). They presented later, with higher blood sugar (p-value <0.0001) and creatinine values (p-value=0.009) and had a lower Ejection Fraction (EF) (p-value=0.003). Killip class (OR=16.0), presence of Ventricular Septal Rupture (VSR) (OR=23.4), no-reflow phenomenon (OR=23.4) and development of renal dysfunction (OR=9.0) were identified as predictors of mortality. Conclusion: Despite a high rate of revascularisation and fewer procedure-related complications, outcomes remain grim, with a higher incidence of heart failure, cardiogenic shock, renal dysfunction and mortality. A worse clinical profile, left ventricular dysfunction and renal dysfunction were significant predictors of mortality

Escalating Lipid Therapy After Achieving LDL-C

Guidelines recommend target levels of low-density lipoprotein cholesterol (LDL-C) and intensive lipid-lowering therapy (LLT) in high-risk patients. However, the value of escalating LLT when the LDL-C targets are achieved with moderate-intensity statins is unknown. We aimed to evaluate the benefits of LLT escalation in this population. In this retrospective propensity score-matched study, we screened data from two university hospitals between 2006 and 2021. Of the 54,069 patients with atherosclerotic cardiovascular disease (ASCVD), 3,205 who achieved LDL-C levels <70 mg/dL with moderate-intensity statins were included. After 1:3 matching, 1,315 patients (339 with LLT escalation and 976 without) were ultimately examined. The primary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE)1 (cardiovascular death, nonfatal myocardial infarction, and nonfatal ischemic stroke) and all-cause death. During a median follow-up of 5.7 years, the MACCE1 rate was not significantly lower in the escalation group than in the non-escalation group (9.8 and 14.3/1,000 person-years, respectively; hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.43-1.09; p=0.11). Kaplan-Meier curves showed similar results (log-rank p=0.11). The risk of all-cause death did not differ between the groups. MACCE2 rate, which additionally includes coronary/peripheral revascularization, was lower in the escalation group (24.5 and 35.4/1,000 person-years, respectively; HR, 0.70; 95% CI, 0.52-0.94; p=0.017). LLT escalation did not significantly lower hard cardiovascular outcomes and all-cause death in patients with ASCVD achieving LDL-C levels <70 mg/dL with moderate-intensity statins. However, it had benefit in reducing revascularization rates in this population.

Hospitalized upper extremity artery disease patients: treatment and long-term outcomes.

Current knowledge about upper extremity artery disease (UEAD) is scarce. This study aimed to evaluate the prevalence, treatment patterns, and short- and long-term outcomes of patients suffering from UEAD. Retrospective health claims data of patients who were hospitalized with a primary diagnosis of UEAD between 2010 and 2017 were analysed. The data were obtained from 11 legally independent statutory health insurance funds of the 'AOK-Die Gesundheitskasse'. Risk factors, comorbidities, pharmacotherapy, revascularization procedure, and outcome were evaluated with a particular focus on sex-related disparities (median follow-up time: 5.5 years). Among 2437 UEAD patients (43% female, median age of 67 years), 80% were solely atherosclerotic (UEADa), while 20% had concomitant inflammatory/connective tissue diseases (UEADc/i). Cardiovascular risk factors and comorbidities were highly prevalent in both sexes. Coronary, cerebrovascular, and lower extremity artery diseases and organ failure such as chronic kidney and heart failure were more frequent in men compared with women. At index stay, women had higher rate of revascularization than men (37% vs. 27%). The 5 year mortality among the entire population was almost 50%, even higher in men (UEADa: 51% vs. 36% P < .001; UEADc/i: 44% vs. 36%, P < .05). Furthermore, men had higher rates of upper limb amputation compared with women despite equal secondary preventive pharmacotherapy (UEADa: 26% vs. 11%, P < .001; UEADc/i: 30% vs. 18%, P < .01). Upper extremity artery disease patients, irrespective of the underlying disease type, face a poor prognosis with elevated proportion of amputation and mortality. Male sex was linked to increased risk of future cardiovascular and limb events including death. Further investigation is warranted to understand the underlying causes of the sex-related disparities and identify treatment improvements.

Therapeutic Efficacy of Tirofiban Combined With Thrombus Aspiration and Stent Thrombectomy in the Treatment of Large Vessel Occlusion Ischemic Stroke.

