Revascularization Group Research Articles

Complete vs culprit-lesion-only myocardial revascularization in patients with out-of-hospital cardiac arrest: insights from the multicentric "Lombardia CARe" registry

Abstract Background Out-of-hospital Cardiac Arrest (OHCA) is a potentially devastating complication of patients with Myocardial Infarction (MI). Multivessel Disease (MVD) is a frequent occurrence in this setting, being present in nearly half patients undergoing Coronary Angiography (CAG). We previously reported that, in case of MI complicated by OHCA and evidence of MVD, a complete myocardial revascularization, as compared to culprit-lesion-only revascularization, was associated with an improved 1-year survival and favorable neurological outcomes. We aimed to validate and confirm these results on a multicentric scale with a larger patient cohort. Methods This is a multicentric, prospective, observational study. We considered all the consecutive patients with OHCA and MI enrolled in the Lombardia CARe Registry from January 1st 2015 to December 31st 2022 who underwent CAG in 6 centers in Northen Italy. Results A total of 623 patients were included; of these, 403 underwent CAG. Median age was 64 years, and about 80% had no previous history of ischemic heart disease. Median ejection fraction (EF) at presentation was 40%. MVD was present in 186 (46.1%) patients and was subsequently treated with either complete (32.3%) or incomplete (67.7%) coronary revascularization. Left anterior descendent (LAD) artery was the culprit lesion in almost 1/3 of patients. The 1-year survival rate was 78.3% in the complete revascularization group and 42.9% in the culprit-lesion-only revascularization group (p-value < 0.001). After correction for factors that were predictors on univariate analysis, complete revascularization strategy was independently associated with a reduced risk of death [HR: 0.27 (95% CI: 0.01 to 0.739; p = 0.01] and death or unfavorable neurological outcome [HR: 0.23 (95% CI: 0.08 to 0.67); p = 0.007]. Conclusions Complete revascularization strategy was confirmed to be associated with an improvement of 1-year survival and with a good neurological outcome in patients resuscitated from OHCA. These results highlight the independent impact on survival of a complete coronary intervention strategy in patients with OHCA plus MVD.

Revascularization strategies in elderly patients with acute coronary syndromes and multivessel disease: comparative analysis of culprit-only vs complete revascularization

Abstract Background Acute coronary syndromes (ACS) are more challenging in elderly patients, particularly when related to multivessel disease (MVD). Concerns about outcomes, and the lack of evidence, lead to more conservative treatment. While benefits of complete revascularization are well established among the youngest, doubts persist in older patients. Despite FIRE trial having showed superiority of complete revascularization with coronary physiology, in older patients with ACS and MVD, more evidence is needed. Methods Multicenter retrospective cohort of 629 patients, older than 75 years, with ACS and MVD, was divided into complete or culprit-only revascularization groups. In-hospital outcome of death and major adverse cardiovascular events (MACE) and follow-up outcome of death and cardiovascular hospital admission were assessed. Results From the 629 patients, 383 (61%) were submitted to PCI, of which 66% (n=254) were submitted to culprit-only revascularization and 34% (n=129) to complete revascularization. Culprit-only group's mean age was 83±5 years and median age in complete revascularization group was 81 (IQ 78-84) years. There was similar number of female patients in both groups (42% and 37%, p=0,26), and the culprit only group was significantly older (p=0,006). There were more ST-segment elevation myocardial infarctions in culprit- only group (p<0,001). Regarding diabetes, previous ACS, Killip classification, heart failure, stroke, peripheral artery disease, and chronic kidney disease, there were no statistically significant differences between groups (p>0,05). Complete revascularization was associated with lower in-hospital events, with 36% against 48% in culprit-only (p=0,025 OR 0,62 [0,4-0,9]), mainly due to lower in-hospital deaths, with 3% against 13% (p<0,01 OR 0,3 [0,15-0,67]) but also due to lower in-hospital MACE with 29% against 27% (p=0,02 OR 0,6 [0,4-0,9]). The mean follow-up was 13±7 months, during which, in complete revascularization group, there was non-statistically significant decrease of deaths, with 13% against 15% (p=0,4), hospital readmissions, with 21,8%, in comparison with 24,9% (p=0,2), and composite outcome, with 35% and 40% (p=0,16) of composite events in the culprit-only group There was a non-statistically significant decrease of the mean for survival time for culprit only group which was 10±8 months comparing with complete group of 13±8 months (p=0,16). Conclusion In older patients with ACS and MVD the ideal strategy is yet to be determined. Still complete revascularization strategy showed a statistically significant decrease of in-hospital death and MACE, and non-statistically significant decrease in follow-up mortality and readmissions. This study suggests, like FIRE trial, that when clinically and anatomically feasible, it seems legit to attempt complete revascularization in elderly patients with ACS and MVD.

Complete revascularisation versus culprit lesion only PCI in patients with non-ST-elevation myocardial infarction and multivessel disease.

