Severe Calcified Lesions Research Articles

Impact of severe lesion calcification on clinical outcome of patients with stable angina, treated with newer generation permanent polymer-coated drug-eluting stents: A patient-level pooled analysis from TWENTE and DUTCH PEERS (TWENTE II)

The outcome of percutaneous coronary intervention with newer generation permanent polymer-coated drug-eluting stents (DES) in patients with severely calcified lesions is greatly unknown. We assessed the impact of severe lesion calcification on clinical outcome in patients with stable angina who underwent percutaneous coronary intervention with newer generation DES. TWENTE and DUTCH PEERS randomized trials enrolled 1423 patients with stable angina, who were categorized into patients with versus without severe target lesion calcification. A patient-level pooled analysis assessed clinical outcome, including target vessel failure (TVF), a composite of cardiac death, target vessel-related myocardial infarction, or target vessel revascularization (TVR). Patients with severe calcification (n = 342) were older (66.6 ± 9.1 vs 64.2 ± 9.8 years, P < .001) and had more diabetes (25.7% vs 20.4%, P = .04) than other patients (n = 1081). Patients with calcified lesions had higher rates of TVF (16.4% vs 9.8%, pLogrank = .001), cardiac death (4.4% vs 1.5%, P = .03), target vessel myocardial infarction (7.6% vs 3.4%, P = .001), and definite stent thrombosis (1.8% vs 0.4%, P = .02). Multivariate analysis demonstrated that severe calcification was an independent risk factor of 2-year TVF (HR 1.42, 95% CI: 1.02-1.99, pLogrank = .04); landmark analysis showed that this was based on a difference during the first year (periprocedural: 5.8% vs. 3.1%, pLogrank = .02; first year: 7.5% vs. 3.8%, pLogrank = .007; second year: 4.1% vs. 3.3%, pLogrank = .54). In patients with stable angina, severe target lesion calcification is associated with an increased risk of adverse cardiovascular events following treatment with newer generation permanent polymer-coated DES. This increase in risk is restricted to the first year of follow-up, which is an encouraging finding.

Planned versus provisional rotational atherectomy for severe calcified coronary lesions: Insights From the ROTATE multi-center registry.

We aimed to investigate procedural feasibility and outcomes associated with planned rotational atherectomy (RA) for severely calcified coronary lesions. Limited data are available addressing the benefits of planned RA compared to provisional RA. Between 2002 and 2013, all patients with calcified lesions treated by RA were enrolled. Of these, patients treated with planned RA (358 patients) were compared to those treated with provisional RA (309 patients). In-hospital major adverse cardiovascular events (MACE) were tended to be better in the planned RA group (unadjusted OR: 0.76; 95% CI: 0.44-1.31, P = 0.32, and adjusted OR: 0.59; 95% CI: 0.33-1.05, P = 0.07). The number of pre-dilation balloon catheters was significantly lower in the planned RA group (1.17 ± 0.60 vs. 1.47 ± 0.76, P < 0.001). Procedure time, fluoroscopy time, and contrast volume used were all significantly reduced in the planned RA group compared to the provisional RA group (procedure time; 65.2 ± 36.8min vs. 84.4 ± 43.1min, P < 0.001, fluoroscopy time; 33.1 ± 22.9min vs. 51.2 ± 29.6min, P < 0.001, and contrast volume; 232.9 ± 141.6ml vs. 302.9 ± 150.3ml, P < 0.001). The incidence of MACE at 1-year was significantly higher amongst the unadjusted population, whereas the difference was less marked between groups after propensity-score adjustment (unadjusted HR: 1.78; 95% CI: 1.16-2.74, P = 0.01, and adjusted HR: 1.44; 95% CI: 0.92-2.26, P = 0.11). Planned RA appears to be safe and was associated with a reduction in procedural and fluoroscopy times, contrast volume, and the number of pre-dilation balloon catheters used. If there is a strong likelihood of requiring RA for the treatment of severely calcified lesions, operators should have a low threshold for adopting a planned RA strategy. © 2016 Wiley Periodicals, Inc.

Excimer Laser Coronary Angioplasty for the treatment of under-expanded coronary stent newly deployed in severe calcified lesion : The first case report in Japan

Excimer Laser Coronary Angioplasty for the treatment of under-expanded coronary stent newly deployed in severe calcified lesion : The first case report in Japan

Low-dose adjunctive cilostazol in patients with complex lesions undergoing percutaneous coronary intervention.