This research aimed to ascertain the effects of tirofiban combined with thrombus aspiration and stent thrombectomy on large vessel occlusion ischemic stroke (LVO-IS). Sixty patients with acute ischemic stroke (AIS) caused by LVO were randomized into the control group and the intervention group (n=30). Patients in the control group received thrombus aspiration combined with stent thrombectomy, while those in the intervention group were treated with tirofiban combined with thrombus aspiration and stent thrombectomy. General data, perioperative-related indicators, cerebral blood flow perfusion, coagulation function indicators, and neurological function indicators were collected, and the prognosis was observed after 3-month treatment. A comparison of symptomatic cerebral hemorrhage rate and hospital mortality rate between the 2 groups displayed no significant difference (P>0.05). The rate of revascularization in the intervention group (90.00%) was higher versus the control group (66.67%). After treatment, the mean blood flow and cerebral blood volume of the intervention group were higher and the time to peak cerebral blood flow was less versus the control group. The prothrombin time, activated partial thromboplastin time, and prothrombinogen time of the intervention group were higher, and fibrinogen was lower versus the control group. A lower National Institutes of Health Stroke Scale score was observed in the intervention group versus the control group. Tirofiban combined with thrombus aspiration and stent thrombectomy has good efficacy in LVO-IS patients.

Drug-Coated Balloons Versus Drug-Eluting Stents or Plain Old Balloon Angioplasty: A Long-Term in-Stent Restenosis Study.

Balloon angioplasty with drug-coated balloons (DCBs) is frequently used during percutaneous coronary intervention for in-stent restenosis. Despite its frequent use, there is a lack of long-term data on the efficacy of DCB angioplasty. We conducted an investigation on the long-term efficacy outcome of in-stent restenosis, comparing DCBs, drug-eluting stents, and plain old balloon angioplasty. We conducted a nationwide analysis from the SCAAR (Swedish Coronary Angiography and Angioplasty Registry) including in-stent restenosis lesions undergoing coronary angiography between June 11, 2013, and January 14, 2022. The primary outcome of this study was target-lesion revascularization within a 5-year follow-up. Secondary outcomes included all-cause death, cardiovascular death, myocardial infarction, and any percutaneous coronary intervention. The outcomes were analyzed using a multivariable Cox proportional hazard model or Poisson regression, as appropriate. A total of 10 561 lesions from 9062 patients were included. Compared with plain old balloon angioplasty, the use of DCB angioplasty was associated with less target-lesion revascularization (risk ratio, 0.69 [95% CI, 0.57-0.82]), all-cause death (risk ratio, 0.72 [95% CI, 0.59-0.88]), and cardiovascular death (hazard ratio [HR], 0.59 [95% CI, 0.45-0.78]). No difference was observed for myocardial infarction or any percutaneous coronary intervention. Compared with drug-eluting stents, the use of DCBs was associated with higher rates of target-lesion revascularization (HR, 1.20 [95% CI, 1.06-1.37]). No difference was observed for all-cause death, cardiovascular death, myocardial infarction, or any percutaneous coronary intervention. In this long-term nationwide analysis, the use of DCB angioplasty showed superior outcomes compared with plain old balloon angioplasty within 5 years but higher rates of repeat revascularizations compared with drug-eluting stents.

Clinical and economic implications of focal dissection treatment following percutaneous transluminal angioplasty of the superficial femoral artery: an exploratory analysis based on the TOBA II Study.

Aim: Percutaneous transluminal angioplasty (PTA) for peripheral artery disease (PAD) commonly leads to dissections which are associated with higher target lesion revascularization (TLR) rates. Clinical and economic consequences of dissection management in the femoropopliteal artery following PTA, and specifically the potential economic benefit of focal dissection repair using the novel Tack Endovascular System, remain unknown. Methods: A decision-analytic model was used to estimate 24-month clinical events, costs and quality-adjusted life year (QALY) gain for a Tack-supported versus status-quo PTA strategy. Patient and lesion characteristics and TLR rates were derived from the PTA cohort of the TOBA II clinical trial, an observational cohort, and literature. Cost-effectiveness was determined from a US payer and provider perspective separately for the non-severe (grade A or B), severe (grade C and higher) and the entire dissection cohort. Results: TLR rates were lower for the Tack-supported strategy compared with PTA (7.7 vs 27.4% in the non-severe, 13.9 vs 25.8% in the severe and 12.0 vs 26.3% in the entire dissection cohort). Cost and QALY differences were +$297/+0.0110 in the non-severe dissection cohort and -$1602/+0.0067 in the severe dissection cohort, resulting in an incremental cost-effectiveness ratio (ICER) of $25,622 in the non-severe cohort and dominance in the severe cohort and the entire cohort. Conclusion: Compared with a 'status-quo' approach, proactive focal stenting may lead to fewer reinterventions and improved quality of life. There appears to be a graded economic benefit of focal dissection treatment, being cost-effective in non-severe dissections and even cost saving in severe dissections.

Off-Pump Coronary Artery Bypass Grafting is Overutilized.

