Search

BACKGROUND: Techniques for provisional and dual-stent left main bifurcation stenting require optimization.AIM: To identify technical variables influencing procedural outcomes and periprocedural myocardial infarction following left main bifurcation intervention.METHODS: Procedural and outcome data were analyzed in 438 patients from the per-protocol cohort of the European Bifurcation Club Left Main Trial (EBC MAIN). These patients were randomized to the provisional strategy or a compatible dual-stent extension (T, T-and-protrude, or culotte).RESULTS: Mean age was 71 years and 37.4% presented with an acute coronary syndrome. Transient reduction of side vessel thrombolysis in myocardial infarction flow occurred after initial stent placement in 5% of procedures but was not associated with periprocedural myocardial infarction. Failure to rewire a jailed vessel during any strategy was more common when jailed wires were not used (9.5% vs. 2.5%, odds ratio [OR]: 6.4, p = 0.002). In the provisional cohort, the use of the proximal optimization technique was associated with less subsequent side vessel intervention (23.3% vs. 41.9%, OR: 0.4, p = 0.048). Side vessel stenting was predominantly required for dissection, which occurred more often following side vessel preparation (15.3% vs. 4.4%, OR: 3.1, p = 0.040). Exclusive use of noncompliant balloons for kissing balloon inflation was associated with reduced need for side vessel intervention in provisional cases (20.5% vs. 38.5%, OR: 0.4, p = 0.013), and a reduced risk of periprocedural myocardial infarction across all strategies (2.9% vs. 7.7%, OR: 0.2, p = 0.020).CONCLUSION: When performing provisional or compatible dual-stent left main bifurcation intervention, jailed wire use is associated with successful jailed vessel rewiring. Side vessel preparation in provisional patients is linked to increased side vessel dissection requiring stenting. Use of the proximal optimization technique may reduce the need for additional side vessel intervention, and noncompliant balloon use for kissing balloon inflation is associated with a reduction in both side vessel stenting and periprocedural myocardial infarction.CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02497014.

BACKGROUND In patients at high bleeding risk (HBR), the LEADERS FREE (LF) trial established the safety and efficacy of a polymer-free drug coated (Biolimus-A9) stainless steel stent (SS-DCS) with 30 days of dual antiplatelet treatment (DAPT). In LEADERS FREE III, we studied a new cobalt-chromium thin-strut stent (CoCr-DCS) in HBR patients. METHODS The CoCr-DCS shares all of the design features of the SS-DCS but has a CoCr stent platform with strut thickness of 84-88 μm. The primary safety endpoint was a composite of cardiac death, myocardial infarction (MI), and definite/probable stent thrombosis. The primary efficacy endpoint was clinically indicated target lesion revascularization. Outcomes were compared to those of LF (non-inferiority to SS-DCS for safety and superiority to SS-BMS for efficacy). Additional propensity-matched comparisons were performed to account for baseline differences. RESULTS We recruited 401 HBR patients using identical criteria to the LF trial. At 1 year, the primary safety endpoint was reached by 31/401 (8.0%) of patients treated with the CoCr-DCS versus 35/401 (8.9%) for the propensity-matched cohort (HR: 0.89, [0.55-1.44], p

Objectives: We investigated the impact of total stent length (TSL) and average nominal stent diameter (ASD) on 10-year mortality after percutaneous coronary intervention (PCI) in the SYNTAXES trial. Background: TSL and ASD in patients treated with PCI are associated with major adverse cardiovascular events. However, the treatment effect of PCI with extensive and/or small stenting as compared with coronary artery bypass grafting (CABG) for complex coronary artery disease has not been fully evaluated. Methods: Impacts on mortality of extensive stenting defined as TSL >100 mm and small stenting as ASD