Abstract Background The incidence of non-ST-elevation myocardial infarction (NSTEMI) is escalating, with patients diagnosed with multivessel disease (MVD) facing more adverse clinical outcomes. Yet, optimal treatment strategies for NSTEMI patients with MVD remain uncertain. Objectives This study aimed to assess the clinical outcome of NSTEMI patients with MVD who underwent complete revascularization compared to those treated with the culprit lesion only. Methods Between 2014 and 2017, patients presenting with NSTEMI and MVD undergoing successful percutaneous coronary intervention (PCI) were retrospectively included. MVD was defined as patients having more than one lesion considered angiographically significant, exhibiting at least 50% stenosis of the vessel diameter on visual estimation, or having a Coronary Angiography-Derived Fractional Flow Reserve (caFFR) measurement of 0.80 or less. The main exclusion criteria were single vessel disease, and previous coronary-artery bypass grafting surgery. The primary endpoint of this study was major adverse cardiac events (MACE) at 3 years, defined as a composite of cardiac death, myocardial infarction, and ischemia-driven revascularization. Results A total of 358 patients were included (mean age: 67.34±12.77; male: 70.1%), 155 and 203 patients were stratified into complete revascularisation group and culprit-lesion-only PCI group respectively. During 3-year follow-up, the culprit-lesion-only PCI group exhibited a significantly elevated risk of MACE compared to the complete revascularization group (17.7% vs 7.74%; hazard ratio [HR] 2.412, 95% confidence interval [CI] 1.255 - 4.636, P = 0.008). The increase 3-year MACE rate was mainly driven by the higher rate of ischaemia-driven revascularization in the culprit-lesion-only PCI group (11.3% vs 3.23%, HR 3.637, 95% CI 1.383 - 9.566, P = 0.009). Conclusion In NSTEMI patients with MVD, complete revascularization was superior to culprit-lesion-only PCI in mitigating the risk of future MACE at 3 years, which is predominantly attributed by a reduced incidence of repeat revascularisations.

Comparative Outcomes of Unilateral vs Bilateral Revascularization in Moyamoya Disease: A Multicenter Retrospective Study.

Moyamoya disease (MMD) is characterized by progressive steno-occlusion of the internal carotid arteries, leading to compensatory collateral vessel formation. The optimal surgical approach for MMD remains debated, with bilateral revascularization potentially offering more comprehensive protection but involving more extensive surgery compared to unilateral revascularization. This study aims to compare bilateral revascularization and unilateral revascularization short-term safety profile in the treatment of MMD. This multicenter retrospective study included patients with MMD who underwent surgical revascularization at 13 academic institutions. Patients were categorized into unilateral and bilateral revascularization groups. Data collected included demographics, clinical characteristics, and outcomes. Propensity score matching was used to balance baseline characteristics. Statistical analyses were conducted using Stata (V.17.0; StataCorp). A total of 497 patients were included, including 90 who had bilateral revascularization and 407 who had unilateral revascularization. Bilateral revascularization was associated with more perioperative asymptomatic strokes (10% vs 2.4%; odds ratio [OR] 4.41, 95% CI 1.73 to 11.19, P = .002) and higher rates of excellent functional outcomes (modified Rankin Scale 0-1) at discharge (92.2% vs 79.1%; OR 3.12, 95% CI 1.39 to 7, P = .006). After propensity score matching, 57 matched pairs were analyzed. There was a higher rate, though not statistically significant difference, of perioperative stroke in the bilateral revascularization group (15.7% vs 8.7%; OR 1.95, 95% CI 0.61 to 6.22, P = .26). No significant differences were noted in modified Rankin scale 0 to 1 and 0 to 2 scores at discharge, National Institute of Health Stroke Scale at discharge, intraoperative complications, or length of hospital stay. The follow-up stroke rates were also not significantly different (OR 0.40, 95% CI 0.11 to 1.39, P = .15). This study found no significant differences between bilateral and unilateral revascularization in MMD. Patients who had bilateral revascularization had higher tendency of perioperative stroke, though not statistically significant. Further prospective studies are needed to validate these results.

Primary Percutaneous Coronary Intervention in Multivessel Disease: Complete versus Culprit-only Revascularization

Objective: To compare the clinical outcomes of complete revascularization and culprit-only revascularization in patients with multivessel coronary artery disease (CAD) who presented with ST-segment elevation myocardial infarction (STEMI) at Hayatabad Medical Complex, Peshawar. Methodology: A prospective, randomized controlled trial was conducted, enrolling 400 patients with multivessel CAD. Patients were randomly assigned to either the complete revascularization group (n=200) or the culprit-only revascularization group (n=200). The primary outcomes assessed included cardiovascular death, reinfarction, and the need for repeat revascularization over a six-month follow-up period. Statistical analysis was performed using chi-square tests and Kaplan-Meier survival analysis. Results: Complete revascularization significantly reduced the rates of major adverse cardiovascular events compared to culprit-only revascularization. Cardiovascular death was lower in the complete revascularization group (4% vs 9%, p = 0.02), as was reinfarction (5% vs 11%, p = 0.01), and repeat revascularization (7% vs 15%, p = 0.004). Kaplan-Meier analysis showed a significant improvement in event-free survival in the complete revascularization group. Conclusion: Complete revascularization significantly improves clinical outcomes in patients with multivessel CAD presenting with STEMI, reducing cardiovascular death, reinfarction, and repeat revascularization. This study supports complete revascularization as a preferred treatment strategy in such patients to improve long-term outcomes. Keywords: coronary artery disease, STEMI, complete revascularization, culprit-only PCI, cardiovascular outcomes

Analysis of two reperfusion techniques in uterine transplantation in an experimental model.