Off-pump coronary artery bypass grafting (CABG), developed to avoid the potential complications of cardiopulmonary bypass, remains a subject of debate. Studies have demonstrated that off-pump CABG is associated with higher rates of incomplete revascularization, inferior graft patency, and increased reintervention rates compared to on-pump CABG, leading to worse outcomes. The theoretical neuroprotective and renal-protective benefits associated with off-pump CABG have not been definitively proven, with stroke and renal failure rates similar to those of on-pump CABG in both short- and long-term follow-up. Off-pump CABG presents technical challenges, contributing to a steep learning curve, and its effectiveness is dependent on surgeon and center experience. Lower-volume centers and surgeons performing off-pump CABG have shown increased rates of mortality and reintervention. Despite the potential cost savings by avoiding cardiopulmonary bypass, the need for repeat interventions and associated complications can lead to higher long-term healthcare costs. This paper advocates for a more selective use of off-pump CABG while maintaining on-pump CABG as the standard approach for patients with coronary artery disease.

Procedural factors influencing successful coronary sinus reducer implantation for refractory angina: A single-centre experience.

Coronary sinus reducer (CSR) implantation is emerging as a novel effective percutaneous therapy for patients with refractory angina. Limited data exists examining the factors influencing successful CSR implantation. As CSR implantation becomes more widely adopted, a greater understanding of the procedural challenges which operators encounter is required. To evaluate the patient and procedural characteristics influencing successful CSR implantation. This was a retrospective cohort study of consecutive patients with refractory angina undergoing clinically indicated CSR implantation (February 2016 to August 2024) at a high-volume implanting centre in the UK. Patient and procedural characteristics affecting procedural difficulty were systematically analysed. Procedural difficulty was determined by 1) increasing total procedural time or 2) features of challenging equipment handling such as bellying, swan-necking or complete equipment fallout from the coronary sinus (CS). 102 out of 105 (97%) patients underwent a successful CSR implant at the first attempt. Patients had a high rate of previous revascularisation (PCI: 85%; CABG 64%) and diabetes (58%). Significant improvements in Canadian Cardiovascular Society (CCS) class were observed with 36% of patients improving by ≥2 CCS classes and 71% improving by ≥1 CCS class. A C- or non-C-shape of the CS was not associated with differences in procedural time (P=0.52). However, the presence of both a valve and ridge in the CS was associated with significantly longer procedural times (P=0.03). A ridge, alone or together with a valve, predicted features of procedural difficulty, such as bellying (ridge - OR: 2.69, P=0.02; valve and ridge - OR: 4.58, P=0.0006) and swan-necking (ridge - OR: 5.43, P=0.001; valve and ridge - OR: 4.74, P=0.002). Bellying, swan-necking, and complete fallout of equipment from the CS were associated with longer procedural times, but also with each other, suggesting their utility as indicators of procedural complexity. In our experience, CSR implantation is safe and associated with high rates of procedural success. However, patient and procedural factors can influence the difficulty of CSR implantation. The presence of a ridge may make implantation more challenging. Bellying, swan-necking and complete equipment fallout may indicate increased procedural complexity. Greater awareness of these features will encourage operators to remain vigilant and adapt their implantation strategy when encountering challenging cases.

Application of Drug-Eluting Stent With Drug-Coated Balloon Strategy for the Endovascular Treatment of Long-Segment Femoropopliteal Artery Disease.

Endovascular therapy (EVT) has emerged as a primary approach for managing femoropopliteal artery (FPA) lesions, leveraging drug-eluting stents (DESs), and drug-coated balloons (DCBs), to enhance clinical outcomes. Although a full DES coverage strategy is effective in treating complex lesions, concerns over long-term complications prompt the exploration of alternative strategies. The aim of this study was to investigate clinical result of combination therapy of DES with DCB and compare them with full DES implantation. This retrospective, single-center study analyzed 131 patients with occlusive FPA lesions treated at our institution between 2019 and 2022. Patients with Rutherford classification stages 2 to 5 who underwent successful EVT were included. The study compared the outcomes of the drug-within-drug (DWD) strategy, ie, combining DES for failed vessel preparation segments and DCB for successful ones, with those of full DES implantation. The primary outcomes were the primary patency rates, and the secondary outcomes included clinically-driven target lesion revascularization (CD-TLR) rates, restenosis patterns, and survival outcomes. Of the 131 patients initially considered, 118 met the inclusion criteria, with 45 in the DWD group and 73 in the full metal jacket (FMJ) stent group. The DWD group demonstrated equivalent 1-year primary patency rates (85.3%) to the FMJ group (87.9%, p=0.239). Similarly, no significant differences in CD-TLR rates were found between the 2 groups. The restenosis patterns and subsequent treatment strategies were not significantly different. The DWD strategy offers a viable alternative to full DES coverage in treating long-segment FPA lesions, with comparable restenosis and target lesion revascularization (TLR) rates. This approach may mitigate risks associated with full-length stenting, such as thrombosis, and challenges in repeat revascularizations by tailoring treatment to lesion characteristics. The DWD strategy represents a promising approach for complex FPA lesions, providing a balanced solution that potentially reduces long-term complications while maintaining effective patency and revascularization rates. The efficacy of drug-eluting stents (DES) in treating femoropopliteal artery (FPA) lesions has been well demonstrated. However, concerns remain regarding complications such as thrombotic occlusion and aneurysmal degeneration, especially when full stemt coverage of whole lesions is performed. The "Drug-with-Drug" (DWD) strategy, which involves implanting DES only at sites with severe dissection or residual stenosis after pre-balloon dilation and using drug coated balloons (DCB) for segments successfully prepared without stenting, has shown comparable outcomes to full stent coverage. Unlike traditional bailout stenting or spot stenting, the DWD approach maximizes the benefits of drug technology and presents a valuable option for treating long-segment FPA lesions.