Objectives: To describe the incidence, predictors, and clinical impact of permanent pacemaker insertion (PPI) following transcatheter aortic valve replacement (TAVR) in women. Background: Data on pacemaker insertion complicating TAVR in women are scarce. Methods: The Women's International Transcatheter Aortic Valve implantation (WIN-TAVI) is a prospective registry evaluating the safety and efficacy of TAVR in women. We included patients without preprocedural pacemakers and divided them into two groups: (1) PPI and (2) no-PPI. We identified PPI predictors using logistic regression and studied its clinical impact on the Valve Academic Research Consortium (VARC)-2 efficacy and safety endpoints. Results: Out of 1019 patients, 922 were included in the analysis. Post-TAVR PPI occurred in 132 (14.3%) patients. Clinical and procedural characteristics were similar in both groups. Pre-existing right bundle branch block (RBBB) was associated with a high risk of post-TAVR PPI (OR 3.62, 95% CI 1.85–7.06, p < 0.001), while implantation of balloon-expandable prosthesis was associated with a lower risk (OR 0.47, 95% CI 0.30–0.74, p < 0.001). Post-TAVR PPI prolonged in-hospital stay by a median of 2 days (11 [9–16] days in PPI vs. 9 [7–14] days in no-PPI, p = 0.005), yet risks of VARC-2 efficacy and safety endpoints at 1 year were similar in both groups (adjHR 0.95, 95% CI 0.60–1.52, p = 0.84 and adjHR 1.22, 95% CI 0.83–1.79, p = 0.31, respectively). Conclusion: Pacemaker implantation following TAVR is frequent among women and is associated with pre-existing RBBB and valve type. PPI prolongs hospital stay, albeit without any significant impact on 1-year outcomes.

Objectives To assess long-term safety and efficacy of the Xposition S self-apposing stent in the treatment of unprotected left main coronary artery (ULMCA) disease. Background Percutaneous intervention with stents has emerged as a valid alternative to surgical revascularization to treat ULMCA disease. Conventional balloon-expandable stents face technical challenges, particularly in large left main diameter requiring extensive optimization and side branch access in distal bifurcation. Xposition S allows for optimal apposition, bridging diameter differences, and allows expansion to vessel diameters up to 6.0 mm. Methods Between June 2016 and July 2017, 205 patients were enrolled in this international, prospective, multicenter registry. Patients with SYNTAX score ≥ 33 or recent STEMI were excluded. IVUS during procedure was performed in a prespecified subgroup of 50 patients. The primary clinical endpoint was 12 months Target lesion failure (TLF) and the primary efficacy endpoint was angiographic success. Results Distal left main bifurcation was involved in 92.7%, treated with provisional approach in most cases (79.4%). TLF rate at 12 months was 8.3%, which was defined as a composite of cardiac death (2.0%), target-vessel MI (2.9%), and TLR (5.4%). Most revascularizations occurred at SB ostium. IVUS analysis demonstrated optimal stent apposition with only one reported malapposition and promising poststenting minimal stent area measures. Conclusions The TRUNC study confirms that Xposition S self-apposing stent is a valid and feasible option for the treatment of ULMCA disease. Such results were reached without the systematic need of stent optimisation techniques, focusing mainly on lesion treatment.

Objectives Coronary obstruction (CO) is a rare but serious complication of transcatheter aortic valve implantation (TAVI). There are very limited data regarding CO following TAVI. The aim of this study was to evaluate the incidence and outcomes of CO after TAVI and identify the predictors including the valve type. Methods Between October 2006 and March 2015, 1,203 TAVI cases were performed in our institution. Of them, 814 cases whose coronary height was measured using computed tomography for screening were analyzed in this study. Results The Edwards SAPIEN/SAPIEN XT (S/XT) was used in 427 (52.4%) cases, the CoreValve in 265 (32.6%), and the S3 in 122 (15.0%). CO occurred in 8 (1.0%) cases, 1.6% with S/XT, 0.4% with CoreValve, and 0% with S3. All instances of CO occurred at the left coronary artery. The 30-day mortality was significantly higher in cases of CO (37.5% vs. 5.8%, P = 0.010). The frequency of CO tended to be lower in recipients of the CoreValve (0.4%) and S3 (0%) compared with the S/XT (1.6%) (P = 0.188 for CoreValve vs. S/XT, P = 0.022 for S3 vs. S/XT). Conclusions CO has poor outcomes and identification of patients at risk of CO to take preventive measures is crucial. The preliminary data showing that the occurrence of CO is low in patients receiving the S3 despite increased prosthesis height need further confirmation. © 2017 Wiley Periodicals, Inc.

