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OBJECTIVES The aim of this study was to characterize the feasibility of coronary angiography (CA) and percutaneous coronary intervention (PCI) in acute settings among patients who have undergone transcatheter aortic valve replacement (TAVR). BACKGROUND Impaired coronary access after TAVR may be challenging and particularly in acute settings could have deleterious consequences. METHODS In this international registry, data from patients with prior TAVR requiring urgent or emergent CA were retrospectively collected. A total of 449 patients from 25 sites with acute coronary syndromes (89.1%) and other acute cardiovascular situations (10.9%) were included. RESULTS Success rates were high for CA of the right coronary artery (98.3%) and left coronary artery (99.3%) and were higher among patients with short stent-frame prostheses (SFPs) than in those with long SFPs for CA of the right coronary artery (99.6% vs 95.9%; P��=��0.005) but not for CA of the left coronary artery (99.7% vs 98.7%; P��=��0.24). PCI of native coronary arteries was successful in 91.4% of cases and independent of valve type (short SFP 90.4% vs long SFP 93.4%; P��=��0.44). Guide engagement failed in 6 patients, of whom 3 underwent emergent coronary artery bypass grafting and another 3 died in the hospital. Among patients requiring revascularization of native vessels, independent predictors of 30-day all-cause mortality were prior diabetes, cardiogenic shock, and failed PCI but not valve type or success of coronary engagement. CONCLUSIONS CA or PCI after TAVR in acute settings is usually successful, but selective coronary engagement may be more challenging in the presence of long SFPs. Among patients requiring PCI, prior diabetes, cardiogenic shock, and failed PCI were predictors of early mortality.

A 52-year-old man, with a history of allergic rhinitis and without coronary risk factors, transferred to our hospital because of cardiac arrest. Coronary angiography revealed no significant stenosis in left coronary arteries ([Figure 1A][1]), and mild stenosis in right coronary artery ([Figure 1B

Objectives The aim of this study was to determine the safety and efficacy of chimney stenting, a bailout technique to treat coronary artery occlusion (CAO). Background CAO during transcatheter aortic valve replacement (TAVR) is a rare but often fatal complication. Methods In the international Chimney Registry, patient and procedural characteristics and data on outcomes are retrospectively collected from patients who underwent chimney stenting during TAVR. Results To date, 16 centers have contributed 60 cases among 12,800 TAVR procedures (0.5%). Chimney stenting was performed for 2 reasons: 1) due to the development of an established CAO (n = 25 [41.6%]); or 2) due to an impending CAO (n = 35 [58.3%]). The majority of cases (92.9%) had 1 or more classical risk factors for CAO. Upfront coronary protection was performed in 44 patients (73.3%). Procedural and in-hospital mortality occurred in 1 and 2 patients, respectively. Myocardial infarction (52.0% vs. 0.0%; p Conclusions Chimney stenting appears to be an acceptable bailout technique for CAO, with higher event rates among those with established CAO and among those without upfront coronary protection.

Objectives The aim of this study was to investigate the safety and efficacy of coronary protection by preventive coronary wiring and stenting across the coronary ostia in patients at high risk for coronary obstruction after transcatheter aortic valve replacement (TAVR). Background Coronary obstruction following TAVR is a life-threatening complication with high procedural and short-term mortality. Methods Data were collected retrospectively from a multicenter international registry between April 2011 and February 2019. Results Among 236 patients undergoing coronary protection with preventive coronary wiring, 143 had eventually stents implanted across the coronary ostia after valve deployment. At 3-year follow-up, rates of cardiac death were 7.8% in patients receiving stents and 15.7% in those not receiving stents (adjusted hazard ratio: 0.42; 95% confidence interval: 0.14 to 1.28; p = 0.13). There were 2 definite stent thromboses (0.9%) in patients receiving stents, both occurring after TAVR in “valve-in-valve” procedures. In patients not receiving stents, there were 4 delayed coronary occlusions (DCOs) (4.3%), occurring from 5 min to 6 h after wire removal. Three cases occurred in valve-in-valve procedures and 1 in a native aortic valve procedure. Distance between the virtual transcatheter valve and the protected coronary ostia Conclusions In patients undergoing TAVR at high risk for coronary obstruction, preventive stent implantation across the coronary ostia is associated with good mid-term survival rates and low rates of stent thrombosis. Patients undergoing coronary protection with wire only have a considerable risk for DCO.