Abstract 4144554: Revascularization of Patients with Low-Density Non-Calcified Plaque was Associated with Lower Occurrence of Acute Coronary Syndrome

INTRODUCTION: Coronary CT angiography (CCTA) is a powerful noninvasive tool for identifying high-risk plaque, such as low-density non-calcified plaque (LD-NCP). Though, the optimal treatment of patients with LD-NCP remains unclear. This study explored the association of revascularization in the setting of LD-NCP with the occurrence of acute coronary syndrome (ACS). Methods: This was a post-hoc analysis of the ICONIC study. A subset of 234 patients that underwent CCTA with subsequent ACS were matched to 234 control patients who also underwent CCTA but did not have ACS during follow-up. Patients were also followed for occurrence of revascularization, either coronary artery bypass graft or percutaneous coronary intervention. Atherosclerosis imaging-enabled quantitative CT (AI-QCT) was used to measure diameter stenosis, and LD-NCP, non-calcified plaque, and calcified plaque volumes from each CCTA. LD-NCP was defined as plaque with -190 to 30 Hounsfield Units. Patients were stratified based on the presence of LD-NCP. Subgroup analysis was conducted to compare the occurrence of ACS with the rate of revascularization. Kaplan-Meier survival curves and extended Cox regression analysis were used to evaluate the effect size of revascularization and LD-NCP on occurrence of ACS. Results: AI-QCT was completed in 448/468 subjects (follow-up time [MEAN±SD] 2.44±2.48 years). The median of LD-NCP was 1.2 mm 3 for patients with &gt;0 mm 3 LD-NCP. There were 85 patients with LD-NCP &gt;1.2 mm 3 and 363 patients with LD-NCP ≤1.2 mm 3 . In patients with LD-NCP &gt;1.2 mm 3 , the rate of revascularization in patients with and without ACS was 3/52 (5.8%) versus 14/33 (42.4%) (p&lt;0.001). In patients with LD-NCP ≤1.2 mm 3 , the rate of revascularization in patients with and without ACS was 36/170 (21.2%) versus 39/193 (20.2%) (p=0.897). In comparison to patients without revascularization and LD-NCP ≤1.2 mm 3 , patients with LD-NCP &gt;1.2 mm 3 and revascularization were less likely to have ACS during follow-up (adjusted HR: 0.20 [0.07, 0.61]; p=0.005). Additionally, patients with LD-NCP &gt;1.2 mm 3 who did not undergo revascularization were more likely to have ACS (adjusted HR: 1.47 [1.03, 2.12]; p=0.036). Hazard ratios were adjusted for diameter stenosis, and non-calcified and calcified plaque volume. Time-dependent coefficients were included for diameter stenosis. Conclusion: Revascularization of patients with LD-NCP &gt;1.2 mm 3 identified on CCTA with AI-QCT was associated with less risk for ACS.

Abstract 4135655: Gender Differences in Invasive Angiography and Early Revascularization after Coronary Computed Tomography Angiography