BACKGROUND Whether the efficacy and safety of dual antiplatelet therapy (DAPT) are uniform between sexes is unclear. We sought to compare clinical outcomes between short- (≤6 months) versus long-term (≥1 year) DAPT after drug-eluting stent (DES) placement in women and men. METHODS AND RESULTS We pooled individual patient data from 6 randomized trials of DAPT (EXCELLENT, OPTIMIZE, PRODIGY, RESET, SECURITY, ITALIC PLUS). The primary outcome was 1-year risk of major adverse cardiac events (MACE). The main secondary outcome was 1-year risk of any bleeding. Out of the 11,473 randomized patients included in the pooled dataset, 3,454 (30%) were females. At 1-year follow-up, women had higher risk of MACE (3.6% vs. 2.8%; P = 0.01) but similar risk of bleeding (1.9% vs. 1.6%; P = 0.16) as compared with men. Compared with long-term DAPT, short-term DAPT was associated with similar rates of MACE in both women (HR 0.88; 95% CI 0.62-1.25) and men (HR 1.25; 95% CI 0.95-1.6; P interaction = 0.08)]. At 1-year follow-up, short-term DAPT was associated with lower rates of bleeding as compared with long-term DAPT in both women (HR 0.84; 95% CI 0.51-1.37) and men (HR 0.58; 95% CI 0.40-0.84; P-interaction = 0.25). The presence of MVD was associated with higher MACE rates in the short-term DAPT group in women (HR: 1.16; CI 0.60-2.23) and men (HR: 2.29; CI 1.22-4.29; P interaction = 0.25). CONCLUSIONS Short-term DAPT is associated with similar rates of MACE but lower risk of bleeding when as compared with prolonged DAPT. There was no significant difference between sexes in the population studied. © 2016 Wiley Periodicals, Inc.

BACKGROUND Historically, percutaneous coronary intervention (PCI) of bifurcation lesions was associated with worse procedural and clinical outcomes when compared with PCI of non-bifurcation lesions. Newer generation drug-eluting stents (DES) might improve long-term clinical outcomes after bifurcation PCI. METHODS AND RESULTS The LEADERS trial was a 10-center, assessor-blind, non-inferiority, all-comers trial, randomizing 1,707 patients to treatment with a biolimus A9(TM) -eluting stent (BES) with an abluminal biodegradable polymer or a sirolimus-eluting stent (SES) with a durable polymer (ClinicalTrials.gov Identifier: NCT00389220). Five-year clinical outcomes were compared between patients with and without bifurcation lesions and between BES and SES in the bifurcation lesion subgroup. There were 497 (29%) patients with at least 1 bifurcation lesion (BES = 258; SES = 239). At 5-year follow-up, the composite endpoint of cardiac death, myocardial infarction (MI) and clinically-indicated (CI) target vessel revascularization (TVR) was observed more frequently in the bifurcation group (26.6% vs. 22.4%, P = 0.049). Within the bifurcation lesion subgroup, no differences were observed in (cardiac) death or MI rates between BES and SES. However, CI target lesion revascularization (TLR) (10.1% vs. 15.9%, P = 0.0495), and CI TVR (12.0% vs. 19.2%, P = 0.023) rates were significantly lower in the BES group. Definite/probable stent thrombosis (ST) rate was numerically lower in the BES group (3.1% vs. 5.9%, P = 0.15). Very late (>1 year) definite/probable ST rates trended to be lower with BES (0.4% vs. 3.1%, P = 0.057). CONCLUSIONS In the treatment of bifurcation lesions, use of BES led to superior long-term efficacy compared with SES. Safety outcomes were comparable between BES and SES, with an observed trend toward a lower rate of very late definite/probable ST between 1 and 5 years with the BES. © 2015 Wiley Periodicals, Inc.

Backgrounds To facilitate the learning process of transcatheter aortic valve implantation (TAVI) in Japan, unique supporting systems (e.g., on-site proctor and web-based screening systems) have been developed. Nevertheless, little is known about real-world clinical outcomes after TAVI in Japan compared with their European counterparts. Methods From the optimized catheter valvular intervention (OCEAN-TAVI, Japan) and the Institut Cardiovasculaire Paris Sud (Massy, France) registries, we evaluated a total of 134 and 178 patients, respectively, who underwent transfemoral TAVI during the same time period. Results Among the French cohort, about half of the patients (N = 81, 45.5%) were treated with the Edwards SAPIEN XT. Body surface area was significantly smaller in the Japanese cohort, although operative risks for both cohorts were almost the same. A greater percentage of patients in the Japanese cohort were implanted with 23 mm valves compared with the French cohort (73.1% vs. 23.0%, P