Patients with complex coronary lesions undergoing percutaneous coronary intervention (PCI) have more major adverse cardiac events (MACE) than do those with simpler cases. Therefore, intensive antiplatelet therapy might be needed in these patients. A total of 127 patients with complex lesions undergoing PCI in the Second Hospital of Tianjin Medical University from October 2012 to April 2014 were randomized to receive either dual (aspirin plus clopidogrel, DAPT, n=66), or triple antiplatelet therapy (aspirin plus clopidogrel plus cilostazol; TAPT, n=61). Patients in the TAPT group received low-dose cilostazol (100mg loading, followed with 50mg twice per day) for 3-6months. The primary endpoint was composite MACE. The complex coronary target lesions were defined as at least one of the following: left main disease; severe 3-vessel disease; chronic total occlusion lesions; true bifurcation lesion; ostial lesions; severe calcified lesions; and highly thrombotic lesions. The two groups had similar baseline clinical and angiographic characteristics. One-year clinical outcomes showed that the TAPT group had significantly lower incidences of myocardial infarction (1.6% vs 13.6%, P=0.018) and MACE (1.6% vs 16.7%, P=0.004) than DAPT group. The DAPT group had two cases of stent thrombosis, while the TAPT group did not. Furthermore, adjunctive low-dose cilostazol didn't significantly increase the incidence of bleeding events (26.2% vs 19.7%, P=0.381) regardless of major (4.9% vs 4.5%, P=0.921) or minor (21.3% vs 15.2%, P=0.368) bleeding events. In conclusion, low-dose adjunctive cilostazol seems superior to dual antiplatelet therapy in reducing recurrent ischemic events in patients with complex coronary lesions and the two test groups have a similar incidence of bleeding events.

Perioperative nursing care of 30 patients treated with percutaneous coronary rotational atherectomy

Objective To discuss the importance and methods of nursing care in patients treated with coronary rotational atherectomy combined with percutaneous coronary intervention (PCI). Methods Totals of 30 patients treated with coronary rotational atherectomy from June 2012 to December 2013 were retrospectively analyzed. Results All of 30 patients had multi-vessel complex coronary artery lesions, and most of them had 1 to 2 vessels with chronic total occlusion companied with severe calcification which could be seen clearly under X ray. Rotational atherectomy was performed in the left anterior descending artery among 28 patients, and in the right coronary artery between 2 patients. Stents were placed through the calcified lesions post rotational atherectomy. Under intensive nursing care, 11 patients had different complications but without any death. Conclusions Rotational atherectomy is performed in patients with severe calcified coronary lesions, which always combined with complex lesions and hard to deal with. So it is reasonable that the procedure should be performed in big heart centers and by experienced doctors. Nurses in the lab should be familiar with the operation devices and have the experience in emergency events and complications. Intensive nursing care can ensure the safety and success of the operation. Key words: Coronary rotational atherectomy; Perioperative nursing; Nursing coordinate

TCTAP C-078 Successful Recanalization of Long Severe Calcified RCA CTO Lesion Using Retrograde Approach in a Hemodialysis Patient

TCTAP C-078 Successful Recanalization of Long Severe Calcified RCA CTO Lesion Using Retrograde Approach in a Hemodialysis Patient

TCTAP C-191 Successful Endovascular Therapy of Severe Calcified Lesion in Coronary Artery Disease and Peripheral Artery Disease

TCTAP C-191 Successful Endovascular Therapy of Severe Calcified Lesion in Coronary Artery Disease and Peripheral Artery Disease

Abstract 16117: Clinical and Angiographic Scoring System to Predict the Probability of Successful First Attempt PCI in Patients With Coronary Chronic Total Occlusion