Uterine transplantation was developed for the treatment of absolute uterine factor infertility. As it is a new modality of transplantation, there is still room for technical improvement. A factor that impacts graft survival in organ transplantation is the warm ischemia time. In uterine transplantation specifically, at least two vascular anastomoses are performed on each side of the uterus, and the graft revascularization takes place when the vascular clamps of the arteries and veins are released on both sides simultaneously. For this reason, the warm ischemia time in uterine transplant is expected to be considerably long. The purpose of this study was to compare the sequential technique of uterine graft revascularization, which aims to reduce the warm ischemia time of the procedure, with the simultaneous revascularization technique. For the procedure, the uterine auto-transplantation technique was performed using 10 non-pregnant adult ewes weighing about 45 kg, divided into two groups: simultaneous revascularization group (5 animals) and sequential revascularization group (5 animals). To evaluate the groups, we analyzed the procedure and warm ischemia times, graft macroscopy, hemodynamic, laboratory, and histological parameters of the uterus. The sequential revascularization technique group had similar surgical procedure times, and the warm ischemia time was significantly shorter with medians of 32 min in the sequential group versus 72 min in the simultaneous group (p < 0.008). The graft macroscopy and hemodynamic, laboratory, and histological parameters evaluated were similar between the groups. The sequential revascularization technique proved to reduce the warm ischemia time in the sheep uterine auto-transplantation model without compromising graft viability.

The Efficacy of Leukocyte-Platelet-Rich Fibrin in Combination with Sub-Epithelial Connective Tissue Graft in Peri-Implant Soft Tissue Augmentation: A Randomized Controlled Clinical Trial

Aims and Background The aim of the current study is to assess and compare the efficacy of the leukocyte-platelet-rich fibrin [L-PRF] in combination with sub-epithelial connective tissue graft [SCTG] and SCTG only in promoting aesthetic results and strengthening the state of the soft tissue surrounding implants. Materials and Methods A parallel-arm randomized controlled clinical trial was used for this investigation. A total of 120 patients who had missing teeth with a thin gingival biotype [less than 1.5 mm] were included in this study. The patients of Group I were treated with PRF and SCTG during second-stage implant surgery, while the patients of Group II were treated with SCTG only. Treatment outcomes included the assessment of the width and thickness of the keratinized tissue at the baseline, 3 and 6 months postoperatively; pro- and anti-inflammatory cytokines [IL-1β, TNF-α, and IL-4] in the peri-implant crevicular fluid on the 1st, 7th and 30th days after surgical procedure; swabs from the surface of postoperative wounds of the mucous membrane on days 3, 5, 7, and 10; Pink aesthetic score [PES] 6 months after prosthesis placement; and laser Doppler flowmetry on days 1, 7, and 14 after augmentation. Results and Discussion Patients who received L-PRF+SCTG had a significant increase in keratinized tissue thickness [KTT] [p = 0.08] than those who received SCTG only [KTT 1.86 ± 0.17 Vs 1.48 ± 0.15] 6 months after surgery. The mean [±SD] of PES was found to be 13.1 [±0.02] for Group I and 11.3 [±0.08] for Group II. The cytology, LDF, and local immunoassay analysis demonstrated faster epithelialization and better revascularization in Group I. Conclusion The use of L-PRF and SCTG is an effective method in augmenting peri-implant soft tissue and improving gingival biotype and aesthetic outcomes, which would help overcome complications and increase patients’ satisfaction.

Revascularization and outcomes in ischaemic left ventricular dysfunction after heart failure admission: The RevascHeart study.

Despite numerous trials on revascularization in patients with heart failure (HF) and ischaemic left ventricular (LV) dysfunction, its role remains unsettled. Guideline-directed medical therapy (GDMT) for HF has shown benefits on outcomes. This multicentre study aims to compare long-term mortality between revascularization and GDMT in patients with ischaemic LV dysfunction following admission for HF. Between 2012 and 2023, 408 patients admitted for HF with a LV ejection fraction (LVEF) of 40% or less and documented coronary artery disease (CAD) were included. Patients were categorized into two groups based on their initial treatment decision: revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass graft [CABG]) or GDMT. The primary outcome was rate of all-cause or cardiovascular mortality, and secondary outcomes included type of revascularization (PCI vs. CABG) and LV reverse remodelling. After a median 44.6-month follow-up, 100 patients (33%) died in the revascularization group, compared to 44 (43%) in the GDMT group. Multivariate analysis showed no significant benefit of revascularization on all-cause mortality (hazard ratio [HR] 0.81, 95% confidence interval [CI] 0.48-1.39, p = 0.45) or cardiovascular mortality (HR 0.97, 95% CI 0.62-1.52, p = 0.90) compared to GDMT. Neither CABG (HR 0.74, 95% CI 0.51-1.08, p = 0.13) nor PCI (HR 0.98, 95% CI 0.62-1.55, p = 0.93) demonstrated a mortality reduction compared to GDMT. Both groups experienced significant reductions in LV size and improvements in LVEF, greater in the revascularization group. Revascularization did not outperform GDMT in ischaemic LV dysfunction following HF admission in this retrospective analysis. Larger prospective studies are needed to clarify the potential role of revascularization in improving outcomes.

