Revascularization Strategy Research Articles

Covered Endovascular Reconstruction of the Iliac Artery Bifurcation (CERIB).

The aim of this study was to present the covered endovascular reconstruction of the iliac artery bifurcation (CERIB) technique as a revascularization option for aorto-iliac occlusive disease (AIOD) involving the iliac artery bifurcation. This was a retrospective single-center study including all patients undergoing a CERIB procedure from January 2021 until December 2022. Covered endovascular reconstruction of the iliac artery bifurcation procedures were performed percutaneously with bilateral femoral access, excepting cases where simultaneous open femoral artery reconstruction was required due to the extension of peripheral arterial occlusive disease. Standard patient, procedural, and follow-up (FU) data including survival and arterial reinterventions were gathered and analyzed. A total of 13 patients were included (11/13 male, median age=70 [60-76] years). Additional open and/or endovascular procedures included endarterectomy of the femoral bifurcation (n=6), rotational atherectomy (n=2), and 1 axillary artery cutdown for upper limb access (n=1). Median operating time was 2.9 hours (1.5-4.9 hours); median radiation duration and dose were 28.4 (14.3-63.3 minutes) and 4090.6 (384.4-9430.1 cGray/cm2), respectively. The stent grafts used for CERIB were BeGraft peripheral n=31, BeGraft Aortic n=4 and BeGraft peripheral plus n=1 (Bentley InnoMed GmbH, Hechingen, Germany). In 2 patients with prior stenting of the common iliac artery (CIA), only the internal and external iliac arteries (IIA and EIA) were treated in this study, and in 2 cases, additional uncovered stents were required for relining. Technical success was 100%. During a midterm FU (median 18 [4-31] months), 2 patients died from cardiovascular reasons and 1 patient with prior iliac stenting required reinterventions for recurring occlusion. Covered endovascular reconstruction of the iliac artery bifurcation is a straightforward option for treating AIOD involving the iliac artery bifurcation that allows preservation of internal iliac artery perfusion and shows good early and midterm results. Prior iliac artery stenting may be a risk factor for early occlusion after CERIB. Aorto-iliac occlusive disease with involvement of the internal iliac artery is encountered regularly in vascular surgical practice, but the internal iliac artery is often not included in the revascularization strategy. The present article will increase the awareness for the relevance of including the internal iliac artery in revascularization strategies and presents CERIB as another method to be added to the armamentarium of (endo-)vascular surgeons and interventionalists.

Impact of Postprocedural Graft Flow on Outcomes Following Chronic Total Occlusion Intervention in Postcoronary Artery Bypass Graft Patients: A Detailed Angiographic Analysis

Chronic total occlusions (CTOs) are frequent in patients with previous coronary artery bypass graft (CABG) surgery. Percutaneous coronary intervention (PCI) is the usual revascularization strategy. Whether or not the presence of a graft on a CTO vessel and post-PCI graft patency impacts outcomes after CTO-PCI is unknown. We sought to evaluate the impact of post-PCI graft patency on the durability of CTO-PCI. In total, 259 patients with previous CABG who underwent CTO-PCI in 12 international centers in 2019 to 2023 were categorized into "grafted" and "ungrafted" groups based on the presence of graft on a CTO vessel. The grafted group was subdivided into "graft-occluded" and "graft-patent" groups, depending on graft patency. The primary end points were (1) technical success rate, (2) target vessel failure, and (3) CTO failure rates at 1 year. CTO failure was defined as target vessel revascularization and/or significant in-stent restenosis. A total of 199 patients (77%) were in the grafted group. Grafted CTOs showed higher complexity and lower technical success rates (70% vs 80%, p = 0.004) than nongrafted CTOs. Of the grafted CTOs, 140 (70%) were in the grafted-occluded group and 59 (30%) were in the grafted-patent group. The technical success was lower in the former group (65% vs 81%, p = 0.022). An occluded graft was an independent predictor of technical failure (odds ratio 2.04, 95% confidence interval 1.03 to 4.76, p = 0.049) and persistent post-PCI graft patency was a strong independent predictor of CTO failure at 1 year (hazard ratio 5.6, 95% confidence interval 1.2 to 27.5, log-rank p = 0.033). In conclusion, in patients with previous CABG who underwent CTO-PCI, post-PCI graft patency was a significant predictor of CTO failure.

Optional Revascularization Strategies for Patients with ST-Segment Elevation Myocardial Infarction and Multivessel Disease.