Background: Coronary CT angiography (CCTA) has emerged as a first line tool for detecting CAD and assessing need for invasive coronary angiography (ICA). Historically, women have higher cardiovascular mortality compared to men with similar coronary plaque burden, yet remain undertreated. This study aims to investigate gender differences in ICA rates and subsequent revascularization following CCTA. Methods: This study included adults who underwent CCTA between 2013-2019 at a single institution. CCTA stenosis severity was categorized as &lt;50%, 50-69% and ≥70%. Plaque burden was assessed by segment involvement score (SIS), defined as number of coronary segments with plaque. Outcomes included ICA and revascularization within 90 days of CCTA. Multivariable logistic regression analysis was performed after adjustment for demographic, clinical, and imaging variables. Results: Of 5,855 patients (mean age 61 years, 58% men) who underwent CCTA, 582 (9.9%) and 386 (6.6%) underwent ICA and revascularization, respectively. There was no significant difference in ICA rates between men and women with similar CCTA stenosis severity ( Figure 1A ; stenosis 50-69%: 17.9% vs. 19.2%, p=0.677; stenosis ≥70%: 53.8% vs. 58.3%: p=0.313). However, among patients with stenosis ≥70% who underwent ICA, men had significantly higher rates of revascularization ( Figure 1A . 80.1% vs. 69.2%, p=0.029). In multivariable analysis, male gender was an independent predictor of revascularization after adjustment for clinical characteristics, including CCTA stenosis severity and SIS (male gender: OR 1.58, 95% CI: 1.01-2.47, p=0.047). Of note, in patients with stenosis ≥70%, rates of revascularization in women were significantly lower in the early study period (years 2013-2015, p=0.020); however, the difference narrowed in the recent study period (years 2016-2019, p=0.309) ( Figure 1B) . Conclusion: There were comparable ICA rates between men and women. Women with severe stenosis (≥70%) by CCTA had significantly lower rates of revascularization, particularly in the early study period. These findings suggest a disparity in the management of CCTA-identified severe CAD, though it has demonstrated improvement in recent years.

Abstract 4125157: Efficacy of Adding Sodium-Glucose Co-Transporter 2 Inhibitor versus Standard Therapy Alone in Post-Percutaneous Coronary Intervention Patients: A Systematic Review and Meta-Analysis

Background: Recent evidence suggests that sodium-glucose cotransporter-2 inhibitors (SGLT2-i) may improve outcomes in patients with coronary artery disease (CAD) through various physiological pathways. However, their impact on patients who have undergone percutaneous coronary intervention (PCI) is not well established. This meta-analysis aims to evaluate the effectiveness of additive SGLT2 inhibitors versus standard therapy alone in patients with CAD after PCI. Methods: A systematic search was conducted across the Medline, Embase, and Cochrane Library databases for randomized controlled trials (RCTs) and observational studies that compared the addition of SGLT2 inhibitors to standard therapy versus standard therapy alone in patients post-PCI. The outcomes analyzed were Major Adverse Cardiovascular Events (MACE), all-cause death, cardiovascular death, recurrent acute myocardial infarction (AMI), nonfatal stroke, revascularization, and hospitalization for heart failure (HF). Results: A total of 7 studies met the inclusion criteria, encompassing a total of 11,800 individuals (5,004 on SGLT2-i and 6,796 non-SGLT2-i; mean age of 62.7 years; 28% women; 95% diabetic patients). SGLT2 inhibitors significantly reduced the risk of all-cause mortality (RR 0.6, 95% CI: 0.5-0.72, p&lt;0.01), cardiovascular death (RR 0.39, 95% CI: 0.16-0.94, p=0.03) and hospitalization for HF (RR 0.55, 95% CI: 0.4-0.76, p&lt;0.01) compared to standard therapy alone. The occurrence of the composite endpoint (MACE) (RR 0.67, 95% CI: 0.44-1.01, p=0.056), any revascularization (RR 0.93, 95% CI: 0.57-1.53, p=0.784), recurrent AMI (RR 0.70, 95% CI: 0.41-1.18, p=0.176) and stroke (RR 0.94, 95% CI: 0.68-1.30, p=0.717) did not differ significantly between groups. Conclusions: Adding SGLT2 inhibitors to standard therapy significantly improved cardiovascular outcomes in patients with CAD who have undergone PCI, including reduced mortality and hospitalization for HF rates, with similar rates of recurrent AMI, coronary revascularization and stroke. These findings support the consideration of adding SGLT2 inhibitors as part of the therapeutic regimen for post-angioplasty patients, especially those with diabetes.

Abstract 4138246: Differences in Major Adverse Cardiovascular and Lower Limb Events and Guideline-Directed Medical Therapy Among Males and Females Within an Integrated Healthcare System