Background: Coronary chronic total occlusion (CTO) remains the lesion subtype in which angioplasty has the lowest success rate. Although many independent predictors of final procedural success have been identified, no studies have yet analyzed their combined impact on final procedural outcome. In order to obtain a scoring model to predict final CTO-PCI success, we analyzed a population of patients who underwent a percutaneous coronary intervention for a chronic total occlusion (CTO-PCI) at our institution. Methods: We included 1,657 consecutive patients who underwent a first-attempt CTO-PCI at ICPS from January 2004 to December 2013. Clinical, angiographic procedural and technical characteristics were prospectively collected. A backword stepwise logistic regression including clinical and angiographic variables was used to create a multivariable model of independent predictors of CTO-PCI success. Independent variables were then scored. Results: Overall procedural success rate was 72.5%. The backward logistic regression model showed that two clinical variables: previous CABG (OR2.28, 95%CI1.53-3.4), previous MI (1.56, 95%CI 1.19-2.0) and four angiographic variables: severe lesion calcification (OR 2.95, 95%CI 2.08-4.2), longer CTOs (≥20 mm: OR 2.04, 95%CI 1.62-2.58), non LAD location (OR 1.58, 95%CI 1.21-2-06) and blunt stump morphology (OR 1.57, 95%CI 1.24-1.99) were independent predictors of CTO-PCI failure. The OR values of these variables were used to create the Clinical and Angiographic Scoring System (CL-SCORE). CL-Score values of 0, 1-3, &gt;3 and ≤5 and &gt;5 indentified subgroups at high (class 0), intermediate (class 1), low (class 2), very low (class 3) probability of CTO-PCI success (80.3%, 64.2%, 49.4 and 29% respectively; p&lt;0,0001) Figure 1. The probability of CTO-PCI failure increased significantly from class 0 to class 1 (19.7% to 35.8%, p&lt;0.0001), from class 1 to class 2 (35.8 to 50.6 p&lt;0.0001) and from class 2 to class 3 (50.6% to 81% p=0.001), respectively. Conclusion: This clinical and angiographic score strongly predicted the final CTO-PCI procedural outcome of our study population. Further studies are required to validate this model.

Prognostic implications of severe coronary calcification in patients undergoing coronary artery bypass surgery: an analysis of the SYNTAX study.

To investigate the prognostic implications of the presence of severe lesion calcification in patients undergoing coronary artery bypass graft (CABG) operation. There is robust evidence that lesion calcification is a predictor of worse prognosis in patients undergoing percutaneous coronary intervention; however, there is limited data about the prognostic implication of lesion calcium in patients treated with CABG. We retrospectively analyzed data from 1,545 patients who underwent CABG and were recruited in the SYNTAX study and CABG registry. Two experts reviewed the angiographic data and classified patients in two groups: those with severely calcified coronary arteries and those without severe lesion calcification. Clinical outcomes at 5-year follow-up were collected and compared in the two groups. One out of three patients exhibited severe lesion calcification (n = 588). Patients with calcified coronaries had an increased mortality at 5-year follow-up (17.1% vs. 9.9%, P < 0.001) and a higher event rate of death-myocardial infarction (MI) compared with those without (19.4% vs. 13.2%, P = 0.003), but there was no statistical significant difference between the two groups for major adverse cardiovascular events (MACE, 26.8% vs. 21.8%, P = 0.057). In multivariate Cox regression analysis severe lesion calcification was an independent predictor of an increased all-cause mortality (hazard ratio: 1.39, 95% confidence interval: 1.02-1.89; P = 0.037) but it was not an independent predictor of the combined end-points death-MI or MACE. Severe lesion calcification is associated with an increased mortality in patients undergoing CABG, but it is not an independent predictor of death-MI or MACE. This paradox can be attributed to the fact that CABG allows perfusion of the healthy coronaries bypassing the diseased arteries and thus it minimizes the risk of coronary events due to progressive atherosclerosis.

Prognostic implications of coronary calcification in patients with obstructive coronary artery disease treated by percutaneous coronary intervention: a patient-level pooled analysis of 7 contemporary stent trials

ObjectiveTo investigate the long-term prognostic implications of coronary calcification in patients undergoing percutaneous coronary intervention for obstructive coronary artery disease.MethodsPatient-level data from 6296 patients enrolled in seven clinical drug-eluting stents...

CLINICAL OUTCOMES OF ROTATIONAL ATHERECTOMY FOLLOWED BY FIRST-GENERATION DRUG-ELUTING STENT IMPLANTATION VERSUS SECOND-GENERATION DRUG-ELUTING STENT IMPLANTATION

Rotational atherectomy (RA) followed by first-generation drug-eluting stent (DES) have favorable result compared with bare-metal stent in severe calcified lesion. However, the efficacy of second-generation DES implantation after RA remains unclear. Between April 2008 and December 2012, 116 patients

Initial Success Rate of Percutaneous Coronary Intervention for Chronic Total Occlusion in a Native Coronary Artery Is Decreased in Patients Who Underwent Previous Coronary Artery Bypass Graft Surgery