Objectives The aim of this study was to assess the incidence of unfavorable coronary access after transcatheter aortic valve replacement (TAVR) using post-implantation computed tomography (CT). Background Real-world data regarding coronary access after TAVR assessed using post-implantation CT are scarce. Methods Post-TAVR CT of 66 patients treated with Evolut R or Evolut PRO valves and 345 patients treated with SAPIEN 3 valves were analyzed. The distance from inflow of the transcatheter heart valve (THV) to the coronary ostia and the overlap between THV commissures and the coronary ostia were assessed. Coronary access was defined as unfavorable if the coronary ostium was below the skirt or in front of the THV commissural posts above the skirt in each coronary artery. Results CT-identified features of unfavorable coronary access were observed in 34.8% (n = 23) for the left coronary artery and 25.8% (n = 17) for the right coronary artery in the Evolut R/Evolut PRO group, while those percentages were 15.7% (n = 54) for the left coronary artery and 8.1% (n = 28) for the right coronary artery in the SAPIEN 3 group. In the Evolut R/Evolut PRO group, 16 coronary engagements were performed after TAVR, while 64 coronary engagements were performed in the SAPIEN 3 group after TAVR. In an engagement-level analysis, the success rates of selective coronary engagement were significantly lower in patients with CT-identified features of unfavorable coronary access compared with those with favorable coronary access in both the Evolut R/Evolut PRO (0.0% vs. 77.8%; p = 0.003) and SAPIEN 3 (33.3% vs. 91.4%; p = 0.003) groups. Conclusions Coronary access may be challenging in a significant proportion of patients after TAVR. THVs with low skirt or commissure height and large open cells that are designed to achieve commissure-to-commissure alignment with the native aortic valve may facilitate future coronary access. (Assessment of Transcatheter and Surgical Aortic Bioprosthetic Valve Thrombosis and Its Treatment With Anticoagulation [RESOLVE]; NCT02318342)

A 63-year-old man with a history of triple coronary artery bypass graft surgery underwent retrograde chronic total occlusion percutaneous coronary intervention of the native right coronary artery. After successful retrograde crossing of the chronic total occlusion lesion, the wire was advanced and

A 37-year-old man, an active smoker, presented with progressive chest pain, radiating into left shoulder and arm, associated with nausea, vomiting, dizziness, diaphoresis, and shortness of breath. Electrocardiogram showed T-wave inversions in precordial leads V1 to V3, troponin T peaked at 0.78

A 13-year-old girl with repaired truncus arteriosus and single right coronary artery presented with progressive exertional dyspnea for 1 year. She underwent initial cardiac repair at 6 weeks of age, followed by 2 subsequent right ventricle to pulmonary artery (RV-PA) conduit replacement surgeries

A 67-year-old man with multiple cardiovascular risk factors and adequately rate-controlled atrial fibrillation was referred for coronary angiography because of progressive dyspnea on effort. The left-sided coronary arteries were normal, but the right coronary artery (RCA) originated from the left

A 59-year-old man with diabetes presented with exertional dyspnea and angina for 3 months. He had a history of inferior wall myocardial infarction 9 months previously, with percutaneous intervention of an 80% tubular lesion of the mid-right coronary artery (RCA) with a 3.5 × 28 mm drug eluting