Retrospective Analysis of a Novel Grading System for Evaluating the Long-Term Benefit of Revascularization on Carotid Artery Stenosis

ObjectiveTo estimate revascularization benefit for carotid artery stenosis, with a novel grading system containing symptoms, stenosis, plaque, and collaterals collateral compensation (SSPC grading system). MethodsA retrospective multicenter study examined 945 consecutive patients diagnosed with carotid stenosis from January 2013 to December 2017. The cohort was classified into two groups: the revascularization group and the best medical therapy (BMT) group. Demographic, clinical, and lesion characteristics of all patients were recorded and five-year non-procedural stroke survival was calculated using Kaplan-Meier curve analyses. ResultsOf the 945 patients, 514 underwent carotid revascularization (483 for carotid endarterectomy [CEA] and 31 for transfemoral-carotid artery stenting [TF-CAS]) and 431 patients were treated with BMT. Patients in the revascularization group had a significantly higher proportion of preprocedural stroke/transient ischemic attack (TIA) and grades of stenosis. Of the patients in the revascularization group, 3.1% were classified as SSPC I, 10.3% as SSPC II, 41.4% as SSPC III, and 45.1% as SSPC IV. Meanwhile, 17.9% were classified as SSPC I, 19.7% as SSPC II, 49.2% as class III, and 13.2% had class IV in the BMT group. Procedural stroke developed in 13 patients (2.5%) following revascularization (10 of them were non-disabling). The overall rate of freedom from any non-procedural stroke was 94.1±1.1% in the revascularization group and 89.5±1.6% in the BMT group (P=0.01). Subgroup analysis was conducted for asymptomatic carotid stenosis (ACS) and carotid near-occlusion (CNO) patients. Non-significance was noted in the rate of freedom from any non-procedural stroke between revascularization and BMT in both ACS and CNO subgroups (P=0.09 and 0.12, respectively). Of note, in ACS patients graded as SSPC III, a significant difference in stroke survival was found between the revascularization and BMT group (96.0±2.0% vs. 89.1±2.4%, P=0.04). Meanwhile, in symptomatic CNO patients, similar results were found regarding SSPC classification (94.8±3.6% vs. 63.8±14.9%, P=0.01). ConclusionsThe SSPC grading system stratifies the patients with carotid artery stenosis and predicts the long-term benefits of revascularization. Meanwhile, potential revascularization benefits could be better attained via SSPC classes in specific patients with ACS and CNO.

Can wound blush be used as an indicator for termination of endovascular procedures in chronic limb-threatening ischemia patients?

Predicting the outcomes of endovascular revascularization of chronic limb-threatening ischemia (CLTI) patients with foot wounds can be challenging. Angiographic wound blush (WB) assessment has been found to be a helpful tool to assess wound perfusion. The aim of this study is to evaluate WB during endovascular revascularization of CLTI patients and its effects on treatment outcomes. This prospective study included all CLTI patients with foot wounds who underwent successful endovascular revascularization of infrainguinal arterial disease between 2019 and 2021. Patients were grouped according to the WB status into positive WB (group A) and negative WB (group B). Both groups were compared for demographics, comorbidities, clinical picture, and 12-month limb-based patency (LBP) and amputation-free survival (AFS) rates. The study included 69 patients of Rutherford classes 5 (46.4%) and 6 (53.6%), with the main arterial lesion located at the femoropopliteal (58%) or infrapopliteal (42%) segments. Completion angiography showed positive WB in 38 (55.1%) patients and negative WB in 31 (44.9%) patients. Both groups were comparable regarding patient presentation, site of the main arterial lesion, and distribution of foot lesions in relation to the feeding artery. The overall 12-month LBP and AFS rates were 21.7% and 39.1%, respectively, with significantly better rates in group A than in group B (LBP, 31.6% vs 9.7%, p = 0.001 and AFS, 54.1% vs 22.2%, p = 0.006, respectively). Successful angiosome-based direct flow to the foot was achieved in 38 patients (55.1%), resulting in significantly better 12-month AFS rates than those with indirect revascularization (54.8% vs 26.3%, p = 0.036, respectively), despite the comparable 12-LBP rates between the direct and indirect revascularization groups (29% vs 15.8%, p = 0.133, respectively). Multivariate logistic regression analysis identified smoking as a significant predictor of a major amputation, whereas positive WB and successful direct revascularization were significant predictors of limb salvage. WB can serve as a predictor for AFS and LBP during endovascular revascularization of CLTI patients with foot wounds. A positive WB may guide the decision to conclude an endovascular procedure, potentially avoiding unnecessary complicated maneuvers to recanalize more vessels. Conversely, a negative WB may suggest the need for further revascularization attempts to augment wound perfusion and healing.