This study sought to compare the initial success rate of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in a native coronary artery (NCA) in patients with and without previous coronary artery bypass grafting (CABG) and to assess predictive factors. Landmark novel wiring techniques for CTO-PCI have contributed to improvement in the initial success of CTO-PCI. However, challenges persist in CTO-PCI in NCA in pCABG patients. Patients who underwent CTO-PCI in an NCA were selected and classified into 2 groups: pCABG (206 PCIs in 153 patients) and nCABG (1,431 PCIs in 1,139 patients). CTO was located more often in the left anterior descending artery (p = 0.0003), and severe calcified lesions were observed more frequently in the pCABG group (p < 0.0001). Although the retrograde attempt was tried more frequently in the pCABG group, the CTO-PCI success rate was significantly lower in the pCABG patients than in the nCABG patients (71% vs. 83%). Longer procedural time and greater radiation exposure were needed in the pCABG patients. Logistic regression analysis among the pCABG patients revealed that intravascular ultrasound use and parallel wiring were positive factors, and lesion tortuosity was a negative factor. The initial success rate of CTO-PCI of an NCA in the pCABG group was significantly decreased compared with that in the nCABG group. Anatomic complexity and unstable hemodynamic state were unfavorable conditions. This study reveals that the issues to be overcome are lying with CTO revascularization in an NCA in pCABG patients.

Long term outcome after rotablation for bail-out in severely calcified coronary lesions

Background: Rotablation is mostly used to enable stent implantation in severely calcified coronary lesions. There is a lack of long term data regarding the outcome after rotablation in severe calcified lesions with either failed balloon crossing or in case of failed balloon expansion. Methods: To assess the 1-year outcome of rotabloation in this setting, we analyzed 210 consecutive patients undergoing rotablation required for preparation of stent implantation in severely calcified coronary lesions. Complete 1-year follow-up data was available for all patients. Results: Patients were on average 71 years old. The reasons for rotablation were in 42% inability to cross the lesion with the balloon and in 58% inability to expand the balloon in severe calcified lesion. Sixteen % of patients needed rotablation during PCI for acute coronary syndrom (ACS). The procedural success was 99,5%. Drug eluting stents (DES) were implanted in 88%. The majority of patients received initial rotablation with 1,5 mm burr. Elevated troponin a day post rotablation was measured in 38% of patients and elevated creatine kinase (CK) in 12%. Target vessel revascularisation (TVR) after 1 year post index PCI was performed in 13,2% of patients. The combined endpoint of death and myocardial infarction (MI) as marker for safety was reached by 14,4%. Death during 1-year follow-up occurred in 10,4%. Conclusions: Rotablation as a part of lesion preparation for stent implantation in otherwise untreatable severe calcified coronary lesions is associated with high procedural success rate. One-year event rates, however, indicate that patients in need for bail-out rotablation represent a high risk subset.

An Unusual Case of Single Coronary Artery

An 81-year-old man with a history of hypertension, dyslipidemia, and diabetes consulted for progressive angina. Ergometry findings indicated a poor prognosis. Coronary angiography showed a severe lesion in the dominant circumflex artery (CX) at the bifurcation with the obtuse marginal artery. A severe calcified lesion was seen in the middle portion of the left anterior descending artery (LAD) at the bifurcation with an anomalous artery that ran anterior to the right ventricular outflow tract and reached the coronary sulcus, where it continued in the normal course of the right coronary artery (RCA) (Figs. 1 and 2). Angiography showed agenesis of the right coronary ostium. Myocardial revascularization surgery was undertaken. Anomalous coronary arteries are seen in 0.3% to 1.3% of coronary angiography studies. Single coronary artery is uncommon (0.0024%-0.066%). Origin of the RCA from the LAD is extremely rare. Only 8 cases of RCA arising from the middle LAD have been described, and this is the first published case in Spain. Single coronary artery does not usually have clinical repercussions, although it can present with angina or sudden death. An association with an increase in arteriosclerotic disease has been hypothesized. Computed tomography angiography is an aid to the diagnosis of coronary anomalies. It is not absolutely necessary if management is clarified by angiography. In patients older than 30 years with ischemic symptoms, the treatment is similar to that used in other patients because of the low risk of sudden death. In young patients with an interarterial course, a more aggressive management is recommended, and surgical treatment can be considered.

Directional atherectomy of a heavy calcified axillary artery stenosis inducing critical hand ischemia

The presence of a severe calcified peripheral artery lesion is responsible for a poor response to balloon dilation, due to significant acute vessel recoil and frequent flow-limiting dissections requiring stent implantation. This possibility could be associated with very high compression and/or fracture rates particularly in cases of lesion located at the mobile joints. In this setting directional atherectomy offers the theoretical advantages of eliminating stretch injury on arterial walls and reducing the restenosis rate by direct plaque excision. In this report, we present a case of critical hand ischemia due to a heavily calcified axillary artery lesion managed by directional atherectomy and balloon angioplasty followed by immediate angiographic success and sustained clinical benefit up to 3years of follow-up.