Percutaneous coronary intervention is the main strategy of revascularization and has been shown to improve outcomes in some patients with ST-segment elevation myocardial infarction (STEMI). However, multivessel disease (MVD), a common condition in these patients, is associated with worse clinical outcomes compared to single-vessel disease. Despite intervention being a standard treatment for coronary artery disease, optimal strategies and timings for patients with STEMI and MVD remain unclear. Numerous studies and meta-analyses have investigated this topic; however, many current conclusions are based on observational studies. Furthermore, clinical guidelines regarding the management of patients with STEMI and MVD contain conflicting recommendations. Therefore, we aimed to compile relevant studies and newly available evidence-based medicines to explore the most effective approach.

A Novel Interhemispheric Dural Inversion Technique for Indirect Parafalcine Cerebral Revascularization: Case Report

BACKGROUND AND IMPORTANCE: Variety of revascularization strategies have been deployed to treat the deterioration of cerebral blood flow. Blood flow restoration can be achieved by direct or indirect procedures. The indirect reconstructive procedure to augment blood flow involves encephalomyosynangiosis, encephaloduroarteriosynangiosis, or encephalodurosynangiosis, and has been used effectively in ischemic Moyamoya disease. However, the preferred procedure must be evaluated on a case-by-case basis and remains controversial in other cerebral arterial diseases. Here, we report the “interhemispheric dural inversion (IDI)” as a novel technique for indirect parafalcine cortical revascularization. CLINICAL PRESENTATION: A 54-year-old white man with a complex history of neck radiation secondary to childhood Hodgkin's lymphoma presented with focal perfusion deficit in the right mesial occipital lobe near the primary visual cortex. A large c-shaped dural flap with a paramedian base is harvested and, after an interhemispheric dissection, placed in contact with the ischemic parafalcine cortical tissue (IDI). CONCLUSION: The IDI was used successfully for indirect revascularization of a focal right paramedian occipital lobe deficit in a 54-year-old man with complex cerebro-occlusive disease from childhood radiation and multiple previous bypass surgeries. The IDI is a simple approach for targeted indirect parafalcine cortical revascularization to facilitate an increased blood supply and prompt new vessels to sprout from preexisting dural arteries. It can be used as a standalone technique or combined with other revascularization strategies, as warranted.

Complete versus culprit-only percutaneous coronary intervention in elderly patients with acute coronary syndrome and multivessel coronary artery disease: A systematic review and meta-analysis

BackgroundCulprit-only percutaneous coronary intervention (PCI) is commonly performed for acute coronary syndrome (ACS) with multivessel coronary artery disease (MVD) in the elderly. Complete revascularization has been shown to benefit the general population, yet its safety and efficacy in older patients are uncertain. MethodsFollowing PRISMA guidelines, we systematically searched PubMed, Embase, and Cochrane databases for randomized controlled trials (RCTs) comparing complete versus culprit-only PCI in patients ≥65 years old with ACS and MVD. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes included myocardial infarction (MI), ischemia-driven revascularization (IDR), all-cause mortality, and cardiovascular mortality. Data were pooled using a random effects model with a restricted maximum likelihood estimator to generate risk ratios (RRs). ResultsFive RCTs with 4105 patients aged ≥65 years were included. Compared with culprit-only PCI, complete revascularization reduced MI (RR 0.65; 95 % CI 0.49–0.85; p < 0.01). MACE (RR 0.75; 95 % CI 0.54–1.05; p = 0.09) and IDR (RR 0.41; 95 % CI 0.16–1.04; p = 0.06) were not significantly different between both strategies among those aged ≥65. However, there was a significant reduction in MI (RR 0.69; 95 % CI 0.49–0.96; p-value = 0.03), MACE (RR 0.78; 95 % CI 0.65–0.94; p < 0.01), and IDR (RR 0.60; 95 % CI 0.41–0.89; p < 0.01) in those aged ≥75. ConclusionsIn elderly patients aged ≥65 years with ACS and MVD, a strategy of complete revascularization by PCI reduces MI compared to culprit-only PCI with no significant difference in MACE and IDR. However, complete revascularization reduced MI, MACE, and IDR in those aged ≥75 years suggesting a possible benefit in this age group.