Background: Health disparities based on gender have been recognized as having a detrimental impact on care delivery and early identification of disease processes. Peripheral arterial disease (PAD) is the third leading cause of atherosclerotic disease mortality. It is unclear what role, if any, gender plays in the diagnosis, treatment, and outcomes of PAD. Hypotheses: Females are less likely to have guideline-directed medical therapy (GDMT) and more likely to have major adverse cardiovascular events (MACE) and major adverse lower limb events (MALE) than males. Methods: The Intermountain Health electronic database was queried for patients meeting the following criteria: ≥18-years of age, PAD diagnosis between Jan 2006 to Dec 2021, seen at least once within the 18-months following initial PAD diagnosis, and had a symptom of PAD (see table). Follow-up GDMT, based on the 2016 AHA/ACC PAD guidelines, was determined by medication and procedures. Time to outcomes of MACE (all-cause death, MI, stroke, or unstable angina hospitalization) and MALE (limb ischemia, limb revascularization, or limb amputation) were examined using Cox-proportional hazard adjusted for GDMT, age, and prior CAD. Results: A total of 7522 patients had a symptomatic PAD diagnosis, with 38% female and 62% male. Females tended to be older (70.1±13.0 vs 68.6±11.7), more likely to be obese (25% v 21%), and less likely to have Afib (21% v. 24%), CAD (30% v 41%), MI (11% v 16%), renal failure (19% v 22%) but more likely to have a bleeding history (30% v 26%) (all p&lt;0.01). Females were slightly less likely to have all the GDMT and yet had similar rates of referrals to specialists but higher rates to primary care providers (Table). After adjustment, females were less likely to have MACE (HR=0.94; 95% CI: 0.88, 0.99) and MALE (HR=0.85; 95% CI: 0.80, 0.92). Conclusion: Females had lower rates of MALE, driven by lower limb revascularization or amputation rates, and slightly lower rates, after adjustment, for MACE. This was observed despite the high rates of GDMT for both females and males (~80% in any category), with females having slightly less GDMT.

Stent strategies: Endothelial progenitor cell coated stents vs sirolimus eluting stents in a pairwise meta-analysis

BackgroundEndothelial progenitor cells (EPCs) capturing stents were developed to enhance endothelial repair and reduce the risk of stent thrombosis, addressing limitations of Sirolimus-Eluting Stents (SES). This study aims to compare the safety and efficacy of EPC stents versus SES in patients undergoing percutaneous coronary intervention (PCI). MethodsWe performed a meta-analysis following PRISMA guidelines in patients undergoing PCI treated with Sirolimus eluting stent (SES) vs the use of EPC stents and recognized 8 clinical trials with patients undergoing PCI and reporting outcomes such as Target Lesion Failure (TLF), stent thrombosis, and revascularisation. Relative risks were calculated using a random effects model and heterogeneity was assessed with I^2 statistics. ResultsThe EPC group showed higher incidence of TLF (RR ​= ​1.28), MI(RR ​= ​1.10), and cardiac death (RR ​= ​1.19) compared to SES, though these differences were not statistically significant. Revascularisation rates were significantly higher in EPC group with TVR (RR ​= ​1.60) and TLR(RR ​= ​2.20) while stent thrombosis was lower (RR ​= ​0.93). ConclusionThe results of this EPC study reveals that while EPC stents show promise in revascularisation and lowering stent thrombosis, they are also associated with higher incidence of adverse events. The utility of EPC, especially vast reendothelialization, may have niche applications but their full potential can be realized with more rigorous trials as a clear advantage over SES remains lacking.

Impact of the Affordable Care Act on Revascularization Versus Amputation in Patients Presenting With Chronic Limb-Threatening Ischemia in Maryland.

The Affordable Care Act (ACA) aimed to expand Medicaid, enhance health care quality and efficiency, and address health disparities. These goals have potentially influenced medical care, notably revascularization rates in patients presenting with chronic limb-threatening ischemia (CLTI). This study examines the effect of the ACA on revascularization vs amputation rates in patients presenting with CTLI in Maryland. This was a retrospective analysis of the Maryland State Inpatient Database comparing the rate of revascularization to rate of major amputation in patients presenting with CLTI over 2 periods: pre-ACA (2007-2009) and post-ACA (2018-2020). In this study, we included patients presenting with CLTI and underwent a major amputation or revascularization during that same admission. Using regression analysis, we estimated the odds of revascularization vs amputation pre- and post-ACA implementation, adjusting for pertinent variables. During the study period, 12,131 CLTI patients were treated. Post-ACA, revascularization rate increased from 43.9% to 77.4% among patients presenting with CLTI. This was associated with a concomitant decrease in the proportion of CLTI patients undergoing major amputation from 56.1% to 22.6%. In the multivariate analysis, there was a 4-fold odds of revascularization among patients with CLTI compared to amputation (OR = 4.73, 95% CI 4.34-5.16) post-ACA. This pattern was seen across all insurance groups. The post-ACA period in Maryland was associated with an increased revascularization rate for patients presenting with CLTI with overall benefits across all insurance types.

