Total Occlusion Research Articles

Ultrasound guided percutaneous sharp recanalization for restoring patency from peripheral chronic total occlusions of hemodialysis accesses.

Resistant chronic total occlusion (CTO) lesions present an ongoing challenge for conventional endovascular interventions to restore functional hemodialysis (HD) access. This study endeavors to present a novel endovascular approach utilizing ultrasound (USG)-guided percutaneous sharp recanalization to cross the resistant occlusions and evaluates its effectiveness. This is a multi-center retrospective review of consecutive patients received USG guided sharp recanalization for the treatment of resistant CTO lesions of their HD access between 1st January 2019 and 31st July 2023. Data encompassing patient demographics, access and lesion characteristics, procedural specifics, associated complications, immediate clinical outcomes, and outcomes during follow-up were collected. The procedural technical and clinical success, Kaplan-Meier estimated target lesion (TLPP), access circuit primary patency (ACPP), and index access secondary patency (SP) were reported. During the study period, 22 patients underwent USG-guided sharp recanalization procedures in the three participating centers with median follow-up of 14.5 months. Both the technical and clinical success were 100%. Only two patients experienced minor complications of localized hematoma over the access, with no instances of major complication. Kaplan-Meier estimated TLPP and ACPP at 3-, 6-, and 12 months were 90.9%, 68.2%, 56.8%, and 90.9%, 63.6%, 52.1% respectively. The SP rates were 100%, 95.5%, and 84.1% at 3-, 6-, and 12 months respectively. USG guided percutaneous sharp recanalization is an effective and safe endovascular approach to treat resistant CTO lesions of dysfunctional HD access.

Changes in donor vessel physiology following coronary computed tomography angiography guided chronic total occlusion percutaneous coronary intervention: insights from computed tomography fractional flow reserve and artificial intelligence-guided ischemia model.

Donor vessel fractional flow reserve (FFR) usually increases following successful chronic total occlusion (CTO) percutaneous coronary intervention, as documented by pressure wires. In this case, donor vessel physiology changes were assessed using FFR derived from coronary computed tomography angiography (CCTA) and an artificial Intelligence-guided quantitative CCTA ischemia model in combination with pressure wire-based FFR.

Same-day discharge coronary interventions: How to succeed?

Percutaneous coronary interventions(PCI) are the cornerstone of treatment in patients with coronary artery disease, generating substantial costs for the healthcare system. Considerable improvement in PCI technique, stent technology and antiplatelet therapy led to a complication rate of <5%, a success rate of >95% and lack of routine cardiothoracic surgical support. Thereby, the concept of same-day discharge following PCI has been proposed due to comparable efficacy, safety, and socioeconomic benefits to inpatient PCI. Although single-vessel disease was the primary indication for outpatient (OP) PCI, more complex scenarios such as multivessel disease, left main disease and chronic total occlusions were shown to be feasible and safe in OP setting as well. Currently available data shows that OP PCI leads to cost optimization, increased PCI center capacity, decrease in nosocomial infections rate and increased patient satisfaction, along with good clinical outcomes. Although OP PCI seems promising in a subset of well-prepared and compliant patients without severe comorbidities, there are some challenges to overcome before its routine implementation. To prevent unnecessary hospitalizations and unsafe same-day discharges, interventional cardiology teams should be trained to perform reliable risk-benefit assessments. Standardized forms should be created to obtain informed consent and instruct OP PCI patients and their relatives about postprocedural management. Here, we summarize the available data on OP and inpatient PCI outcomes, discuss the opportunities and challenges of OP PCI and propose a periprocedural patient management checklist, with the goal of facilitating OP PCI implementation in interventional cardiology centers.

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.