Management of Anomalous Left Vertebral Artery During Open Total Arch Replacement

BackgroundAn anomalous left vertebral artery (aLVA) can complicate aortic arch surgery. We examined the safety of various aLVA revascularization strategies during open total arch replacement. MethodsWe retrospectively evaluated 92 patients undergoing total arch replacement from January 2018 to May 2023 and identified 11 patients with aLVA. A comparison group (n = 31) with conventional 3-branched anatomy was selected by 3:1 matching on age, sex, circulatory arrest time, and operative mortality. Forty-two patients were selected for analysis. The primary outcome was perioperative stroke within 30 days. Secondary outcomes included spinal cord ischemia and long-term stroke. ResultsPatients with aLVA had an average age of 53 ±16 years. Indications included Stanford type A dissection (n = 4), chronic dissection with aneurysmal degeneration (n = 4), and primary aneurysmal disease (n = 3). The aLVA was reconstructed by transposition to the left carotid (n = 2) or subclavian (n = 8). In 1 case, partial zone 2 arch replacement was performed proximal to the aLVA and manipulation was not required. Total arch replacement with frozen elephant trunk was performed in 8 of 11 cases. No postoperative mortality was observed. One patient experienced transient postoperative stroke (9% vs 9%, P = 1.00). One patient received lumbar drain for suspected spinal cord ischemia (9% vs 7%, P = 0.59). One patient experienced stroke 6 months post operation. One-year patency of transposition was 100%. ConclusionsThe presence of aLVA does not impact outcomes of open arch surgery. Our strategy to preserve the aLVA may be preferable to simple ligation. We describe several safe and feasible approaches for reimplantation of this anomalous variant.

Preliminary outcomes of quantitative flow ratio-guided coronary bypass grafting in primary valve surgery: A propensity score weighted analysis

ObjectivesThe guidelines recommend fractional flow reserve-guided coronary artery bypass grafting (CABG) during primary valve surgery without evidence. Quantitative flow ratio (QFR) is a novel coronary angiography (CAG)-based fractional flow reserve measurement. We aimed to compare the early clinical outcomes between QFR-guided and CAG-guided CABG in these patients. MethodsThis observational study screened all 2081 patients admitted to our institution for elective primary mitral and/or aortic valve surgery from January 2017 to September 2020. Of them, all 188 patients with comorbid coronary artery lesions (visual estimated stenosis ≥50%) were included. Sixty-nine patients with QFR analysis received bypasses only for lesions with QFR ≤0.80 (QFR-guided group). The remaining 119 patients without QFR analysis received bypasses for all stenosis ≥50% (CAG-guided group). Propensity overlap weighting was used to neutralize the intergroup imbalance. The primary end point was major adverse cardiovascular events. ResultsAfter propensity score weighting, the baseline characteristics were comparable. Concomitant coronary artery bypass grafting was performed 58.1% versus 100% in the QFR-guided and CAG-guided groups, respectively. The mean number of grafts was significantly lower in QFR-guided group than in the CAG-guided group (0.9 ± 0.7 vs 1.6 ± 0.5 [P < .001]). The weighted 30-day incidence of major adverse cardiovascular events was numerically lower in the QFR-guided group than in the CAG-guided group, but not statistically significant (6.3% vs 11.8% [P = .429]). After a median follow-up of 31.6 months, the weighted risk of major adverse cardiovascular events and mortality were significantly lower in the QFR-guided group than in the CAG-guided group (major adverse cardiovascular events: hazard ratio, 0.45; 95% CI, 0.24-0.84; P = .012; mortality: hazard ratio, 0.38; 95% CI, 0.16-0.93; P = .029). ConclusionsCompared with CAG-guided coronary artery bypass grafting, QFR-guided CABG is associated with less grafting and better clinical outcome in primary valve surgery with comorbid coronary artery disease. To confirm this finding, the Quantitative Flow Ratio Guided Revascularization Strategy for Patients Undergoing Primary Valve Surgery With Comorbid Coronary Artery Disease trial (NCT03977129) is ongoing.