Gender disparity in morbidity and mortality among patients with ST-elevation myocardial infarction due to spontaneous coronary artery dissection complicated by cardiogenic shock

BackgroundThere is limited data on gender differences among patients with spontaneous coronary artery dissection (SCAD) who present as ST-elevation myocardial infarction (STEMI) and develop cardiogenic shock (CS). ObjectivesTo describe outcomes of SCAD patients presenting with STEMI and CS and outline the differences between men and women. MethodsWe queried the US Nationwide Readmissions Database (NRD) from January 2016 to December 2020 to identify patients with SCAD presenting with STEMI who developed CS. We compared the characteristics, trends, and outcomes between men and women in this cohort. ResultsOut of 582,633 hospitalizations with STEMI, 0.2 % (1176 patients) had SCAD, of which 346 (29.4 %) had CS. There was no difference in median age between men and women (64 years (IQR 57–71) vs. 63 years (IQR 49–72), p = 0.181). Men had a higher prevalence of prior myocardial infarction (MI) (14.2 % vs. 6.2 %, p = 0.021). The overall mortality rate of SCAD patients with AMI-CS was 28.2 %, with no difference between men and women. Patients with SCAD who had CS and underwent CABG had a mortality of 20.3 %. ECMO was used in 6.1 % of SCAD patients presenting with STEMI and CS, with a survival rate of 49.9 %. ConclusionThere were no differences in the baseline characteristics, rates of revascularization, or in-hospital mortality between men and women who had SCAD complicated by CS (SCAD-CS). Patients with SCAD-CS patients who underwent CABG had around 80 % in-hospital survival. CABG should be considered as a method of revascularization in this patient cohort.

Abstract 005: In vitro evaluation of a novel peristaltic pump for mechanical thrombectomy

Introduction Aspiration thrombectomy is a widely accepted frontline treatment for large vessel occlusions in acute ischemic stroke. While revascularization rates have improved with advancements in catheter technology, innovation in aspiration pumps has been limited. The ALGO Smart Pump (Von Vascular, Sunrise, FL) is a sterile, miniaturized, on‐field, operator‐driven peristaltic pump offering two aspiration modes: Adaptive Pulsatile Aspiration (APA™) Mode and a continuous ‘Static’ mode. Compared to traditional aspiration pumps, where negative pressure is applied in an abrupt step‐change, the ALGO Smart pump creates negative pressure via a peristaltic mechanism that allows for incremental increase in vacuum force, potentially allowing for a more controlled and complete ingestion of clot and avoidance of “corking” and resultant microemboli on catheter withdrawal. This study evaluates the performance of the ALGO Smart Pump in Static Mode compared to a commercially available aspiration pump. Methods A pulsatile flow bench model was used with a silicone replica of the middle cerebral artery to simulate thrombectomy conditions. Synthetic clots were positioned in the model and operators performed aspiration thrombectomy with ALGO and with the Penumbra ENGINE (Penumbra, Alameda, CA) using a combination of large bore and medium bore aspiration catheters. Primary endpoint was complete clot ingestion (CCI) into the pump reservoir. Complete clot ingestion, without “corking” of clot in the catheter tip, has been demonstrated to be associated with smaller and fewer distal emboli and higher rates of first pass recanalization (1). Secondary endpoints included first pass recanalization, embolization to new territories (ENT) and total aspiration time. Results In 180 thrombectomies evaluating large bore catheters, ALGO achieved a CCI rate of 93.3% and ENGINE achieved 87.8% (p =.30). Time to clot clearance was not significantly different between groups (p =.11). In 180 thrombectomies evaluating medium bore catheters, ALGO demonstrated a higher CCI rate than ENGINE (77.8% versus 63.3%, p =.048). Time to clot clearance was not significantly different between groups (p =.74). In all 360 thrombectomies, the synthetic clot was completely removed from the vasculature in one pass without evidence of ENT. Conclusion The ALGO Smart Pump in static mode is highly effective in achieving complete clot ingestion, with similar rates of CCI compared to the Penumbra ENGINE in large bore catheters and higher rates of CCI in medium bore catheters. The ALGO Smart Pump may represent a reliable alternative in mechanical thrombectomy compared to existing commercially available aspiration pumps with additional user friendly benefits including a sterile, on‐field apparatus that can be driven by the operator without need for off‐field assistance and a simple to navigate graphical user interface with clear operating instructions. Further research is required to understand how the peristaltic slow rise of negative pressure contributes to improved rates of CCI in medium bore catheters.

Sex-related differences in demographics, diagnosis and management of patients with chronic coronary syndromes.