Chronic total occlusions and coronary artery bypass grafting outcomes

ObjectiveTo investigate the association between the presence and grafting of chronic total occlusions (CTOs) and coronary artery bypass grafting (CABG) outcomes. MethodsThis was a post hoc analysis of the Randomized Endograft vs Open Prospective (REGROUP) trial, which randomized veterans undergoing isolated on-pump CABG to endoscopic versus open vein harvest (2014-2017). Patients were stratified on the basis of the presence of at least 1 CTO vessel (a 100% occluded coronary lesion for greater than or equal to 3 months) and according to whether all CTO vessels were bypassed. Rates of major cardiac adverse events (MACE) were compared. ResultsAt least 1 CTO was present in 453 of 1149 patients (39.4%). Over a median follow-up of 4.7 years (interquartile range, 3.84-5.45), MACE rates were 23.4% versus 22.2% for the CTO versus no CTO group, respectively (adjusted hazard ratio [aHR], 0.92; 95% confidence interval [CI], 0.70-1.20). MACE rates for patients with complete CTO grafting versus not were 23.1% versus 25.0%, respectively (aHR, 0.95; 95% CI, 0.57-1.57). In patients with right coronary dominance undergoing left anterior descending artery grafting, bypassing a right coronary artery CTO was associated with significantly lower rates of all-cause mortality (aHR, 0.38; 95% CI, 0.17-0.83). ConclusionsIn this REGROUP trial subanalysis, neither CTO presence or complete grafting of CTO vessels was associated with significantly different rates of MACE. However, the finding of possible survival benefit among a subgroup of patients undergoing grafting of a dominant RCA CTO vessel alongside left anterior descending artery grafting warrants additional study.

Significance of Wellens Pattern in Electrocardiogram Revisited – Electrocardiogram and Angiographic Correlation

Abstract Background: In patients with non-ST elevation acute coronary syndrome (NSTEACS), electrocardiogram (ECG) may show deep or biphasic T-wave inversions in precordial leads. Previous reports had linked this ECG change with a lesion in the left anterior descending artery (LAD). However, it is often overlooked in the emergency department and is not included in the major scoring systems for risk stratification of acute coronary syndrome. Objectives: We assessed coronary angiogram (CAG) lesions in patients with biphasic T inversion and/or deep T inversions by ECG. Methods: From July 2019 to November 2021, ECGs of all NSTEACS patients were analyzed and 202 patients who satisfied the criteria were chosen. CAGs were analyzed for the site, severity, and type of lesion. Treatment modality advice was noted. Results: One hundred and ninety-five patients had severe disease in the LAD, of which 178 patients had a lesion proximal to the first septal perforator branch. LAD lesions were discrete in 98, tubular in 68, diffuse in 25, and total occlusion in 11 patients. One hundred and thirty-four patients were advised to have percutaneous coronary intervention (PCI) as treatment. Sixty-three patients with a severe lesion had no recurrent angina and 103 were negative for troponin. Conclusion: 96.5% of patients with NSTEACS and an ECG abnormality had a significant lesion in the LAD. In 88.1% of patients, the lesion was before the first septal perforator branch. Overall, 66.3% of patients were advised to undergo PCI. The sensitivity of troponin in predicting severe lesion was 47.7%, and the sensitivity of recurrent angina was 67.7% only. This ECG abnormality by itself, even without recurrent angina or troponin elevation, should be an indication for invasive evaluation such as CAG.

Outcomes following antegrade-only versus retrograde chronic total occlusion percutaneous coronary intervention: insights from the CCTOP registry.

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can be performed using an antegrade-only (AO) approach or a retrograde approach (RA). Whether an RA carries a higher risk of complications needs further investigation. The Canadian CTO PCI (CCTOP) was a multicenter, prospective, investigator-initiated cohort study conducted at 6 experienced centers across Canada between March 2014 and October 2019. Patients who underwent an RA were compared to AO patients. The primary endpoint was in-hospital major adverse cardiac events (MACE), defined as death, any post-PCI cardiac enzyme elevation, urgent revascularization, and tamponade. A multivariable analysis was performed to control for potential confounders. A total of 1033 patients were included in the study, and an RA was used in 48.4% of the cases. The RA was associated with higher lesions complexity (J-CTO score 2.7 ± 1.1 vs 2.3 ± 1.1, P < .001) and lower technical success (81.2% vs 91.5%, P < .001). The risk of in-hospital MACE was higher with the RA (10.2% vs 4.7%, P < .001), and all deaths occurred in the RA group (0.8% vs 0%, P = .038). In the multivariable model, the RA remained associated with an increased risk of MACE (OR, 2.25; 95% CI, 1.26 to 4.02). Our experience confirms that the RA is associated with an independent increased risk of in-hospital MACE when compared with an AO approach.