Targeting the histone methyltransferase SETD7 rescues diabetes-induced impairment of angiogenic response by transcriptional repression of semaphorin 3G

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Swiss National Science Foundation (n. 310030_197557), the Swiss Heart Foundation (n. FF19045) Background Peripheral artery disease (PAD) is highly prevalent in patients with diabetes (DM) and associates with a poor prognosis (1). Revascularization strategies failed to improve outcome, highlighting the need to develop new strategies to promote blood vessel growth (2). Histone modifications have emerged as key modulators of gene expression (3), however their role in angiogenic response in DM remains poorly understood. The present study investigates the role of chromatin remodelling in DM-related impairment of angiogenic response. Methodology Primary human aortic endothelial cells (HAECs) were exposed to normal glucose (NG, 5 mM) or high glucose (HG, 25 mM) levels for 48 hours. Unbiased gene expression profiling was performed by RNA sequencing (RNA-seq). Cell migration and tube formation were employed to study angiogenic properties in HAECs. Levels of the histone methyltransferase SETD7 and its chromatin signature at histone 3 on lysine 4 (H3K4me1) were investigated by Western blot and chromatin immunoprecipitation (ChIP). Pharmacological blockade of SETD7 was achieved by using the selective inhibitor (R)-PFI-2 while the inactive enantiomer (S)-PFI-2 was used as a control. Mice with streptozotocin-induced DM were orally treated with (R)-PFI-2 or vehicle and underwent hindlimb ischemia by femoral artery ligation. Blood flow was analysed at 24 hours, 7 and 14 days by laser Doppler imaging. Our experimental findings were also translated in endothelial cells (ECs) and gastrocnemius muscle samples obtained from DM patients with PAD. Results RNA-seq in HG-treated HAECs unveiled the histone methyltransferase SETD7 as the top-ranking transcript. SETD7 upregulation was associated with increased H3K4me1 levels as well as with impaired HAECs migration and tube formation. Both SETD7 silencing and inhibition by (R)PFI-2 rescued hyperglycemia-induced impairment of HAECs migration and tube formation, while SETD7 overexpression blunted the angiogenic response. RNA-seq and ChIP assays showed that SETD7-induced H3K4me1 enables the transcription of the angiogenesis inhibitor semaphorin-3G (SEMA-3G) by increasing chromatin accessibility to PPARγ. Moreover, SEMA-3G overexpression mimicked the impairment of angiogenic response observed during hyperglycemia. In DM mice with hindlimb ischemia, (R)-PFI-2 improved limb perfusion by suppressing SEMA-3G. Finally, RNAseq in vascular specimens from DM patients with PAD confirmed the upregulation of SETD7/SEMA3G signalling, whereas SETD inhibition restored angiogenic properties in ECs from DM patients. Conclusion SETD7 is a novel epigenetic target to boost neovascularization in DM patients with PAD.

Clinical outcomes in acute coronary syndrome after presentation of unique electrocardiographic findings

BackgroundUnique electrocardiographic findings are rarely observed in acute coronary syndrome (ACS) with a culprit left anterior coronary artery (LAD). The aim of this study was to assess the epidemiological features and prognostic impact. MethodsThis study was designed as an observational study. A total of 641 patients with a culprit lesion in the left main trunk or LAD were extracted from a cohort of 1776 ACS patients. The primary endpoint was mortality, comparing patients presenting with unique electrocardiogram patterns, specifically the de Winter pattern or Wellens' syndrome (type A or B), upon hospital arrival, with those presenting common electrocardiogram patterns. ResultsA unique electrocardiogram was observed in 7.0% (n = 45; 2 with de Winter pattern, 14 with Wellens' type A and 29 with type B). Compared to patients with a common pattern, cardiogenic shock at hospital arrival were rare in patients with a unique pattern (0% vs. 8.4%, P = 0.04), and percutaneous coronary intervention was primary revascularization strategy in all groups (95.6% vs. 98.2%). The mortality rates were similar between the two groups over a median 565 days of observation period (13.3% vs. 15.7%, P = 0.43), with 0% in Wellens' type A, 13.8% in type B, and both patients with the de Winter pattern died. ConclusionThe de Winter pattern or the Wellens syndrome was found in 7.0% of cases with ACS. They had similar mortality rates compared to those with a common pattern, although the de Winter pattern was identified in only 2 patients.

Hierarchical Chiral Calcium Silicate Hydrate Films Promote Vascularization for Tendon-to-Bone Healing.