Microvascular resistance reserve: impact on health status and myocardial perfusion after revascularization in chronic coronary syndrome.

The microvascular resistance reserve (MRR) is a novel invasive index of the microcirculation, which is independent of epicardial stenoses, and MRR has both diagnostic and prognostic implications. This study investigates whether MRR is associated with health status outcomes by revascularization in patients with moderate coronary stenoses. Consecutive patients with stable chest pain and moderate (30-90% diameter) stenoses on invasive coronary angiography (n=222) underwent invasive physiology assessment. Revascularization was performed by guideline recommendations. At baseline and follow-up, health status and myocardial perfusion were assessed by Seattle Angina Questionnaire (SAQ) and positron emission tomography. The primary endpoint was freedom from angina at follow-up with secondary endpoints including changes in health status by SAQ domains and myocardial perfusion by MRR and revascularization status. Low MRR was defined as ≤3.0. Freedom from angina occurred in 38/173 patients. In multivariate analyses, MRR was associated with freedom from angina at follow-up (odds ratio 0.860, 95% confidence interval 0.740-0.987). By MRR and revascularization groups, patients with normal MRR who did not undergo revascularization, and patients with abnormal MRR who underwent revascularization, improved health status of angina frequency (mean difference SAQ angina frequency score 8.5 [3.07-13.11] and 13.5 [2.82-23.16], respectively). For both groups, health status of physical limitation (mean difference in SAQ physical limitation score 9.7 [4.79-11.93] and 8.7 [0.53-13.88], respectively) and general health status (mean difference in SAQ summary score 9.3 [5.18-12.50] and 10.8 [2.51-17.28], respectively) also improved. Only patients with abnormal MRR who underwent revascularization improved myocardial perfusion. In patients with moderate coronary stenoses, MRR seems to predict symptomatic and perfusion benefit of revascularization.

Percutaneous coronary revascularization versus medical therapy in chronic coronary syndromes: An updated meta-analysis of randomized controlled trials.

Coronary artery disease (CAD) is a main cause of morbidity and mortality. The effectiveness of coronary revascularization in chronic coronary syndromes (CCS) is still debated. Our recent study showed the superiority of coronary revascularization over optimal medical therapy (OMT) in reducing cardiovascular (CV) mortality and myocardial infarction (MI). The recent publication of the ORBITA-2 trial suggested superiority of percutaneous coronary revascularization (PCI) in reducing angina and improving quality of life. Therefore, we aimed to provide an updated meta-analysis evaluating the impact of PCI on both clinical outcomes and angina in CCS. Relevant studies were screened in PubMed/Medline until 08/01/2024. Randomized controlled trials (RCTs) comparing PCI to OMT in CCS were selected. The primary outcome was CV death. Secondary outcomes were MI, all-cause mortality, stroke, major bleeding and angina severity. Nineteen RCTs involving 8616 patients were included. Median follow-up duration was 3.3 years. Revascularization significantly reduced CV death (4.2% vs. 5.5%; OR = .77; 95% CI .62-.96, p = .02). Subgroup analyses favoured revascularization in patients without chronic total occlusions (CTOs) (p = .052) and those aged <65 years (p = .02). Finally, a follow-up duration beyond 3 years showed increased benefit of coronary revascularization (p = .04). Secondary outcomes analyses showed no significant differences, except for a lower angina severity in the revascularization group according to the Seattle Angina Questionnaire (SAQ) (p = .04) and to the Canadian Cardiovascular Society (CCS) classification (p = .005). PCI compared to OMT significantly reduces CV mortality and angina severity, improving quality of life in CCS patients. This benefit was larger without CTOs, in patients aged <65 years and with follow-up duration beyond 3 years.

Safety and Efficacy of Combined Coronary and Peripheral Percutaneous Revascularization: A Proof-of-Concept Study.