"Wire kissing technique" and "externalization and pull-through technique" for treating chronic total occlusion in hemodialysis vascular access: A case report.

The construction and utilization of dependable vascular access are essential for hemodialysis. Despite its importance, complications with vascular access are common, significantly impacting patient morbidity and mortality. This report presents a novel approach to treating chronic total occlusion (CTO) in hemodialysis vascular access using the "wire kissing technique" an "externalization and pull-through technique." An 82-year-old woman on hemodialysis had a thrombotic obstruction in her cephalic vein, which conventional methods failed to address. The wire kissing technique allowed the meeting of antegrade and retrograde wires within the CTO lesion, stabilizing the wire and facilitating balloon passage. The externalization and pull-through technique further enabled the balloon to cross the rigid CTO lesion, successfully completing percutaneous transluminal angioplasty (PTA). Post-procedure ultrasonography showed significant improvements in flow volume and resistance index. These techniques, commonly used in coronary and femoral arteries, have not been previously reported for dialysis vascular access. This case highlights a novel and effective solution for overcoming technical difficulties in crossing CTO lesions, potentially improving outcomes in vascular access for hemodialysis patients.

Intraluminal crossing of infrainguinal SFA chronic total occlusions may offer patency superiority compared to subintimal crossing.

Patency for chronic total occlusions (CTO) of the superficial femoral artery (SFA) after endovascular interventions traditionally demonstrate a low 1-year patency ranging from 40%-60%. The optical coherence tomography (OCT) catheter (Avinger Inc., Redwood City, CA) uses light-based technology imaging to cross Trans-Atlantic Inter-Society Consensus D (TASC D) lesions intraluminally with direct intra-arterial visualization. Insufficient data exist evaluating intraluminal crossing with OCT imaging compared with traditional subintimal techniques. We evaluated outcomes for TASC D lesions crossed intraluminally. A retrospective analysis of patients with SFA TASC D lesions crossed intra-arterially with the OCT catheter imaging. Descriptive statistics evaluated patient characteristics which included patient demographics, Rutherford scores, ABIs, CTA information, lesion categorization, as well as runoff score. Patency at baseline, 30-day, 6-month, and 1-year outcomes were compared using t-tests. Cumulative patency rates were evaluated using Kaplan-Meier analysis. 101 patients underwent elective intervention for SFA TASC D lesions with the OCT catheter. The crossing rate was 78.2%, mean lesion length was 16.2cm, and runoff at the tibial level was 2.2 patent vessels. Mean age and BMI were 64 years and 29kg/m2, respectively. Patient characteristics are male (57%); Caucasian (90%); ever smoking (85%); hypertension (82%), hyperlipidemia (70%), and diabetes (46%). Pre-operative computed tomography demonstrated SFA lesions were predominantly eccentric (91%) with mild to moderate calcification (90%). All underwent PTA, 87% were stented (mean stent length: 186.1mm), mean crossing time was 13.4 min. Pre-operative, 30-day, 6-month, and 1-year post-operative mean Rutherford-Becker scores were 4, 1, 1, and 1, respectively (p < 0.0001). Mean pre-operative ABI was 0.49, compared to 0.84 at 30 days, 0.64 at 6 months, and 0.67 at 1 year (p < .0001). Duplex demonstrated 6- and 12-month primary patency of 89% and 75%; primary-assisted patency was 94% and 84%. The OCT imaging catheter successfully crossed long chronic total occlusions of the SFA using direct intra-arterial imaging. Compared to subintimal techniques, patients had high 1-year primary patency and prolonged symptom improvement with intraluminal crossing. These data suggest that intraluminal crossing of TASC D lesions may be superior to traditional subintimal crossing techniques.