Revascularization after rotator cuff repair is crucial for tendon-to-bone healing. The chirality of materials has been reported to influence their performance in tissue repair. However, data on the use of chiral structures to optimize biomaterials as a revascularization strategy remain scarce. Here, calcium silicate hydrate (CSO) films with hierarchical chirality on the atomic to micrometer scale are developed. Interestingly, levorotatory CSO (L-CSO) films promote the migration and angiogenesis of endothelial cells, whereas dextral and racemic CSO films do not induce the same effects. Molecular analysis demonstrates that L-chirality can be recognized by integrin receptors and leads to the formation of focal adhesion, which activates mechanosensitive ion channel transient receptor potential vanilloid 4 to conduct Ca2+ influx. Consequently, the phosphorylation of serum response factor is biased by Ca2+ influx to promote the vascular endothelial growth factor receptor 2 signaling pathway, resulting in enhanced angiogenesis. After implanted in a rat rotator cuff tear model, L-CSO films strongly enhance vascularization at the enthesis, promoting collagen maturation, increasing bone and fibrocartilage formation, and eventually improving the biomechanical strength. This study reveals the mechanism through which chirality influences angiogenesis in endothelial cells and provides a critical theoretical foundation for the clinical application of chiral biomaterials.

Impact of Incomplete Revascularization on Long-term Survival Based on Revascularization Strategy

BackgroundThis study investigated the impact of complete revascularization (CR) and incomplete revascularization (IR) on long-term survival in patients undergoing isolated coronary artery bypass grafting (CABG) using multiple arterial graft (MAGs) or a single artery with saphenous vein grafts (SAGs). MethodsBetween January 2006 and December 2020, 12,625 patients underwent CABG and were divided into 4 groups: MAG CR (n = 1066), MAG IR (n = 286), SAG CR (n = 8360), and SAG IR (n = 2913). Inverse probability of treatment weighting based on the generalized propensity score was used to minimize imbalance between the groups. ResultsIn the weighted cohort, median follow-up time was 8.35 years (interquartile range, 5.01-11.6 years). MAG CR was associated with similar long-term survival compared with MAG IR (hazard ratio [HR], 0.79; 95% CI, 0.60-1.03; P = .084). SAG CR was associated with improved long-term survival compared with SAG IR (HR, 0.67; 95% CI, 0.52-0.84; P = .01). MAG CR was associated with better long-term survival compared with SAG CR (HR, 0.45; 95% CI, 0.35-0.57; P < .001). Moreover, MAG IR was protective compared with SAG IR (HR, 0.62; 95% CI, 0.45-0.85; P = .033). Additional analysis was performed comparing perfect CR vs imperfect CR vs IR in MAG and SAG patients, separately. In the weighted sample of MAG, there were no differences in the long-term survival between perfect CR, imperfect CR, and IR. However, in the weighted sample of the SAG cohort, SAG perfect CR was associated with improved survival compared with SAG imperfect CR (HR, 0.81; 95% CI, 0.0.72-0.92; P = .001). Whereas, SAG perfect and imperfect CR were both associated with improved survival compared with SAG IR (HR, 0.51; 95% CI, 0.0.35-0.87; P = .006 and HR, 0.72; 95% CI, 0.64-0.82; P < .001), respectively. ConclusionsMAG CR is associated with better survival compared with SAG CR. If IR is inevitable, patients with MAG IR had better long-term survival compared with patients receiving SAG IR. Moreover, similar long-term survival is observed whether perfect CR, imperfect CR, or IR is achieved in the MAG population but not in SAG patients.

ALTERNATIVE STRATEGIES FOR LEFT SUBCLAVIAN ARTERY REVASCULARIZATION DURING ZONE–2 AORTIC ARCH SURGERYEMENT

Abstract Objective Anatomical extension of surgical treatment of thoracic aortic pathologies involving the aortic arch is still controversial. The adoption of distal anastomosis in aortic arch zone–2 (Z2–AAR), in order to facilitate bleeding control, has been widely recommended. In such case the revascularization of left subclavian artery (LSA) may add further concerns. Here we report our different strategy of LSA revascularization in 2 different scenario of Z2–AAR Clinical. Cases Case#1 17 yo male patient affected by Loeys–Dietz Syndrome and a previous David procedure at age of 11yo. He presented complaining chest pain and CT scan revealed a dilatation (5,8 cm) of ascending aorta and an intimal flap with preserved previous distal anastomosis. Surgical strategy #1 (Left subclavian artery in situ): Arch replacement (Zone 2 distal anastomosis) with Siena Graft 24mm and modified Elephant Trunk Tecnique (2cm distal endoluminal graft). Innominate artery and left carotid artery reimplantation. Distal Anastomosis Siena 24 (Z2). Case #2 78 yo male with a previous (6 month before) Biological AVR (Trifecta 25) + ascending aorta replacement (Jotec 30). Presented complaining acute chest pain, CT Scan revealed a residual dilatation of distal ascending aorta, dissection/rupture of distal aortic arch at level of a complicated plaque. Surgical strategy #2 (Left subclavian artery reimplanted): Arch replacement (Zone 2 distal anastomosis) with Siena Graft 30mm and Elephant trunk Teccnique (10cm distal endoluminal graft). Closure of the extended ulcera. Total epiaortic vessels de–branching 10 mm Tube on LSA – Distal Anastomosis Siena 30 (Z2). Conclusion Surgical extension of aortic arch replacement is still matter of discussion. Zone–2 approach for aortic arch replacement seems a safe and effective option. In our mind strategy for left subclavian revascularization should be tailored according patient’s anatomy and potential future scenarios.