Background Few data are available about whether aortic root calcification may impact the outcomes after transcatheter aortic valve implantation (TAVI). Objectives This study sought to evaluate the impact of aortic root calcification volume on clinical outcome after TAVI with balloon expandable Edwards Sapien XT valve (Edwards Lifesciences, Irvine, California). Methods A total of 162 TAVI patients (aged 84.0 [Interquartile Range (IQR) 81.0–84.0] years, Logistic EuroSCORE 14.5 [IQR 9.8–25.1]) with preprocedural MDCT were studied. Aortic root calcification volume was measured by MDCT image and using the dedicated software for aortic valve assessment (the automated 3mensioTM Valves 5.1, sp1, 3mensio Pie Medical Imaging BV, Maastricht, the Netherlands). A valve calcification index (VCI) was defined as calcification volume (mm3)/body surface area (mm2). Results VCI was significantly higher among patients with 30-day mortality. A VCI threshold of 517.4 (area under the curve 0.69, 95% CI 0.50–0.87, P = 0.03) predicted a higher incidence of annulus rupture (9.1 vs. 0.9%, P = 0.02) and cardiac tamponade (12.7 vs. 1.9%, P

Objectives This study investigated the feasibility and the safety of using a 6.5-French sheathless guide catheter in patients with small radial arteries. Background The small size of radial arteries is a limitation of transradial coronary intervention. A new sheathless guiding catheter with a diameter almost 2-Fr smaller than conventional sheaths and a full-length hydrophilic coating has been introduced. Methods A total of 148 patients from three French hospitals were consecutively enrolled from March 2009 to February 2012. They underwent transradial approach (TRA) for percutaneous coronary interventions (PCI) using the 6.5-F ASAHI sheathless Eaucath guiding catheter system. Results Among the 148 patients enrolled, 95 were females (64%), and 183 lesions were treated. Procedural success rate was 100%. Thirteen patients (9%) underwent same-procedure multivessel interventions for the right and left coronary artery. Among the group of 46 patients undergoing bifurcation PCI, 35 (76%) bifurcated lesions were treated with a kissing balloon technique, one patient had a saphenous vein bypass graft lesion requiring filter wire placement prior to intervention, nine (6.1%) patients required rotational atherectomy, thrombus-aspiration catheters were used in 19 (12.8%) patients, fractional flow reserve (FFR)-guided PCI in 10 (6.7%) patients, alcohol septal ablation in three (2%) patients. Ten (6.7%) cases of chronic total occlusion were successfully treated in nine (6.1%) patients using the hydrophilic catheter. No radial artery site complications was noted. Conclusion The use of sheathless guiding catheters is a safe, effective method for PCI via TRA in small radial arteries without catheter-related complications. © 2015 Wiley Periodicals, Inc.

Background Postprocedural paravalvular leak (PVL) ≥ 2 has been shown to be associated with worse outcomes after transcatheter aortic valve implantation (TAVI). This study sought to identify predictive factors of postprocedural PVL ≥ 2 after TAVI with the Edwards valve. Methods and Results A total of 176 patients with Edwards TAVI (aged 83.4 ± 7.4 years, Logistic EuroSCORE [the Logistic European System for Cardiac Operative Risk Evaluation] 18.8 ± 12.0, transfemoral 54.5%) who had preprocedural multidetector computed tomography (MDCT) were studied. A PVL ≥ 2 was observed in 12.5% of cases. By multivariate analysis, only the valve calcification index (VCI) defined as aortic root calcification volume/body surface area (odds ratio [OR] = 1.002, 95% confidence interval [CI] = 1.001–1.004, P = 0.006) and the valve diameter/the calculated average annulus diameter (CAAD) by MDCT (OR = 0.683, 95% CI = 0.474–0.984, P = 0.041) were identified as independent predictors of postprocedural PVL ≥ 2. A score predicting postprocedural PVL ≥ 2 (PVL score) was determined by allotting one point when the valve diameter/CAAD ratio was 418.4 mm3/m2, and summing all points accrued. Area under receiver-operator characteristic curves of PVL score was 0.71 (95% CI = 0.59–0.83, P