Allergy, infarction, and stress cardiomyopathy: in-depth analysis of a complex clinical case report

Abstract Background Diagnosis of Kounis syndrome, an acute coronary syndrome associated with anaphylactic reactions, is challenging owing to the overlapping symptoms of myocardial ischemia. Takotsubo syndrome (TTS), characterized by stress-induced cardiomyopathy, may share pathophysiological mechanisms with Kounis syndrome and potentially coexist in the same patient. Case Presentation We present a case of a 63-year-old patient who developed an allergic reaction to contrast medium administration, leading to dyspnea and chest pain. Electrocardiography revealed a new-onset left bundle-branch block, and echocardiography indicated wall motion abnormalities with apical ballooning, suggestive of TTS. Coronary angiography displayed a chronic total occlusion of the right coronary artery. Laboratory tests revealed elevated inflammatory markers, supporting the diagnosis of Kounis syndrome and TTS. Conclusion This case highlights the challenges of diagnosing and managing type II Kounis syndrome associated with concurrent TTS. This underscores the need for tailored therapeutic interventions and comprehensive guidelines to address these complex conditions effectively.

Evaluation of novel balloon pulmonary angioplasty using intravascular ultrasound for total occlusion lesions and blood flow in the postprocedural phase after initially unsuccessful procedures.

Outcomes of balloon pulmonary angioplasty (BPA) using intravascular ultrasound (IVUS) with a rounded tip to cross a total occlusion lesion in chronic thromboembolic pulmonary hypertension without passing a conventional guidewire remain unclear. Even in initially unsuccessful cases of total occlusion lesions, improved blood flow may be observed in the postprocedural phase as a result of breaking the thrombosis cap surface. The aim of the study was to verify the initial success of BPA with a new technique using IVUS for total occlusion lesions and to evaluate peripheral blood flow in the postprocedural phase in initially unsuccessful cases. Initial success rate and associated factors were evaluated in 50 total occlusion lesions by attempted IVUS passage using a new technique without a preceding guidewire from August 2016 to February 2024. Peripheral blood flow improvement in the postprocedural phase among initially unsuccessful cases was investigated via subsequent angiographic examination or during follow-up. The success rate was 54%, and the sole determinant of success was the angle of the lesion. Peripheral perfusion improved in 15 of 23 initially unsuccessful cases in the postprocedural phase. Even in the unsuccessful cases, significant improvement in peripheral perfusion occurred in the postprocedural phase in the patients undergoing dilatation with the balloon advanced partway into the total occlusion lesion to confirm intravascular location of the balloon (P = .0257). BPA treatment of total occlusion lesions may improve perfusion in the postprocedural phase even following an initially unsuccessful treatment. Maximizing use of IVUS may provide an adjunctive role in BPA of total occlusion lesions.

A Moderate Blood Flow Restriction Pressure Does Not Affect Maximal Strength or Neuromuscular Responses.

Lubiak, SM, Lawson, JE, Gonzalez Rojas, DH, Proppe, CE, Rivera, PM, Hammer, SM, Trevino, MA, Dinyer-McNeely, TK, Montgomery, TR, Olmos, AA, Sears, KN, Bergstrom, HC, Succi, PJ, Keller, JL, and Hill, EC. A moderate blood flow restriction pressure does not affect maximal strength or neuromuscular responses. J Strength Cond Res XX(X): 000-000, 2024-The purpose of this study was to examine the acute effects of blood flow restriction (BFR) applied at 60% of total arterial occlusion pressure (AOP) on maximal strength. Eleven college-aged female subjects completed two testing sessions of maximal unilateral concentric, isometric, and eccentric leg extension muscle actions performed with and without BFR. Separate 3 (mode [isometric, concentric, eccentric]) × 2 (condition [BFR, no BFR]) × 2 (visit [2, 3]) repeated-measures analysis of variances were used to examine mean differences in maximal strength, neuromuscular function, rating of perceived exertion (RPE), and pain. For maximal strength (collapsed across condition and visit), isometric (128.5 ± 22.7 Nm) and eccentric (114.5 ± 35.4 Nm) strength were greater than concentric maximal strength (89.3 ± 22.3 Nm) (p < 0.001-0.041). Muscle excitation relative (%) to isometric non-BFR was greater during the concentric (108.6 ± 31.5%) than during the eccentric (86.7 ± 29.2%) (p = 0.045) assessments but not different than isometric (93.4 ± 17.9%) (p = 0.109) assessments, collapsed across condition and visit. For RPE, there was an interaction such that RPE was greater during non-BFR (4.3 ± 1.7) than during BFR (3.7 ± 1.7) (p = 0.031) during the maximal concentric strength assessments. Furthermore, during maximal strength assessments performed with BFR, isometric RPE (5.8 ± 1.9) was greater than concentric (3.7 ± 1.7) (p = 0.005) and eccentric (4.6 ± 1.9) (p = 0.009) RPE. Finally, pain was greater during the isometric (2.8 ± 2.1 au) than during the concentric (1.8 ± 1.5 au) (p = 0.016), but not eccentric, maximal strength assessments (2.1 ± 1.6 au) (p = 0.126), collapsed across condition and visit. The application of BFR at 60% AOP did not affect concentric, isometric, or eccentric maximal strength or neuromuscular function. Trainers, clinicians, and researchers can prescribe exercise interventions relative to a restricted (when using a moderate AOP) or nonrestricted assessment of maximal strength.