Background. Lower extremity peripheral artery disease (LEPAD) frequently coexists with coronary artery disease (CAD) in patients with multisite vascular disease (MVD). While percutaneous revascularization is well-established for both LEPAD and CAD, limited evidence exists for patients eligible for both procedures. Specifically, the feasibility of concomitant LEPAD and CAD percutaneous revascularization remains unknown. Objectives. To compare the efficacy and safety of concomitant coronary and lower extremity elective percutaneous revascularization. Methods. Between 2012 and 2021, we included 135 patients in an observational, retrospective single-center registry. The population was stratified into two groups: 45 patients (concomitant group) underwent simultaneous coronary and peripheral percutaneous interventions, and 90 patients (deferred group) underwent two separate procedures within one year. The primary efficacy endpoint was major adverse cardiovascular events (MACE) at one year, while the primary safety endpoint was in-hospital contrast-induced nephropathy (CIN). Results. Study groups were well-balanced in baseline characteristics. In terms of coronary features, the concomitant revascularization group more often underwent single-vessel percutaneous coronary intervention (PCI), while the deferred group had multivessel PCI with diffuse coronary disease. No differences were detected in the number of LEPAD lesions between groups. For the primary efficacy endpoint, the incidence of MACE at one year was 37.8% in the concomitant group vs. 34.4% in the deferred group (HR 1.20, 95% CI 0.64-2.10; p = 0.61). No significant differences were found in CIN occurrence between the concomitant and deferred groups (11.1% vs. 8.9%; OR 1.30; 95% CI 0.36-4.21; p = 0.68). Conclusions. Multisite vascular disease patients eligible for CAD and LEPAD percutaneous revascularization exhibited a high cardiovascular risk profile with diffuse multivessel coronary and lower extremity disease. Our study suggests the efficacy and safety of concomitant coronary and lower extremity percutaneous revascularization based on one-year MACE incidence and in-hospital CIN. However, dedicated studies are warranted to confirm the short- and long-term outcomes of the concomitant revascularization strategy.

The impact of incomplete revascularization on survival in minimal invasive off-pump coronary artery surgery: a propensity score analysis of 1,149 cases.

Minimally invasive concepts are increasingly influential in modern cardiac surgery. This study aimed to evaluate the effect of completeness of revascularization on clinical outcomes and overall survival in minimally invasive, thoracoscopic coronary artery bypass grafting (CABG) surgery. We retrospectively evaluated a consecutive series of 1,149 patients who underwent minimally invasive off-pump CABG with single, double, or triple-vessel revascularization between 2007 and 2018. Of these patients, 185 (16.1%) had incomplete revascularization (IR) (group I), and 964 (83.9%) had complete revascularization (CR) (group C). We used gradient boosted propensity score estimation to account for possible confounding variables. Median age was 69 years, interquartile range (IQR) 60-76 years, and median EuroSCORE II was 4, IQR 2-7. Of the 1,149 patients, 495 patients suffered from two vessel disease (VD) and 353 presented with three VD. Long-term median follow-up 5.58 (3.27-8.48) years was available for 1,089 patients (94.8%). The incidence of recurrent or persisting angina, myocardial infarction, redo-bypass surgery, and stroke during follow-up did not differ significantly between groups. During follow-up, there were 47 deaths in group I and 172 deaths in group C. The 1-, 3-, 5-, 8-, and 10-year unadjusted survival rates were 94%, 84%, 75%, 62%, and 51% for group I, and 97%, 94%, 88%, 77%, and 72% for group C, respectively (long-rank test P<0.001), favouring CR. Following risk adjustment the long-rank test P value for survival was 0.23. In minimally invasive coronary surgery, IR resulted in decreased long-term survival, but did not achieve statistical significance after risk adjustment. However, IR should only be used in carefully selected cases.

Resource Utilization and Costs Associated With Cardiogenic Shock Complicating Myocardial Infarction: A Population-Based Cohort Study

BackgroundCardiogenic shock due to acute myocardial infarction (AMI-CS) is associated with significant short- and long-term morbidity and mortality. Despite this, little is known about associated cost. ObjectivesThe purpose of this study was to evaluate the health care costs and resource use associated with AMI-CS using administrative data from the province of Ontario, Canada. MethodsThis was a retrospective cohort study of adult patients with AMI-CS from April 2009 to March 2019. One-year costs following index admission were reported at an individual level. We used generalized linear models to identify factors associated with increased cost. We stratified patients by revascularization strategy to compare cost in each group and examined total cost at a patient level per individual fiscal year. ResultsWe included 9,789 consecutive patients with AMI-CS across 135 centers in Ontario (mean age 70.5 years; 67.7% male). Mortality in-hospital was 30.2%, and mortality at 2 years was 45.9%. The median inpatient cost per patient was $23,912 (IQR: $12,234-$41,833) with a median total 1-year cost of $37,913 (IQR: $20,113-$66,582). The median 1-year cost was $17,730 (IQR: $9,323-$38,379) for those who died in hospital, and $45,713 (IQR: $29,688-$77,683) for those surviving to discharge, with $12,719 (IQR: $4,262-$35,275) occurring after discharge. Patients who received coronary artery bypass grafting incurred the highest cost among revascularization groups. No significant differences were observed in cost per fiscal year from 2009 to 2019. ConclusionsAMI-CS is associated with significant health care costs, both during the index hospitalization and following discharge. To optimize cost-effectiveness, future therapies should aim to reduce disability in addition to improving mortality.