Objectives The aim of this study was to determine the techniques and outcomes of hybrid chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in a diverse group of patients and operators on 2 continents. Background CTO PCI has been evolving with constant improvement of equipment and techniques. Methods Contemporary outcomes of CTO PCI were examined by analyzing the clinical, angiographic, and procedural characteristics of 3,122 CTO interventions performed in 3,055 patients at 20 centers in the United States, Europe, and Russia. Results The mean age was 65 ± 10 years, and 85% of the patients were men, with high prevalence of diabetes (43%), prior myocardial infarction (46%), prior coronary artery bypass graft surgery (33%), and prior PCI (65%). The CTO target vessels were the right coronary artery (55%), left anterior descending coronary artery (24%), and left circumflex coronary artery (20%). The mean J-CTO (Multicenter Chronic Total Occlusion Registry of Japan) and PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) scores were 2.4 ± 1.3 and 1.3 ± 1.0, respectively. The overall technical and procedural success rate was 87% and 85%, respectively, and the rate of in-hospital major complications was 3.0%. The final successful crossing strategy was antegrade wire escalation in 52.0%, retrograde in 27.1%, and antegrade dissection re-entry in 20.9%; >1 crossing strategy was required in 40.9%. Median contrast volume, air kerma radiation dose, and procedure and fluoroscopy time were 270 ml (interquartile range: 200 to 360 ml), 2.9 Gy (interquartile range: 1.7 to 4.7 Gy), 123 min (interquartile range: 81 to 188 min) and 47 min (interquartile range: 29 to 77 min), respectively. Conclusions CTO PCI is currently being performed with high success and acceptable complication rates among various experienced centers in the United States, Europe, and Russia. (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention [PROGRESS CTO]; NCT02061436)

A 79-year-old woman with prior stent implantation for the right coronary artery 8 years ago was diagnosed with right coronary artery occlusion ([Figures 1A and 1B][1], [Online Videos 1][2] and [2][3]). Due to the absence of an ostium stump, a primary retrograde approach via the septal channel was

A 47-year-old man presented to our hospital after a syncopal event and 1 week of progressive chest pain. His medical history was pertinent for cardiac synovial sarcoma, which had previously undergone subtotal resection. He was seen at an outside hospital, where electrocardiography exhibited ST

A 75-year-old patient with 2-vessel disease underwent percutaneous coronary intervention (PCI) for recanalization of chronic total occlusion (CTO) of the right coronary artery. Successful recanalization of the CTO was achieved by an antegrade approach to the posterolateral branch and by retrograde

Objectives The aim of this study was to examine the current practice and use of transfemoral approach (TFA) for coronary angiography and intervention. Background Wide variability exists in TFA techniques for coronary procedures. Methods The authors developed a survey instrument that was distributed via e-mail lists from professional societies to interventional cardiologists from 88 countries between March and December 2016. Results Of 987 operators, 18% were femoralists, 38% radialists, 42% both, and 2% neither. Access using femoral pulse palpation alone was preferred by 60% of operators, fluoroscopy guidance by 11%, and a combination of palpation, fluoroscopy, or ultrasound by 27%. Only 11% used micropuncture in >90% of their cases. Performing femoral angiography immediately after access was preferred by 23% and at the end of the procedure by 47%, and not done at all by 31% of operators. Hemostasis by manual compression was preferred by 50%, collagen plug vascular closure device by 31%, and suture-based vascular closure device by 11% of operators. Judkins left and right catheters were preferred for diagnostic angiography of the left (99%) and right (94%) coronary arteries. Extra backup curves (XB or EBU) were most commonly preferred for percutaneous coronary intervention of the left anterior descending (80%) and left circumflex (80%), whereas the Judkins right catheter was preferred for percutaneous coronary intervention of the right coronary artery (86%). Conclusions There is significant variability in preferences for femoral access technique. Even though recommended best practices advocate for fluoroscopic and ultrasound guidance, most operators use palpation alone. Femoral angiography is also not consistently used despite guideline recommendations. The lack of adoption of imaging guidance for vascular access deserves further investigation.

Objectives The aim of this study was to define the dynamic in vivo morphology of post-infarct ventricular septal defect (PIVSD), which has not been previously described in living patients. Background PIVSD is a devastating complication of acute myocardial infarction. Methods The anatomic features of PIVSD, as demonstrated by computed tomography or magnetic resonance imaging, were retrospectively reviewed. Results Thirty-two PIVSDs were assessed, 16 left coronary artery and 16 right coronary artery PIVSDs. PIVSDs were large (mean maximum dimension 26.5 ± 11.5 mm, mean area 5.2 ± 4.2 cm 2 ) and oval (mean eccentricity index 1.7 ± 0.5), with thin margins (diastolic mean thickness 5 mm from the edge of the PIVSD 6.4 ± 3.0mm), and only 22% of PIVSDs were entirely confined to the septum. The defects could be larger in diastole or systole. The stem of the largest available Amplatzer occluder stem (St. Jude Medical, St. Paul, Minnesota) filled only 50% of defects. Patients with small defects may survive without closure. Without closure, those with large defects die. If accepted for closure, PIVSD size and coronary territory did not predict survival >1 year (overall 60%). Conclusions This is the first detailed anatomic description of PIVSD in living patients. Defects may be larger in systole or diastole, meaning that single-phase measurement is unsuitable. Its complex nature means that the most commonly available occluder device is frequently unsuitable. Successful closure leads to prolonged survival and should be attempted where possible. This study may lead to improved patient selection, closure techniques, and device design.