Mean Pressure Gradient and Fractional Flow Reserve at A Superficial Femoral Artery Dissection after Drug-Coated Balloon Angioplasty.

Residual dissection is a concern in endovascular treatment with a DCB, and there is limited knowledge of hemodynamics at a dissection lesion. Therefore, the objective of this study is to evaluate the mean pressure gradient (MPG) and fractional flow reserve (FFR) at a residual dissection after DCB angioplasty for the superficial femoral artery (SFA). A total of 59 cases with residual SFA dissection treated with DCB angioplasty at a single center were analyzed retrospectively. The dissection was classified into 6 types (A-F). The primary endpoints were MPG and FFR at a residual dissection lesion after DCB angioplasty, using evaluation with a pressure wire. The median lesion length was 70 (40-130) mm with 24% popliteal involvement, and 11 cases (18%) had chronic total occlusion. A completion angiogram revealed dissection of types A (n = 33, 56%), B (n = 18, 31%), C (n = 7, 12%), and D (n = 1, 2%). The median MPGs in type A, B, and C cases were 0 (0-2), 0 (0-4), and 3 (0-6) mmHg, with a significant lower in type C cases than in type A cases (A vs C, P = .021). The median FFRs in type A, B, and C cases of 1.0 (.98-1.00), 1.0 (.96-1.00), and .98 (.95-1.00) did not differ significantly among dissection types (A vs B, P = .86; A vs C, P = .055; B vs C, P = .15). This is the first report of hemodynamics at a SFA dissection. The results suggest that low-grade dissection (types A or B) does not affect MPG and FFR at a SFA lesion. This indicates that a bailout stent may be unnecessary for patients with dissection of types A or B. A further investigation is needed to determine whether a scaffold is required for a SFA lesion with type C dissection.

External validation of the JR-CTO score in retrograde chronic total occlusion intervention: from the PROGRESS-CTO registry.

In complex chronic total occlusion (CTO) percutaneous coronary interventions (PCI), a retrograde crossing strategy is often necessary. Recently, the Japanese retrograde (JR) CTO score was developed using a simple 4-item tool. This score showed a good performance in predicting guidewire crossing failure in patients undergoing primary retrograde CTO PCI. We evaluated the JR-CTO score’s performance in patients treated at 44 centers between 2013 and 2024 as part of the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO). In an independent cohort, although the JR-CTO score showed an association with crossing and technical failure, its predictive ability for both outcomes was modest.

Comparison of Complete Versus Incomplete Percutaneous Revascularization in Patients With Chronic Total Occlusion: A Systematic Review and Meta-Analysis.