The impact of sex-related factors on current clinical management and outcomes of chronic coronary syndromes (CCS) are unclear. All patients belonging to the prospective, nationwide START registry were included. Their baseline characteristics, diagnostic workup, revascularization strategy, pharmacological treatment and 1-year clinical outcomes were compared with respect to sex overall and in age tertiles. A total of 5070 consecutive patients were included. Most patients were males (80.1%). As expected, the prevalence of females increased with age. Distribution of risk factors and history of cardiovascular disease were different depending on sex, as well as diagnostic workup, with lower use of exercise stress testing in women (25.1% vs. 36.7%, P < 0.0001). The use of coronary angiography was similar in the two groups. Women had lower rates of multivessel coronary artery disease (CAD) (33.0% vs. 40.6% P < 0.0001) and higher rates of nonobstructive CAD (18.3% vs. 11.3%, P < 0.0001). Rates of myocardial revascularization were similar, but women were more likely to receive percutaneous coronary intervention than men (84.3% vs. 77.8%, P < 0.0001) and less likely to receive surgical/hybrid revascularization (10.0% vs. 15.1%, P < 0.0001). At 12-month follow-up, no differences were observed for the combined endpoint of all-cause mortality, re-hospitalization for myocardial infarction, heart failure, stroke or myocardial revascularization between males and females; however, a significantly worse perceived quality of life was observed in women. In a large nationwide cohort of patients with CCS, clinical outcomes were not different depending on sex. However, several differences in the diagnostic work-up, treatment strategies and quality of life were found between sexes.

Restrictive Versus Liberal Transfusion in Symptomatic Coronary Artery Disease and Myocardial Infarction: A Meta-Analysis of Randomized Controlled Trials.

In patients with coronary artery disease (CAD) and/or myocardial infarction (MI), anemia is associated with an increased risk of adverse cardiovascular (CV) outcomes. Transfusion goals in such patients remain unclear. A meta-analysis of the available randomized controlled trials (RCTs) was conducted comparing restrictive and liberal transfusion strategies in patients with symptomatic CAD/MI. Multiple online databases including Cochrane, Pubmed, Embase, and MEDLINE were searched for RCTs. End points of interest were major adverse CV events (MACEs), MI, all-cause death, CV death, revascularization, heart failure (HF), and infection. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random-effects model. A total of 5 RCTs with 4518 patients-2258 in the restrictive transfusion group and 2260 in the liberal transfusion group-were included. The mean age was 72 years, and 59% of patients were men. At 30 days, MACE and MI were similar in the 2 transfusion groups. However, at the longest available follow-up, the restrictive strategy was associated with increased risks of MACE (OR 1.18, 95% CI, 1.02-1.37; P = 0.03) and MI (1.27, 95% CI, 1.02-1.58; P = 0.04), along with the higher trend of all-cause death (1.21, 95% CI, 1.00-1.46; P = 0.05) as compared with liberal transfusion. The 2 groups had comparable rates of CV death, revascularization, HF, and infection. Liberal transfusion strategy may be associated with improved CV outcomes among patients with symptomatic CAD/MI as compared with a restrictive transfusion strategy.

Comparison of the Long Term Safety and Effectiveness of Endovascular Sac Embolisation and the Isolation Technique for Treatment of True Saccular Splenic Artery Aneurysms

To compare the safety, effectiveness, hospital stay (HS), and total hospital cost (THC) of sac embolisation (SE) and the isolation technique (IT) for treating isolated saccular true unruptured splenic artery aneurysms (SAAs). A total of 208 patients with isolated saccular true unruptured SAAs receiving endovascular SE or IT treatment at four medical centres in China between January 2016 and December 2022 were retrospectively included. Technical success rates, splenic infarction (SI) rates, aneurysm revascularisation (AR) rates, HS, and THC were compared between groups. Each group was divided into three subgroups, based on the size of SAAs: 2.0 - 2.9 cm (S1), 3.0 - 3.9 cm (S2), and ≥ 4.0 cm (S3). The technical success was 100%. During the median follow up time of 48.8 (IQR 33.0, 70.4) months, no patients had SAA rupture or died. The two year and five year cumulative incidences of aneurysm revascularisation were 1.8% and 8.7% for the SE group and 2.2% and 2.2% for the IT group, respectively (p = .12). Compared with the SE group, the IT group had a higher SI rate (p < .001), a comparable AR rate (p = .12), a higher median HS (p < .001), and a lower median THC (p < .001). The median THC was comparable between the SE and IT groups in S1. The median THC of the SE group was approximately 1.36 times and 2.2 times of that in the IT group in S2 and S3 (both p < .001), respectively. Sac embolisation and IT are safe and effective methods for treating isolated saccular true unruptured SAAs. The isolation technique seems to be superior in reducing THC, whereas SE may be superior in reducing SI rates and HS. Sac embolisation may be more suitable for smaller SAAs, whereas IT could be a better choice for larger SAAs.