Objectives: To investigate the prognostic implications of the presence of severe lesion calcification in patients undergoing coronary artery bypass graft (CABG) operation. Background: 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. Methods: 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. Results: One out of three patients exhibited severe lesion calcification (n 5588). Patients with calcified coronaries had an increased mortality at 5-year follow-up (17.1% vs. 9.9%, P

Aims The aim of this study was to evaluate the efficacy and safety of transcatheter aortic valve implantation (TAVI) in patients of small body size (SB). Methods and Results Between October 2006 and November 2011, 424 patients undergoing TAVI were evaluated. Patients with a small body surface area (BSA

Although annulus rupture is one of the most severe complications of transcatheter aortic valve implantation (TAVI), the incidence and mechanism of this complication remain unclear. Out of 387 consecutive TAVI cases in our institution, the incidence of annulus rupture was 1.0% (4/387). The first two patients died because of hemodynamic collapse due to tamponade on day 0. Both surviving patients had undergone preprocedural multidetector computed tomography which revealed large calcifications in the epicardial fat part of the aortic annulus. In both cases, annulus rupture occurred after deployment of a balloon expandable valve suggesting that mechanical compression of this "vulnerable area" by calcification may cause annulus rupture.

Objectives The purpose of this study was to examine the performance of the European system for cardiac operative risk evaluation II (ESII) in patients undergoing transcatheter aortic valve implantation (TAVI). Background The ESII was developed recently to improve the predictive value of the original logistic EuroSCORE (LES). Methods Between October 2006 and November 2011, 453 consecutive patients with severe aortic stenosis undergoing TAVI with either the Edwards valve or the Corevalve were included in the current analysis. The performance of the ESII, LES, and society of thoracic surgeons predicted risk of mortality score (STS) was evaluated. Results Mean age was 83.1 ± 6.4 years. The Edwards valve was used in 382 patients (84.3%) of the cohort, transfemoral approach (TF) in 55.0%, transapical approach (TA) in 25.2%, transaortic approach (TAo) 17.8%, transsubclabian approach (SC) 2.0%. The observed 30-day mortality was 12.6% (11.2, 18.4, 7.4, and 22.2% for TF, TA, TAo, SC, respectively). The mean LES, STS, and ESII were 22.4 ± 12.1, 8.1 ± 6.0, and 8.1 ± 5.2, respectively. The Hosmer–Lemeshow test showed ESII was inadequately calibrated for 30-day mortality compared with other risk scores (ESII P = 0.09, LES P = 0.84, STS P = 0.34). By using the area under the receiver operating characteristic curve (AUC), ESII better predicted 30-day mortality, albeit poorly, compared to LES and STS (AUC = 0.68, 0.65, and 0.60, respectively). In the TF cohort, ESII was better in predicting 30-day mortality compared to LES and STS (AUC = 0.74, 0.61, 0.60, respectively). Conclusions Although the ESII demonstrated better predictive performance especially in the TF cohort, ESII is still inadequate in predicting mortality after TAVI as are LES and STS. © 2013 Wiley Periodicals, Inc.

Objectives: To assess the effect of the duration of stent inflation on stent expansion using digital stent enhancement (DSE). Background: Optimal stent expansion and apposition to the vessel wall are of critical importance to optimize the results of percutaneous coronary intervention (PCI). However, it is not known if stent inflation duration impacts on stent expansion. Methods: We performed a prospective cohort study in patients undergoing PCI. Quantitative coronary angiography and DSE data were analyzed. DSE was performed at 5, 15, and 25 sec during stent implantation, after target balloon inflation pressure was achieved. Results: One hundred and four consecutive patients (150 lesions) were enrolled. The mean age was 66.9 ± 11.1 years. Complex lesions (ACC/AHA B2/C) occurred in 26.9%. Stents used: Cypher Select (54.1%), Xience V (30.6%), and Taxus Liberte (15.3%). The minimal stent diameter increased significantly with the duration of stent inflation: 2.60 ± 0.51, 2.76 ± 0.51, and 2.82 ± 0.52 mm at 5, 15, and 25 sec (P 25 sec is recommended. © 2012 Wiley Periodicals, Inc.