The optimal extent of revascularization in patients with chronic total occlusion (CTO) undergoing percutaneous coronary intervention (PCI) remains debated. This meta-analysis aimed to compare the clinical outcomes of complete versus incomplete revascularization in CTO patients. A systematic search of EMBASE, PubMed, and Web of Science was conducted up to July 6, 2024. Studies reporting outcomes in CTO patients undergoing PCI with complete or incomplete revascularization were included. The primary outcomes were major adverse cardiovascular events (MACE), all-cause mortality, and cardiovascular mortality. Eight studies with a total of 7,067 patients (4,854 complete and 2,213 incomplete revascularization) were included. Complete revascularization was associated with a significantly lower risk of MACE (RR: 0.57, 95% CI: 0.43-0.77), all-cause mortality (RR: 0.54, 95% CI: 0.37-0.78), and cardiovascular mortality (RR: 0.46, 95% CI: 0.29-0.75) compared to incomplete revascularization. There was no significant difference in the risk of recurrent myocardial infarction between the two groups (RR: 0.60, 95% CI: 0.20-1.80). In patients with CTO undergoing PCI, complete revascularization is associated with significantly better clinical outcomes, including lower risks of MACE, all-cause mortality, and cardiovascular mortality, compared to incomplete revascularization. These findings suggest that achieving complete revascularization should be prioritized when feasible in CTO patients.

Peripheral artery disease in chronic total occlusion percutaneous coronary intervention.

The impact of peripheral artery disease (PAD) on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is not well studied. We analyzed the association of PAD with CTO-PCI outcomes using data from the PROGRESS-CTO registry of procedures performed at 47 centers between 2012 and 2023. The prevalence of PAD among 12 961 patients who underwent CTO PCI during the study period was 13.9% (1802). PAD patients were older, more likely to be current smokers, and had higher rates of dyslipidemia, diabetes, cerebrovascular disease, hypertension, prior myocardial infarction, PCI, and coronary artery bypass graft surgery. Their PROGRESS-CTO (1.35 vs 1.22; P < .001) and J-CTO (2.63 vs 2.33; P < .001) scores were higher, lesion length was longer, and angiographic characteristics were more complex. Their access site was more likely to be bifemoral (33.6% vs 30.9%; P = .024) compared with patients with no PAD. Technical (82.9% vs 87.7%; P < .001) and procedural (80.5% vs 86.6%; P < .001) success rates were lower in patients with PAD, while the incidence of major adverse cardiovascular events (MACE) was higher (3.1% vs 1.8%; P < .001), with higher mortality (0.8% vs 0.4%; P = .034), acute myocardial infarction rate (0.9% vs 0.4%; P = .010), and perforations rate (6.6% vs 4.5%; P < .001). In multivariable analysis, PAD was associated with higher MACE (odds ratio [OR]: 1.53; 95% CI, 1.01-2.26; P = .038) and lower technical success (OR: 0.82; 95% CI, 0.69-0.99; P = .039). PAD patients undergoing CTO PCI have higher comorbidity burden, more complex CTOs, higher MACE, and lower technical success.

Successful Extracorporeal Cardiopulmonary Resuscitation Despite Aortic Occlusion.

We present the case of a 62-year-old man with severe coronary artery disease who presented to the hospital in refractory ventricular fibrillation cardiac arrest. He showed signs of life despite prolonged resuscitation. We thus decided to initiate extracorporeal cardiopulmonary resuscitation (ECPR). The patient had a known total occlusion of his infrarenal aorta that had been surgically bypassed with a bifemoral-axillary graft. We successfully initiated ECPR via the surgical graft, establishing blood flow to the central circulation through the axillary artery in a peripheral configuration while ensuring blood flow to the left leg via the femoral-femoral graft. The patient was extubated neurologically intact the following day and subsequently underwent coronary artery bypass graft surgery while on extracorporeal membrane oxygenation (ECMO) support. He was subsequently weaned off inotropic support and decannulated from ECMO. He was discharged home neurologically intact and independent in his activities of daily living. This case demonstrates that cannulation for ECPR via a surgical vascular graft is possible and that a total occlusion of the infrarenal aorta in the presence of a surgical bypass is not an absolute contraindication to ECMO.

Initial Experience with the Derivo 2Heal Flow Diverter under Standard or Reduced-Dose Single Antiplatelet Therapy.