Objectives The aim of this study was to develop a hybrid approach–specific model to predict chronic total coronary artery occlusion (CTO) percutaneous coronary intervention success, useful for experienced but not ultra-high-volume operators. Background CTO percutaneous coronary intervention success rates vary widely and have improved with the “hybrid approach,” but current predictive models for success have major limitations. Methods Data were obtained from consecutively attempted patients from 7 clinical sites (9 operators, mean annual CTO volume 61 ± 17 cases). Angiographic analysis of 21 lesion variables was performed centrally. Statistical modeling was performed on a randomly designated training group and tested in a separate validation cohort. The primary outcome of interest was technical success. Results A total of 436 patients (456 lesions) met entry criteria. Twenty-five percent of lesions had prior failed percutaneous coronary interventions at the site. The right coronary artery was the most common location (56.4%), and mean occlusion length was 24 ± 20 mm. The initial approach was most often antegrade wire escalation (70%), followed by retrograde (22%). Success was achieved in 79.4%. Failure was most closely correlated with presence of an ambiguous proximal cap, and in the presence of an ambiguous proximal cap, specifically defined collateral score (combination of Werner and tortuosity scores) and retrograde tortuosity. Without an ambiguous proximal cap, poor distal target, occlusion length >10 mm, ostial location, and 1 operator variable contributed. Prior failure, and Werner and tortuosity scores alone, were only weakly correlated with outcomes. The basic 7-item model predicted success, with C statistics of 0.753 in the training cohort and 0.738 in the validation cohort, the later superior (p Conclusions Success can be reasonably well predicted, but that prediction requires modification and combination of angiographic variables. Differences in operator skill sets may make it challenging to create a powerful, generalizable, predictive tool.

Objectives The aim of this study was to describe the contemporary incidence of chronic total occlusions (CTOs) and the success rates of CTO percutaneous coronary intervention (PCI), as well as the complications and long-term outcomes of these patients. Background The contemporary prevalence and management of coronary CTOs is understudied. Methods Consecutive veterans undergoing coronary angiography at 79 Veterans Affairs sites between 2007 and 2013 were examined. Detailed baseline clinical, angiographic, and follow-up outcomes were evaluated using national data from the Veterans Affairs Clinical Assessment Reporting and Tracking program. Results Among 111,273 patients with obstructive coronary artery disease, 29,399 (26.4%) had ≥1 CTO, most commonly in the right coronary artery distribution (n = 18,986 [64.6%]). Elective CTO PCI was attempted in 2,394 patients (8.1%), with a procedural success rate of 79.7%. The odds of CTO PCI success increased over the years of the study (odds ratio: 1.08; 95% confidence interval [CI]: 1.01 to 1.16; p = 0.03). Compared with failed CTO PCI, successful CTO PCI was associated with a decreased adjusted risk for mortality (hazard ratio: 0.67; 95% CI: 0.47 to 0.95; p = 0.02) and coronary artery bypass graft surgery (hazard ratio: 0.14; 95% CI: 0.08 to 0.24; p Conclusions Approximately 1 in 4 patients with obstructive coronary artery disease on coronary angiography had CTOs. Among patients who went on to elective CTO PCI, the success rate was 79.7%. Compared with failed CTO PCI, successful CTO PCI was associated with a decreased risk for mortality as well as a decreased need for subsequent coronary artery bypass graft surgery.