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.

A Narrative Review of Revascularization in Chronic Coronary Syndrome/Disease: Concepts and Misconceptions.

Ischemic heart disease represents a significant global burden of morbidity and mortality. While revascularization strategies are well defined in acute settings, there are uncertainties regarding chronic coronary artery disease treatment. Recent trials have raised doubts about the necessity of revascularization for "stable", chronic coronary syndromes or disease, leading to a shift towards a more conservative approach. However, the issue remains far from settled. In this narrative review, we offer a summary of the most pertinent evidence regarding revascularization for chronic coronary disease, while reflecting on less-often-discussed details of major clinical trials. The cumulative evidence available indicates that there can be a prognostic benefit from revascularization in chronic coronary syndrome patients, provided there is significant ischemia, as demonstrated by either imaging or coronary physiology. Trials that have effectively met this criterion consistently demonstrate a reduction in rates of spontaneous myocardial infarction, which holds both prognostic and clinical significance. The prognostic benefit of revascularization in patients with heart failure with reduced ejection fraction remains especially problematic, with a single contemporary trial favouring surgical revascularization. The very recent publication of a trial focused on revascularizing non-flow-limiting "vulnerable" plaques adds further complexity to the field. The ongoing debates surrounding revascularization in chronic coronary syndromes emphasize the importance of personalized strategies. Revascularization, added to the foundational pillar of medical therapy, should be considered, taking into account symptoms, patient preferences, coronary anatomy and physiology, ischemia tests and intra-coronary imaging.

Pharmacotherapy for Coronary Artery Disease and Acute Coronary Syndrome in the Aging Population.

To provide a comprehensive summary of relevant studies and evidence concerning the utilization of different pharmacotherapeutic and revascularization strategies in managing coronary artery disease and acute coronary syndrome specifically in the older adult population. Approximately 30% to 40% of hospitalized patients with acute coronary syndrome are older adults, among whom the majority of cardiovascular-related deaths occur. When compared to younger patients, these individuals generally experience inferior clinical outcomes. Most clinical trials assessing the efficacy and safety of various therapeutics have primarily enrolled patients under the age of 75, in addition to excluding those with geriatric complexities. In this review, we emphasize the need for a personalized and comprehensive approach to pharmacotherapy for coronary heart disease and acute coronary syndrome in older adults, considering concomitant geriatric syndromes and age-related factors to optimize treatment outcomes while minimizing potential risks and complications. In the realm of clinical practice, cardiovascular and geriatric risks are closely intertwined, with both being significant factors in determining treatments aimed at reducing negative outcomes and attaining health conditions most valued by older adults.

Drug-coated balloon versus drug-eluting stenting coronary angioplasty for ST-elevation myocardial infarction: a systematic review and meta-analysis of real-world studies