Flow diverters with surface modifications or coatings have been recently introduced to clinical practice with the expectation that they can reduce the rate of thromboembolic complications and residual aneurysms. The purpose of this study is to evaluate the utility of the Derivo 2Heal (D2H) device, a new fibrin and heparin-coated flow diverter. Patients treated by a single operator by using the D2H were retrospectively evaluated for demographic data, aneurysm characteristics, procedural variables, and follow-up data. All patients were treated by using a single D2H, monitored by platelet function testing and kept under single antiplatelet therapy with regular or half-dose clopidogrel or prasugrel after the procedure. Twenty patients with 26 aneurysms were treated. Three presented acutely with subarachnoid hemorrhage. Adjunctive devices were used in 6 patients. There were no technical failures and 2 periprocedural self-limited nonthrombotic minor adverse events. During follow-up, 1 of the acutely ruptured aneurysms reruptured, and 1 patient had a visual TIA. All patients were doing well clinically (19 with mRS of 0 and 1 with 1) at the last follow-up after discharge. The rates of total occlusion on very early angiographic (MRA/CTA or DSA, mean: 2.4 months), DSA (mean: 5.8 months), and midterm angiographic (mean: 14.5 months) follow-up for all versus uncoiled aneurysms were 68% versus 70%, 77.8% versus 90.0%, and 91.7% versus 90.1%, respectively. The absence of permanent neurologic deficits in the periprocedural period and favorable occlusion rates in this preliminary study suggest that the novel coating comprising fibrin and heparin may have the potential to increase the safety and efficacy of flow diversion and needs to be further studied by comparing the D2H device with its bare counterpart and other coated or surface-modified flow diverters.

Delineation of acute coronary syndromes: the acute total occlusion vs. ST-segment paradigm.

Delineation of acute coronary syndromes: the acute total occlusion vs. ST-segment paradigm.

Establishing a Classification System for Predicting Flow-Limiting Dissection After Balloon Angioplasty Using Explainable Machine-Learning Models: A Multicenter Retrospective Cohort Study.

Percutaneous transluminal angioplasty (PTA) is the primary method for treatment in peripheral arterial disease. However, some patients experience flow-limiting dissection (FLD) after PTA. We utilized machine learning and SHapley Additive exPlanations to identify and optimize a classification system to predict FLD after PTA. This was a multi-center, retrospective, cohort study. The cohort comprised 407 patients who underwent treatment of the femoropopliteal (FP) arteries in 3 institutions between January 2021 and June 2023. Preoperative computed tomography angiography images were evaluated to identify FP artery grading, chronic total occlusion (CTO), and vessel calcification (peripheral artery calcium scoring system [PACSS]). After PTA, FLD was identified by angiography. We trained and validated 6 machine-learning models to estimate FLD occurrence after PTA, and the best model was selected. Then, the sum of the Shapley values for each of CTO, FP, and PACSS was calculated for each patient to produce the CTO-FP-PACSS value. The CTO-FP-PACSS classification system was used to classify the patients into classes 1 to 4. Univariate and multivariate analyses were performed to validate the effectiveness of the CTO-FP-PACSS classification system for predicting FLD. Overall, 407 patients were analyzed, comprising 189 patients with FLD and 218 patients without FLD. Differences in sex (71% males vs 54% males, p<0.001), CTO (72% vs 43%, p<0.001), FP (3.26±0.94 vs 2.66±1.06, p<0.001), and PACSS (2.39±1.40 vs 1.74±1.35, p<0.001) were observed between patients with and without FLD, respectively. The random forest model demonstrated the best performance (validation set area under the curve: 0.82). SHapley Additive exPlanations revealed CTO, PACSS, and FP as the 3 most influential FLD predictors, and the univariate and multivariate analyses confirmed CTO-FP-PACSS classification as an independent FLD predictor (multivariate hazard ratio 4.13; p<0.001). The CTO-FP-PACSS classification system accurately predicted FLD after PTA. This user-friendly system may guide surgical decision-making, helping choose between PTA and additional devices to reduce FLD in FP artery treatment. We utilised machine-learning techniques in conjunction with SHapley Additive exPlanations to develop a clinical classification system that predicts the probability of flow-limiting dissection (FLD) after plain old balloon angioplasty. This classification system categorises lesions into Classes 1-4 based on three factors: chronic total occlusion, femoropopliteal grading, and peripheral artery calcium scoring. Each class demonstrated a different probability of developing FLD. This classification system may be valuable for surgeons in their clinical practice, as well as serving as a source of inspiration for other researchers.