Вплив перкутанної тактики повної і неповної реваскуляризації міокарда при гострому коронарному синдромі з елевацією сегмента ST на динаміку лабораторних та інструментальних показників протягом госпітального періоду лікування

The aim – to identify and study the effect of percutaneous tactics of complete and incomplete myocardial revascularization on the dynamics of laboratory and instrumental indicators in patients with acute coronary syndrome (ACS) with ST-segment elevation at the hospital stage of treatment.Materials and methods. 120 patients with ACS with ST segment elevation were examined. The criteria for inclusion in the study were the presence of acute coronary syndrome with ST segment elevation and the presence of at least one lesion of the non infarct-related (non-IRA) coronary artery with stenosis of 70 % or more according to coronary angiography. Exclusion criteria were severe clinical condition of the patient (ischemic time of more than 24 hours, cardiogenic shock, clinical death at the pre-hospital stage, presence of mechanical complications of myocardial infarction), coronary artery bypass grafting, unsuitable for PCI coronary anatomy, etc. All patients were divided into a group of complete (n=60) and a group of incomplete (n=60) revascularization. The complete revascularization group included patients who received stenting of all hemodynamically significant stenoses of the coronary arteries either during primary PCI (subgroup of immediate non-IRA stenting, n=7) or during a separate planned PCI procedure (subgroup of staged stenting non-IRA, n=53).Results and discussion. According to the echocardiography before discharge from the hospital, patients who underwent a complete procedure (both one-time and staged) had a significantly higher left ventricular ejection fraction compared to patients in the incomplete revascularization group (46.3±6.41 % vs. 43.2±8.32 %, p=0.03). The anatomical complexity of the infarct-related lesion according to the SYNTAX score had a positive correlation with the duration of the primary PCI (correlation coefficient r=0.2; p&lt;0.05) and a decrease in the left ventricular ejection fraction before discharge from the hospital (r=–0.26, p&lt;0.05). An increase in the duration of PCI was associated with an increase in leukocyte count and creatinine levels in the first 48-72 hours after the intervention. However, there was no significant difference in the incidence of contrast-induced nephropathy. A positive correlation was found between the level of LDL and the deterioration of kidney function after pPCI (r=0.27, p&lt;0.05), as well as the degree of non-IRA stenosis (3.39±0.99 mmol/l in patients with with non-IRA stenoses &gt; 90 % versus 2.77±0.68 mmol/l in patients with non-IRA stenoses 70-89 %, p&lt;0.05). While the complexity of non-IRA lesions according to the SYNTAX score had a negative correlation with the level of LDL (r=–0.26, p&lt;0.05).Conclusions. Complete revascularization in ACS with ST-elevation patients was associated with higher LVEF before hospital discharge. Immediate stenting of all non-IRA during pPCI is associated with increased procedure time but has a lower total radiation burden compared with a staged PCI strategy. The complexity of the infarct-related lesion according to the SYNTAX score is an unmodified predictor of the duration of the pPCI and the reduction of LVEF in the short observation period. Increasing the duration of pPCI leads to a more pronounced inflammatory response with an increase in the level of leukocyte count and an increase of creatinine in the first 48-72 hours after pPCI. LDL is a risk factor for the deterioration of renal function after PCI and the presence of &gt; 90 % non-IRA lesions. However, these lesions have less anatomical complexity.

Does Timing of Coronary Artery Bypass Grafting after ST-Elevation Myocardial Infarction Impact Early- and Long-Term Outcomes?

The optimal timing of surgical revascularization after ST-elevation myocardial infarction (STEMI) is controversial, with some suggesting higher mortality rates in patients undergoing early surgery. The aim of the study is to determine the effect of the timing of surgical revascularization on 30-day mortality and long-term outcomes in these patients. Retrospective single-center analysis of patients with STEMI undergoing coronary artery bypass grafting (CABG) between January 2008 and December 2019 at our institution. The cohort was split into three groups based on time from symptom onset until surgical revascularization (Group 1: <12 hours, Group 2: 12-72 hours, Group 3: >72 hours). Statistical analyses were performed with and without patients in cardiogenic shock. Primary outcomes were 30-day mortality and 10-year survival. During the study period, 437 consecutive patients underwent surgical revascularization in the setting of STEMI. The mean age was 67.0 years, 96 (22.0%) patients were female, and 281 (64.3%) patients underwent off-pump CABG. The overall 30-day mortality including patients with cardiogenic shock was 12.8%. The 30-day mortality was 16.1, 13.9, and 9.3% in Groups 1, 2, and 3 (p = 0.31), whereas 10-year survival was 48.5, 57.3, and 54.9% (log-rank: p = 0.40). After exclusion of patients in cardiogenic shock, there was no difference between the three groups in 30-day and 10-year mortality. Timing of surgery had no influence on early- and long-term survival. In patients with STEMI, early surgical revascularization achieved similar early- and long-term survival rates compared with a delayed surgical revascularization strategy. Hence, when indicated, an early CABG strategy has no disadvantages in comparison to a delayed strategy.