A 71-year-old woman without a cardiovascular history was transferred to our hospital with persistent hypotension days following an inferior ST-segment elevation myocardial infarction (STEMI). Urgent coronary angiography for refractory shock showed a proximal occlusion of the right coronary artery (

Percutaneous alcohol septal ablation (PTSMA) has been established as therapy in symptomatic patients with hypertrophic obstructive cardiomyopathy [(1)][1]. Collateralization between the target septal branch and the left anterior descending coronary artery as well as another septal branch with

A 74-year-old woman underwent percutaneous coronary intervention in her right coronary artery with 2 zotarolimus-eluting stents. Final angiography and optical coherence tomography (OCT) showed neither stent edge dissection nor significant malapposition; however, a dissection within the stented

Objectives This study evaluated revascularization strategies for patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease. Background In patients with STEMI and multivessel disease, it is unclear whether multivessel intervention (MVI), culprit vessel intervention (CVI) only (CVI-O) or CVI with staged revascularization (CVI-S) is associated with improved outcomes. Whether MVI at primary percutaneous coronary intervention may benefit specific patient groups is unclear. Methods We compared revascularization strategies (MVI, CVI-O, and CVI-S) in 6,503 patients with STEMI and multivessel disease enrolled in the British Columbia Cardiac Registry (2008 to 2014). We evaluated all-cause mortality and repeat revascularization at 2 years. Results Compared with MVI, CVI-O (hazard ratio [HR]: 0.78; 95% confidence interval [CI]: 0.64 to 0.97; p = 0.023) and CVI-S (HR: 0.55; 95% CI: 0.36 to 0.82; p = 0.004) were associated with lower mortality. Comparing CVI-O with CVI-S, CVI-S was associated with lower mortality (HR: 0.65; 95% CI: 0.47 to 0.91; p = 0.013). Compared with MVI, CVI-O was associated with increased repeat revascularization (HR: 1.25; 95% CI: 1.02 to 1.54; p = 0.036). Comparing CVI-O versus CVI-S, CVI-S was associated with lower repeat revascularization (HR: 0.64; 95% CI: 0.46 to 0.90; p = 0.012). CVI was associated with lower mortality in the presence of nonculprit left circumflex artery disease (HR: 0.63; 95% CI: 0.45 to 0.89; p = 0.011) and right coronary artery disease (HR: 0.66; 95% CI: 0.44 to 0.99; p = 0.050), but not nonculprit left anterior descending artery disease (HR: 0.83; 95% CI: 0.54 to 1.28; p = 0.399). Conclusions In patients with STEMI undergoing primary percutaneous coronary intervention, a strategy of CVI-S seems to be associated with lower mortality and repeat revascularization rates. However, MVI may be considered in selected patients and in the setting of nonculprit left anterior descending artery disease. These findings warrant prospective evaluation in large adequately powered randomized controlled trials.

Objectives This study reports a novel transcatheter procedure for residual mitral regurgitation (MR) after MitraClip implantation using the Amplatzer Duct Occluder II (ADO II). Background Although the MitraClip procedure is a transcatheter treatment option for patients at high surgical risk with severe MR, management of significant residual MR after MitraClip implantation is still challenging. Methods We describe a case series of 9 consecutive patients who underwent transcatheter deployment of the ADO II plug for significant residual MR after MitraClip implantation from April to October 2015. Results The mean age was 79.3 ± 11.4 years. The deployment of the ADO II plug was performed at the initial MitraClip procedure in 7 patients and at the second procedure for recurrent symptoms in 2 patients. There were 2 types of residual MR seen after MitraClip implantation: residual commissural MR (n = 3) and residual intraclip MR (n = 6). The ADO II was successfully deployed with significant reduction of MR flow and left atrial pressure in all patients. The ADO II plug was retrieved in 1 patient because of device embolization to the ostial right coronary artery. However, all patients were discharged 1.8 ± 1.2 days after the procedure, with no significant MR on pre-discharge transthoracic echocardiography. In 8 patients who underwent 1-month symptomatic assessment, clinical symptoms were diminished to New York Heart Association functional class I or II. Conclusions Transcatheter deployment of the ADO II plug was effective for the reduction of residual commissural MR and intraclip MR after MitraClip implantation. The potential role of this technique should be established for challenging cases.