Udgivelsesdato: 2008-Oct-27 The treatment of bifurcation lesions is complex and increasingly common. A growing number of dedicated bifurcation devices are under clinical evaluation, but no standardized methodology exists. Specifically, the angiographic analysis of bifurcation lesions is not standardized and current QCA packages are not designed for bifurcation lesions. This consensus statement outlines the limitations of conventional QCA in the bifurcation application, and outlines a new standard approach for the analysis and reporting of the angiographic results of the bifurcation lesion allowing for future trial and device comparisons and mechanistic insight into location and modes of treatment failure. (c) 2008 Wiley-Liss, Inc.

Ischemic cerebrovascular events are a rare complication of cardiac catheterization. Consequently a unique standard of management for these events is yet to be defined. Immediate cerebral angiography followed by local thrombolysis is an effective strategy and we report six cases for which this approach was successfully employed. In contrast the use of immediate neuroimaging by means of MRI or CT scan in two cases delayed the implementation of appropriate therapy. © 2007 Wiley-Liss, Inc.

We present three patients with angulated ostial lesions beyond the insertion point of coronary artery bypass grafts. Use of the Venture Catheter, a deflectable tip 3.5F wire control catheter, facilitated successful percutaneous coronary intervention after prolonged, unsuccessful attempts at conventional guidewire passage. © 2007 Wiley-Liss, Inc.

This study should clarify whether the gold-coated NIROYAL stent is equivalent to the stainless steel NIR stent. Patients were randomized to either NIR stent (n = 298) or a NIROYAL stent (n = 305). The primary endpoint was the minimum lumen diameter of the target lesion at 6 months postprocedure. Secondary endpoints focused on clinical events. At 30 days, adverse events were similar in both groups. At 6 months, the minimal lumen diameter was 1.83/1.64 mm (P < 0.001; 95% CI = 0.08-0.30) and the angiographic restenosis rate was 20.6%/37.7% (P < 0.001; 95% CI = -24.7 to -9.3) for NIR/NIROYAL. The 6-month MACE rates were NIR 7.4% and NIROYAL 10.5% (95% CI = -7.7 to 1.4). Compared to stainless steel stent, the NIROYAL stent demonstrated a smaller minimal lumen diameter, a higher late loss (i.e., higher neointimal hyperplasia in spite of a significantly better initial gain), with higher restenosis and similar MACE rates at 6 months.

The gastroepiploic artery has been successfully used as an arterial conduit in selected patients undergoing CABG with acceptable immediate and long-term results. Myocardial ischemia may occur during the follow-up period as a result of spasm, occlusion, or stenosis at the anastomosis site. Because of tortuosity and in order to avoid graft spasm and to obtain good extra backup support, we require low-profile wide-lumen guiding catheters for deep intubation and increased procedural success. In the case presented here, a gastroepiploic graft stenosis was treated by balloon angioplasty performed through a less invasive approach combining transradial access and use of 5 Fr guiding catheter.

Treatment of bifurcation lesions remains a technical challenge. Among 13 stents previously tested in a bench study, the Bestent seemed of particular interest in this indication as it provided good access to the side branch after stent implantation in the main branch associated with a satisfactory coverage of the lesion after kissing balloon inflation. The use of Bestent implanted in the main branch or both branches for treatment of bifurcation lesions involving a side branch > or = 2.2 mm in diameter was prospectively evaluated in a dual-center prospective study with a prospective 6-month clinical follow-up. All angiographic documents were analyzed by an independent corelab (CORISIS). Between 11 September 1997 and 21 February 1998, 96 patients were consecutively included (mean age, 63.7 +/- 11.4 years; 81.3% male; 58.3% with unstable angina and 6.3% acute myocardial infarction). The lesion involved the left anterior descending-diagonal coronary bifurcation in 55% of cases, left circumflex-marginal 23%, posterior descending-postero-lateral 12%, distal left main 6%, and others 4%. The main branch (proximal reference diameter: 3.43 +/- 0.45 mm) was stented in 98% of cases and the side branch (2.72 +/- 0.38 mm) in 38% (both branches in 34% of cases). T-stenting or provisional T-stenting was used in 88% of cases and final kissing balloon inflation was performed in 78% of cases. Procedural success was obtained in 100% of cases in the main branch and 98% in both branches. Major cardiac and cerebral events (MACCE) during hospitalization occurred in 4.2% of cases, non-Q-wave myocardial infarction (MI) in 3.1%, Q-wave MI in 1.0%, repeat PTCA in 2.1%; there were no major access site complication, no emergency coronary artery bypass grafting operation, no death. At 6-month follow-up, total MACCE rate was 14.6% (Q-wave MI, 3.1%; non-Q-wave MI, 3.1%; target vessel revascularization, 9.4%; death, 2.1%). Patients with target vessel revascularization (TVR) had restenosis of both branches in 22.2% of cases, main branch in 22.2%, and side branch in 55.6%. This study shows that using a simple strategy of provisional T-stenting of the side branch in the majority of cases, the Bestent can be used for treating bifurcation lesions with a high rate of success and an acceptable rate of TVR at 6-month follow-up.