COMPLETE VS CULPRIT–LESION–ONLY MYOCARDIAL REVASCULARIZATION IN PATIENTS WITH OUT–OF–HOSPITAL CARDIAC ARREST: INSIGHTS FROM THE MULTICENTRIC LOMBARDIA CARE REGISTRY

Abstract Background Out–of–hospital Cardiac Arrest (OHCA) is an uncommon yet potentially devastating complication of patients with Myocardial Infarction (MI). Multivessel Disease (MVD) is a frequent occurrence in this setting, being present in nearly half patients undergoing Coronary Angiography (CAG). We previously reported that, in case of MI complicated by OHCA and evidence of MVD, a complete myocardial revascularization, as compared to culprit–lesion–only revascularization, was associated with an improved 1–year survival and favorable neurological outcomes. We aimed to validate and confirm these results on a multicentric scale with a larger patient cohort. Methods This is a multicentric, prospective, observational study. We considered all consecutive patients with OHCA and MI enrolled in the Lombardia CARe Registry from January 1st 2015 to December 31st 2022 who underwent CAG in 6 centers in Northen Italy. Results A total of 623 patients were included; of these, 403 underwent CAG. Median age was 64 years, and about 80% had no history of ischemic heart disease. Median ejection fraction (EF) was 40%. MVD was present in 186 patients and was subsequently treated with either complete (32%) or incomplete (67.7%) coronary revascularization. Left anterior descendent (LAD) artery was the culprit lesion in almost 1/3 of patients. The 1–year survival rate was 78.3% in the complete revascularization group and 42.9% in the culprit–lesion–only revascularization group (p–value &amp;lt; 0.001). After correction for EF, hypercholesterolemia, mechanical or pharmacological support, cardiac arrest time and first shockable rhythm, complete revascularization strategy was independently associated with a reduced risk of death [HR: 0.27 (95% CI: 0.01 to 0.739; p = 0.01] and death or unfavorable neurological outcome [HR: 0.23 (95% CI: 0.08 to 0.67); p = 0.007]. Conclusions in patients resuscitated from OHCA, complete revascularization strategy was confirmed to be associated with an improvement of 1–year survival and with a good neurological outcome. These results highlight the independent impact on survival of a complete percutaneous coronary intervention strategy in patients with OHCA plus MVD.

Predictors of leech therapy failure in revascularized and replanted digits

IntroductionVenous congestion is a common phenomenon following digital revascularization and replantation. Leech therapy allows for venous outflow while angiogenesis and neovascularization take place. The aim of this study is to evaluate the efficacy of leech therapy in the revascularized and replanted digits and determine risk factors for unsuccessful salvage. Materials and methodsA retrospective review was performed to identify all patients with complete or incomplete digital amputations at an academic Level 1 Trauma Center who underwent digital replantation or revascularization from January 2005 to December 2020. Amputations proximal to the palmar arch as well as revascularizations that showed any degree of perfusion on preoperative assessment were excluded. Leech therapy was initiated as soon as any signs of venous congestion appeared and was titrated to clinical effect. Patient demographics, medical history, injury mechanism, extent and level, operative details, leech therapy details, number of blood transfusions, hospitalization length, as well as the digit's ultimate survival data were collected. ResultsOf the 159 patients who underwent 213 digital revascularizations (n ​= ​135) and replantations (n ​= ​78), venous congestion requiring leech therapy developed in 27 digits in the revascularization group and in 26 in the replantation group. Of the digits that were leeched, 15 failed in the revascularization group (56 ​% failure rate) and 17 failed in the replantation group (65 ​% failure rate). Avulsion mechanism of injury and presence of a circumferential laceration were significantly associated with rate of failure in the revascularization cohort (p ​< ​0.01). Proximal level of injury was significantly associated with rate of failure in the replantation group (p ​< ​0.01). ConclusionLeech therapy has limited efficacy in avulsed or more proximally injured digits. These data can aid in determining the prognosis of a digit with venous congestion after revascularization and replantation.

Complete revascularization based on angiography derived fractional flow reserve versus incomplete revascularization in patients with ST-segment elevation myocardial infarction.

Nearly half of ST-segment elevation myocardial infarction (STEMI) patients present with significant multivessel coronary artery disease, they are at high risk of subsequent adverse events. Whether complete revascularization guided by coronary angiography-derived fractional flow reserve (caFFR) further reduces such events risk is not fully investigated. In this study, 367 consecutive STEMI patients who underwent successful primary percutaneous coronary intervention (PCI) were enrolled. caFFR of all three coronary vessels were measured, including 367 culprit vessels and 703 non-culprit vessels. Complete revascularization was defined as post-PCI caFFR > 0.8 of all three coronary vessels. The primary endpoint was major adverse cardiovascular events (MACE, a composite of cardiovascular death, non-fatal recurrent myocardial infarction, ischemia-driven revascularization and non-fatal stroke/transient ischemic attacks) during follow-up. At a median follow-up of 3.8 years, MACE had occurred in 39 patients of the 220 (17.7%) in the complete revascularization group as compared with 49 patients of the 131 (37.4%) in the incomplete revascularization group (hazard ratio [HR] 1.9; 95% confidence interval [CI] 1.2-3.0; p = 0.005). The incomplete revascularization in culprit vessels evaluated by caFFR showed the highest risk for MACE occurrence. In STEMI patients with multivessel coronary artery disease, incomplete revascularization based on caFFR might contribute to identifying patients at high-risk.