A 73-year-old woman with dyslipidemia and diabetes underwent percutaneous coronary intervention in the right coronary artery due to stable angina. Tandem lesions were treated with 2 sirolimus-eluting stents (ULTIMASTER, Terumo, Tokyo, Japan) separately ([Figure 1A][1]). After implantation of a 2.5

A 50-year-old man with an inferior myocardial infarction was admitted after successful fibrinolysis. Coronary angiography showed 2 giant coronary aneurysms in series in the right coronary artery with high thrombus burden ([Figure 1A][1], [Online Video 1][2]), a severe ostial lesion, and ecstatic

A 46-year-old man underwent percutaneous coronary intervention with a drug-eluting stent on the distal right coronary artery. Six years later, he was diagnosed with in-stent chronic total occlusion of the right coronary artery causing inferior-wall ischemia, and was scheduled for percutaneous

A 65-year-old man with myelodysplastic syndrome (MDS) and trisomy 8, and regular blood transfusions due to thrombocytopenia and anemia presented with inferior ST-segment elevation myocardial infarction (MI). Coronary angiography revealed large thrombi in the right coronary artery (RCA) and left

Emergent coronary angiography performed in a 40-year-old noncompetitive male athlete, owing to the occurrence of thoracic pain and syncope during running, revealed an anomalous origin from the opposite sinus of the right coronary artery with a suspected proximal aortic intramural course ([Figure 1A

An 84-year-old male patient with ischemic heart disease was referred to transesophageal echocardiography evaluation of mitral regurgitation. He previously underwent multiple percutaneous coronary interventions (PCI) in another hospital, the last intervention 3 years ago. Flail anterior leaflet of

A 61-year-old smoker with a past medical history of hypertension presented with malaise to his local emergency department and was diagnosed with malignant hypertension. In view of a small cardiac enzyme rise and nonsustained ventricular tachycardia on 24-h monitoring, a coronary angiogram was

A 69-year-old man with established coronary artery disease and left ventricular dysfunction (ejection fraction, 40%) with typical Canadian Cardiovascular Society class III angina underwent percutaneous coronary intervention (PCI) for severe diffuse calcific disease in the right coronary artery ([

Percutaneous revascularization of ostial right coronary artery (RCA) chronic total occlusions (CTO) are challenging due to the lack of antegrade strategy options. A retrograde approach is mandated and when passage of the guidewire through the true lumen is unsuccessful, use of aggressive stiff

An 86-year-old woman presented with chest pain and inferior ST-segment elevation. Her history included coronary artery bypass grafting, percutaneous coronary intervention, and a stroke. She had also undergone transcatheter aortic valve replacement with implantation of a 25-mm Direct Flow Medical (

A 19-year-old woman with no relevant medical history presented to the hospital with typical chest pain, starting while she was running. Her electrocardiogram showed significant ST-segment elevation in inferior and V4 to V6 leads ([Figure 1][1]). In the transthoracic echocardiogram exam the left

A 70-year-old woman who had 3 tandem stenoses with severe calcification in a large tortuous right coronary artery (RCA) ([Figure 1A][1]) underwent percutaneous coronary intervention. Type 3 coronary perforation occurred following rotational atherectomy (1.25-mm burr, 140,000 rotations/min) ([

Bradycardia is a known complication of rotational atherectomy (RA). The manufacturer of the Rotablator system (Boston Scientific, MA) recommends placement of a temporary pacing wire in patients undergoing RA of lesions in the right coronary artery (RCA) and/or dominant left circumflex artery (LCx).

A 71-year-old man underwent percutaneous coronary intervention for chronic total occlusion of the right coronary artery. Following septal dilatation with a 1.25-mm balloon, a Corsair microcatheter (Asahi Intecc, Nagoya, Japan) was advanced retrogradely through the septal artery, with substantial

Objectives This study sought to examine the contemporary outcomes of retrograde chronic total occlusion (CTO) interventions among 3 experienced U.S. centers. Background The retrograde approach, pioneered and developed in Japan, has revolutionized the treatment of coronary CTO, yet limited information exists on procedural efficacy, safety, and reproducibility of outcomes in other settings. Methods Between 2006 and 2011, 462 consecutive retrograde CTO interventions were performed at 3 U.S. institutions. Patient characteristics, procedural outcomes, and in-hospital clinical events were ascertained. Results Mean patient age was 65 ± 9.7 years, 84% were men, and 50% had prior coronary artery bypass surgery. The CTO target vessel was the right coronary artery (66%), circumflex (18%), left anterior descending artery (15.5%), and left main artery or bypass graft (0.5%). The retrograde approach was used as the primary method in 46% of cases and after failed antegrade recanalization in 54%. Retrograde collateral vessels were septal (68%), epicardial (24%), and bypass grafts (8%). Technical and procedural success was 81.4% (n = 376) and 79.4% (n = 367), respectively. The mean contrast volume and fluoroscopy time were 345 ± 177 ml and 61 ± 40 min, respectively. A major complication occurred in 12 patients (2.6%). In multivariable analysis, years since initiation of retrograde CTO percutaneous coronary intervention (PCI) at each center, female sex, and ejection fraction ≥40% were associated with higher technical success. Conclusions Among selected U.S. programs, retrograde CTO PCI is often performed in patients with prior coronary bypass graft surgery and is associated with favorably high success and low complication rates.