Although transradial angioplasty has been shown to have no major entry site–related complications, its clinical applicability for balloon angioplasty and stenting in acute myocardial infarction (AMI) is unclear. In order to assess the feasibility, safety, and clinical outcome of transradial access for coronary angioplasty (PTCA) and stenting during AMI, transradial angioplasty for AMI was registered on a prospective database at two European sites (A and B) with experience in the radial approach (RA); 6 Fr catheters with an inner lumen of at least 0.064″ and low-profile rapid-exchange balloons were used. Primary success rates and procedural complications of 6 Fr RA were determined and compared to 6 Fr femoral approach (FA) procedures. A total of 1,224 AMI patients entered the registry. Study site A enrolled 185 RA patients (13.6% AMI) and study site B 92 RA patients (63.4%). Patient baseline demographics were similar in both study centers and showed no differences between RA and FA patients, except a more frequent use of abciximab in study site B compared to A. PTCA was successful in > 95% of both RA and FA patients. Total procedural time did not differ between RA and FA patients. Severe access site–related bleeding complications, however, were observed in FA patients only: study site A used closure devices routinely and found 2% severe bleedings; study site B used no closure device for FA patients and observed 7% severe bleedings. In selected patients and in experienced hands, transradial PTCA in AMI has a high success rate, is clinically safe, and could become an attractive alternative access site for patients being at high or even low risk for bleeding complications. Cathet Cardiovasc Intervent 2002;55:206–211. © 2002 Wiley-Liss, Inc.

As the safety and feasibility of the transradial approach for percutaneous coronary interventions have already been established by many series, we evaluate the safety and feasibility of this approach in noncoronary interventions such as renal, celiac, mesenteric, and subclavian angioplasty procedures. We present here our preliminary experience of noncoronary interventions via the transradial approach using coronary equipment with 100% technical and clinical success. Nine noncoronary interventions were performed in seven patients (five renal, two celiac, one mesenteric and subclavian angioplasty each). The advantage of this approach is that it limits arterial wall damage as well as potential distal embolization by the use of small guiding catheters and 0.014″ guidewires. The only limitation of this approach for noncoronary interventions is the guiding catheter length in tall patients and the unavailability of large coronary balloons for subclavian, celiac, and renal interventions. With the miniaturization of equipment and improvements in technique, this approach will also become an excellent alternative for noncoronary interventions. Cathet Cardiovasc Intervent 2002;55:197–205. © 2002 Wiley-Liss, Inc.

The retroesophageal right subclavian artery (arteria lusoria) is one of the anatomical abnormalities encountered by interventional cardiologists who perform right transradial procedures. We report on 11 patients with arteria lusoria in whom 14 right transradial coronary angiography or angioplasty procedures were attempted among a series of 3,730 consecutive right transradial attempts. This abnormality can be easily detected by angiographic visualization, in the anteroposterior projection, of the angle of the catheter when it engages the ascending aorta, and by manual angiography at the ostium of the right subclavian artery. In such a case, catheterization of the ascending aorta may be difficult or even impossible (7.1%). Selective catheterization of both coronary arteries is more difficult, takes longer, and requires more catheters. The Judkins catheters are recommended, although they are seldom used for the left coronary artery via the right radial approach, for both arteries. All catheter exchanges should be performed on long guidewires.