Abstract Funding Acknowledgements None. Introduction In the realm of ST-elevation myocardial infarction (STEMI), drug-eluting stent angioplasty (DES) is a well-established strategy for urgent revascularization. However, several challenges arise when selecting stents for these patients. These challenges include dealing with endothelial oedema and vasospasm during acute thrombotic occlusion. Moreover, there are concerns surrounding DES-related complications. These complications include the need for prolonged anti-platelet therapy, which increases the risk of bleeding, late stent thrombosis, and in-stent restenosis (ISR). In light of these issues, drug-coated balloons (DCB) have emerged as a compelling alternative. Purpose: This study aims to explore the safety and efficacy of DCB compared to conventional DES angioplasty in the management of STEMI. Methods A systematic literature search was conducted across electronic databases (PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov, reference lists of relevant publications, and grey literature sources) for studies published from the inception of DCB up to 31st August 2023. Results Nine eligible studies, consisting of four randomised controlled trials and two retrospective propensity-matched studies, were included. These studies, all single-center, involved a total of 2,122 patients (934 in the DCB versus 1,188 in the DES group) over a median follow-up period of 15 months (ranging from 6 to 36 months). The meta-analysis showed no statistically significant differences between DCB and DES angioplasty in terms of technical success (OR: 1.82, 95% CI: 0.22-15.08, p = 0.58), major adverse cardiovascular events (MACE) (OR: 1.24, 95% CI: 0.60–2.56, p = 0.57), all-cause mortality (OR: 1.20, 95% CI: 0.83–1.75, p = 0.33), cardiac death (OR: 1.40, 95% CI: 0.47-4.17, p = 0.54), cardiovascular-related hospitalization (OR: 0.72, 95% CI: 0.32-1.65, p = 0.44), recurrent myocardial infarction (OR: 0.99, 95% CI:0.34-2.90, p = 0.99), target lesion revascularization (OR: 1.15, 95% CI: 0.56–2.34, p = 0.71), late luminal loss (SMD: -0.25mm, 95% CI: -1.05 to 0.54, p = 0.53), postoperative TIMI flow (OR: 1.16, 95% CI: 0.54-2.50, p = 0.71), fractional flow reserve (MD: 0.012, 95% CI -0.018 to 0.032, p = 0.27), and bleeding risk (7.2% in DCB versus 7.5% in DES). It's noteworthy that 8.2% of patients in the DCB group required bailout stenting due to coronary artery dissection type C, a rate 10 times higher than that in the DES group (p &amp;lt; 0.005). Additionally, DCB angioplasty displayed a statistically significant presence of residual stenosis compared to DES angioplasty (OR: 6.48, 95% CI: 1.13-37.2, p = 0.04). Conclusion DCB angioplasty demonstrates promise but presents unique challenges in STEMI management, particularly in complex scenarios requiring bailout stenting and residual stenosis. The study contributes to the ongoing discussion about the role of DCBs in optimizing STEMI treatment, highlighting their potential benefits and areas of concern.

Complete vs Culprit-Only Revascularization in Older Patients With Myocardial Infarction and High Bleeding Risk

Patients with high bleeding risk (HBR) have a poor prognosis, and it is not known if they may benefit from complete revascularization after myocardial infarction (MI). To investigate the benefit of physiology-guided complete revascularization vs a culprit-only strategy in patients with HBR, MI, and multivessel disease. This was a prespecified analysis of the Functional Assessment in Elderly MI Patients With Multivessel Disease (FIRE) randomized clinical trial data. FIRE was an investigator-initiated, open-label, multicenter trial. Patients 75 years or older with MI and multivessel disease were enrolled at 34 European centers from July 2019 through October 2021. Physiology treatment was performed either by angiography- or wire-based assessment. Patients were divided into HBR or non-HBR categories in accordance with the Academic Research Consortium HBR document. Patients were randomized to either physiology-guided complete revascularization or culprit-only strategy. The primary outcome comprised a composite of death, MI, stroke, or revascularization at 1 year. Secondary outcomes included a composite of cardiovascular death or MI and Bleeding Academic Research Consortium (BARC) types 3 to 5. Among 1445 patients (mean [SD] age, 81 [5] years; 917 male [63%]), 1025 (71%) met HBR criteria. Patients with HBR were at higher risk for the primary end point (hazard ratio [HR], 2.01; 95% CI, 1.47-2.76), cardiovascular death or MI (HR, 1.89; 95% CI, 1.26-2.83), and BARC types 3 to 5 (HR, 3.28; 95% CI, 1.40-7.64). The primary end point was significantly reduced with physiology-guided complete revascularization as compared with culprit-only strategy in patients with HBR (HR, 0.73; 95% CI, 0.55-0.96). No indication of interaction was noted between revascularization strategy and HBR status for primary and secondary end points. HBR status is prevalent among older patients with MI, significantly increasing the likelihood of adverse events. Physiology-guided complete revascularization emerges as an effective strategy, in comparison with culprit-only revascularization, for mitigating ischemic adverse events, including cardiovascular death and MI. ClinicalTrials.gov Identifier: NCT03772743.

Invasive and Non-invasive Assessment of Non-culprit Coronary Lesions in Patients with ST-segment Elevation Myocardial Infarction.