Sirolimus-eluting stents versus paclitaxel-eluting stents for coronary intervention in patients with renal failure on hemodialysis

Patients undergoing chronic hemodialysis (HD) are at high risk of restenosis and cardiac events after percutaneous coronary intervention (PCI). This study compared the clinical efficacy of sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) in patients undergoing HD. Between June 2004 and January 2010, the clinical outcomes of 41 consecutive patients on HD who underwent PCI with SES (62 lesions) were compared with those of 38 consecutive patients on HD who underwent PCI with PES (54 lesions). Patient and lesion characteristics were similar between both groups. The target lesion revascularization (TLR) (SES 36.6% vs. PES 15.8%; P=0.037) was significantly higher with SES (36.6%) than with PES (15.8%) (P=0.037), particularly in the context of severe calcified lesions that required rotational atherectomy (SES 72.7% vs. PES 16.7%; P=0.0067). However, 1year after PCI, there was no difference between the two groups in all-cause death, myocardial infarction or major adverse cardiac events. Patients undergoing HD are at a high risk of restenosis after PCI, even when using a drug-eluting stent. The TLR was higher with SES than with PES, particularly when used for severe calcified lesions that required rotational atherectomy.

Influence of additional ballooning with a dual wire balloon after a rotational atherectomy to expand drug-eluting stent for calcified lesions

Calcified lesions have been known as a cause of stent underexpansion which increases the risk of thrombosis and in-stent restenosis. A dual wire balloon has been introduced to create a focal stress pattern in a localized region of the calcification. We evaluated the combination therapy using a dual wire balloon after rotational atherectomy (RA) for heavily calcified lesions. Of 21 consecutive patients with severe calcified lesions, 10 patients were treated with a dual wire balloon after RA, and 11 patients were treated with RA alone or, RA plus the conventional balloon. Finally, drugeluting stents (DES) were implanted in all cases. Baseline characteristics, lesion characteristics, and postdilatation procedures were not different between two groups. Before implantation of DES, a dual wire balloon enabled adequate dilatation with significantly more cracks than RA (1.8 ± 0.4 cracks vs. 1.2 ± 0.6 cracks, P = 0.02). The minimal stent cross sectional area (CSA) and the stent expansion ratio were similar in both groups. However, the symmetrical expansion was significantly accomplished in patients with a dual wire balloon compared to those without it (mean ratio calculated by dividing the shortest diameter by the longest diameter at the site of the minimal stent CSA was 0.83 ± 0.05 vs. 0.76 ± 0.07, P = 0.02). Moreover, no in-stent restenosis was observed in patients treated with a dual wire balloon at follow-up. In conclusion, by using a dual wire balloon after RA, adequate stent expansion and follow-up results were accomplished. This combination therapy is safety and feasible procedure for the treatment of severe calcified lesions.

AS-141: Efficacy of the Corsair Penetration Catheter for Severe Calcified Lesions or Chronic Total Occlusions in Coronary Artery Disease

The presence of severe calcified lesions or chronic total occlusions (CTO) may limit the success of percutaneous coronary interventions (PCI). A novel penetration catheter, the Corsair (Asahi Intecc, Japan) could improve the success rate of these PCIs, although low-profile balloons or other microcatheters fail to penetrate the lesions. This study aimed to evaluate the feasibility of the Corsair penetration catheter in complex PCIs for severe coronary artery diseases.

AS-086 Optical Coherence Tomography Analysis of Characteristics of In-Stent Neointima in Severe Calcified Lesion

Backgrounds: Severe calcified coronary lesion is one of the challenging lesions for perctaneous coronary interventions and the characteristics of in-stent restenosis patterns in calcified lesions have not been well documented. Therefore, we investigated this issue using optical coherence tomography (OCT).

MULTIDETECTOR COMPUTED TOMOGRAPHY MYOCARDIAL PERFUSION IMAGING AND FRACTIONAL FLOW RESERVE IN PATIENTS WITH CALCIFIED CORONARY LESIONS

Although computed tomography (CT) angiography for the non-invasive detection of coronary artery disease has been established, the presence of severe calcified lesions remains a limitation. The aim of the present study is to evaluate the usefulness of multidetector CT myocardial perfusion imaging to