Access site complications occur in 5-15% of cases according to the various series. The predictive factors most often reported in the literature are the size of the puncture site and the intensity of the antiplatelet or anticoagulant treatment associated with the angioplasty procedure. Six senior cardiologists in a high volume Cardiology center (>1,500 procedures a year) with an individual experience >500 procedures in either the radial approach or the percutaneous suture of the femoral artery with the Techstar/Prostar system, conducted a prospective study from January 1 to December 31, 1999. The aim of this study was to eliminate the occurrence of access site complications by using either one of two techniques that were at the operator's discretion, i.e., systematic radial approach, or percutaneous suture of the femoral artery. A total of 956 patients were included over the study period; 60.7% of these patients had percutaneous arterial closure of the femoral artery and the remaining 39.3% were treated via the radial approach; 88.7% were stented. The patients were administered a mean 9,000 IU of heparin during the procedure; 1.9% had been fibrinolyzed and Reopro was used in 5.9%. No complications were documented in the radial group. Of the 580 patients in the femoral suture group, 96.9% had femoral suture, immediately effective in 508 cases (90.4%). Only 3 patients required additional prolonged compression. One significant hematoma (0.2%) necessitating blood transfusion was reported in the femoral group. Infection at the puncture site with subsequent antibiotic treatment was reported in 2 patients (0.3%). No further access site complications were observed at one-month follow-up. After completion of the learning curve, the two techniques (radial approach and percutaneous arterial suture) permit the almost total elimination of access site complications.

This study investigates the influence of coronary stenting on the risk of emergency bypass surgery performed within 24 hr of percutaneous tranluminal coronary angioplasty (PTCA) with particular concern for incidence and indication. Since 1995, coronary stenting has been increasingly performed in France during angioplasty procedures, altering significantly the role of emergency bypass surgery. The outcome of elective stenting and widespread use of coronary stenting and its influence on emergency surgery have not been evaluated so far. Through a retrospective (1995) and prospective (1996) registry, we analyzed the incidence, indication and results of emergency bypass surgery performed within 24 hr of PTCA in 68 and 57 centers, respectively, accounting for nearly half of all angioplasty procedures in France. Data were collected through questionnaires consisting of separate forms for every case report that were sent to every center. Over the two years, 26,885 and 27,497 procedures were investigated with a stenting rate of 46% and 64%, respectively. The observed need for emergency surgery was constantly low throughout this period (0.38% and 0.32%, respectively). Indications for surgery included complications directly due to stent in 37% of cases in the 2-year period. Outcome remained poor, with in-hospital mortality in 10% and 17% and myocardial infarction in 27% and 25% of cases, respectively. A comparison of the results in centers with and without surgical facilities showed no differences in outcome, despite a longer time to surgery (359 min ± 406 min vs. 170 min ± 205 min, P = 0.0001) and a lower incidence of emergency surgery (0.25% vs. 0.44%, P = 0.0001) in centers without on-site surgery backup. The French multicenter registry reveals an increase in the use of stents together with a dramatic decrease in the incidence of emergency bypass surgery (below 0.5 %) following PTCA. There has been a significant evolution in the indication, and stent implantation now accounts for a third of the indications for emergency bypass surgery. Cathet. Cardiovasc. Intervent. 48:441–448, 1999. © 1999 Wiley-Liss, Inc.

We report an acute coronary event in a young patient suffering from cerebral autosomal dominant arteriopathy with sub-cortical infarcts and leucoencephalopathy (CADASIL) successfully treated by primary angioplasty and direct stenting. Coronary involvement and pathophysiology of this genetic disorder is discussed.

In a retrospective study of 40 patients, we evaluated the effectiveness of the new 5 Fr 0.058" lumen diameter guiding catheter in routine PTCA. A total of 54 balloon angioplasties were performed. The mean age was 62.1+/-12.8 years, with 71% men. The artery dilated was the LAD in 50%, the RCA in 37%, and the circumflex in 13%. Sixty percent of the lesions dilated were proximal lesions, with only 25% defined as distal lesions. Significant calcifications were present in 20% of the lesions. Stents were implanted in 96%, and mean stent length was 14.0 mm, ranging from 8 to 24 mm. Mean balloon diameter was 2.7 mm, ranging from 2.0 to 3.5 mm. The procedure was a success in 95%, with only two failures. No other complications occurred. We concluded that the 0.058" 5 Fr guiding catheter could be suitable in the majority of noncomplex, selected PTCA cases. However, limitations and advantages over the standard 6 Fr technique are yet to be defined.