The angiographic evidence of coronary multivessel disease (MVD) increases significantly the risk of recurrent ischemic events in patients with ST-segment elevation myocardial infarction (STEMI). Recent evidence suggests that a complete revascularization strategy should be considered the standard of care in these patients and performed for significant non-culprit lesions (NCLs) after careful assessment of the individual risk-benefit ratio. However, the optimal timing and the modality for the assessment of NCLs is not fully standardized. This brief review aims to summarise the management of MVD in patients with STEMI and to provide an overview of the principal techniques used to guide revascularisation in this high-risk clinical setting.

Clinical significance of residual ischaemia in acute myocardial infarction complicated by cardiogenic shock undergoing venoarterial-extracorporeal membrane oxygenation.

Although culprit-only revascularization during the index procedure has been recommended in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS), the reduction in residual ischaemia is also emphasized to improve clinical outcomes. However, few data are available about the significance of residual ischaemia in patients undergoing mechanical circulatory supports. This study aimed to evaluate the effects of residual ischaemia on clinical outcomes in patients with AMI undergoing venoarterial-extracorporeal membrane oxygenation (VA-ECMO). Patients with AMI with multivessel disease who underwent VA-ECMO due to refractory CS were pooled from the RESCUE and SMC-ECMO registries. The included patients were classified into three groups according to residual ischaemia evaluated using the residual Synergy between percutaneous coronary intervention with Taxus and Cardiac Surgery (SYNTAX) score (rSS): rSS = 0, 0 < rSS ≤ 8, and rSS > 8. The primary outcome was 1-year all-cause death. A total of 408 patients were classified into the rSS = 0 (n = 100, 24.5%), 0 < rSS ≤ 8 (n = 136, 33.3%), and rSS > 8 (n = 172, 42.2%) groups. The cumulative incidence of the primary outcome differed significantly according to rSS (33.9 vs. 55.4 vs. 66.1% for rSS = 0, 0 < rSS ≤ 8, and rSS > 8, respectively, overall P < 0.001). In a multivariable model, rSS was independently associated with the risk of 1-year all-cause death (adjusted hazard ratio 1.03, 95% confidence interval 1.01-1.05, P = 0.003). Conversely, the baseline SYNTAX score was not associated with the risk of the primary outcome. Furthermore, when patients were stratified by rSS, the primary outcome did not differ significantly between the high and low delta SYNTAX score groups. In patients with AMI with refractory CS who underwent VA-ECMO, residual ischaemia was associated with an increased risk of 1-year mortality. Future studies are needed to evaluate the efficacy and safety of revascularization strategies to minimize residual ischaemia in patients with CS supported with VA-ECMO. REtrospective and Prospective Observational Study to Investigate Clinical oUtcomes and Efficacy of Left Ventricular Assist Device for Korean Patients With Cardiogenic Shock (RESCUE), NCT02985008.

Cardiogenic shock complicating acute myocardial infarction and multivessel disease: revascularization strategy according to ischemic territory

Introduction and objectivesThe association of revascularization strategy with clinical outcomes according to the ischemic territory of nonculprit lesion has not been documented in patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS). This study aimed to compare outcomes between culprit-only and immediate multivessel percutaneous coronary intervention (PCI) according to ischemic territory in patients with AMI-CS. MethodsA total of 536 patients with AMI-CS and multivessel disease from the SMART-RESCUE registry were categorized according to ischemic territory (nonculprit left main/proximal left anterior descending artery [LM/pLAD] vs culprit LM/pLAD vs no LM/pLAD). The primary outcome was a patient-oriented composite endpoint (POCE) consisting of all-cause death, myocardial infarction, rehospitalization due to heart failure, or repeat revascularization at 1 year. ResultsAmong the total population, 108 patients had nonculprit LM/pLAD, 228 patients had culprit LM/pLAD, and 200 patients had no LM/pLAD, with the risk of POCE being higher in patients with large ischemic territory lesions (53.6% vs 53.4% vs 39.6%; P = .02). Multivessel PCI was associated with a significantly lower risk of POCE compared with culprit-only PCI in patients with nonculprit LM/pLAD (40.7% vs 66.9%; HR, 0.52; 95%CI, 0.29-0.91; P=.02), but not in those with culprit LM/pLAD (P=.46) or no LM/pLAD (P=.47). A significant interaction existed between revascularization strategy and large nonculprit ischemic territory (P=.03). ConclusionsLarge ischemic territory involvement was associated with worse clinical outcomes in patients with AMI-CS and multivessel disease. Immediate multivessel PCI might improve clinical outcomes in patients with a large nonculprit ischemic burden.