A 70-year-old Caucasian man with a history of coronary artery disease (CAD) 9 months status post–2-vessel coronary artery bypass grafting (left internal mammary artery to left anterior descending artery and saphenous vein graft to the first oblique marginal artery) performed at an outside hospital

A 56-year-old man with diabetes mellitus presented with inferior transient ST-segment elevation acute coronary syndrome. Coronary angiography showed a severe thrombotic lesion at the right coronary artery and a severe lesion at the left anterior descending artery. The lesion of the right coronary

A 76-year-old man had been revascularized with implantation of 2 drug-eluting stents in the middle right coronary artery because of an inferior infarct 11 years previously, through right radial access. Posterior clinical evolution was good, with preserved systolic function. He was referred to our

A 40-year-old man presented to our facility with progressive angina 1 month after an unsuccessful attempt at right coronary artery (RCA) revascularization following a non–ST-segment elevation myocardial infarction. Coronary angiography revealed a dominant RCA with a very large aneurysm in the mid

We describe a case of chronic total occlusion of the right coronary artery (RCA) ostium ([Figure 1A][1]) in a 61-year-old man. Coronary angiography showed good collateral circulation from the left anterior descending artery via the Vieussens arterial ring to the proximal RCA and from the septal

A 70-year-old male underwent coronary angiography because of worsening angina, which demonstrated proximal left anterior descending coronary artery (LAD) chronic total occlusion (CTO) collateralized by septal branches from the right coronary artery and an antegrade bridge ([Figure 1A][1]). The

A 40-year-old man, nonsmoker, presented with chronic stable angina for the past 1 year. The electrocardiogram showed left ventricular hypertrophy, and echocardiography revealed severe concentric left ventricular hypertrophy suggestive of hypertrophic cardiomyopathy. He was taken up for coronary

A 53-year-old woman was admitted for unstable angina pectoris. Coronary angiography revealed a stenosis in the right coronary artery ([Fig. 1][1]A). A 2.75- × 18-mm zotarolimus-eluting stent was implanted at 16 atm. Intravascular ultrasound showed a distal edge dissection ([Fig. 1][1]C), which

Objectives The aim of this study was to evaluate practice of transradial approach (TRA). Background TRA has been adopted as an alternative access site for coronary procedures. Methods A questionnaire was distributed worldwide with Internet-based software. Results The survey was conducted from August 2009 to January 2010 among 1,107 interventional cardiologists in 75 countries. Although pre-TRA dual hand circulation testing is not uniform in the world, >85% in the U.S. perform Allen or oximetry testing. Right radial artery is used in almost 90%. Judkins catheters are the most popular for left coronary artery angiographies (66.5%) and right coronary artery angiographies (58.8%). For percutaneous coronary intervention (PCI), 6-F is now standard. For PCI of left coronary artery, operators use standard extra back-up guiding catheters in >65% and, for right coronary artery 70.4% use right Judkins catheters. Although heparin remains the routine antithrombotic agent in the world, bivalirudin is frequently used in the U.S. for PCI. The incidence of radial artery occlusion before hospital discharge is not assessed in >50%. Overall, approximately 50% responded that their TRA practice will increase in the future (68.4% in the U.S.). Conclusions TRA is already widely used across the world. Diagnostic and guiding-catheters used for TRA remain similar to those used for traditional femoral approach, suggesting that specialized radial catheters are not frequently used. However, there is substantial variation in practice as it relates to specific aspects of TRA, suggesting that more data are needed to determine the optimal strategy to facilitate TRA and optimize radial artery patency after catheterization.