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The use of coils is fundamental in interventional cardiology and can be lifesaving in selected settings. Coils are classified by their materials into bare metal, fiber coated, and hydrogel coated, or by the deliverability method into, pushable or detachable coils. Coils are delivered through microcatheters and the choice of coil size is important to ensure compatibility with the inner diameter of the delivery catheter, firstly to be able to deliver and secondly to prevent the coil from being stuck and damaged. Clinically, coils are used in either acute or in elective setting. The most important acute indication is typically the sealing coronary perforation. In the elective settings, coils can be used for the treatment of certain congenital cardiac abnormalities, aneurysms, fistulas or in the treatment of arterial side branch steal syndrome after CABG. Coils must always be delivered under fluoroscopy guidance. There are some associated complications with coils that can be acute or chronic, that nictitates regular followed-up. There is a need for education, training and regular workshops with hands-on to build the experience to use coils in situations that are infrequently encountered., (© 2023 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

The use of mechanical circulatory support (MCS) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We analyzed the clinical and angiographic characteristics, and procedural outcomes of 7,171 CTO PCIs performed between 2012 and 2021 at 35 international centers. Mean age was 64.5 ± 10 years, mean left ventricular ejection fraction was 50 ± 13%. MCS was used in 4.5%, prophylactically in 78.7%, and urgently in 21.3%. The most common type of MCS overall was Impella CP (Abiomed) (55.5%), followed by intra-aortic balloon pump (14.8%) and TandemHeart (LivaNova Inc.) (10.0%). Prophylactic MCS patients were more likely to have diabetes mellitus (55% vs 42%, p <0.001) and had more complex lesions compared with cases without prophylactic MCS (Japan-CTO score: 2.80 ± 1.22 vs 2.39 ± 1.27, p <0.001). Cases with prophylactic MCS had similar technical (86% vs 87%, p = 0.643) but lower procedural (80% vs 86%, p = 0.028) success rates and higher rates of periprocedural major cardiac adverse events compared with no prophylactic MCS use (6.55% vs 1.68%, p <0.001). Urgent MCS use was associated with lower technical (68% vs 87%, p <0.001) and procedural (39% vs 86%, p <0.001) success rates and higher major cardiac adverse events compared with no-MCS use (32.26% vs 1.68%, p <0.001). The differences persisted in multivariable analyses. In summary, in this contemporary multicenter registry, MCS was used in 4.5% of CTO PCIs, mostly prophylactically (78.7%). Elective MCS cases had similar technical success but a higher risk of complications. Urgent MCS cases had lower technical and procedural success and higher periprocedural major complication rates., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can improve patient symptoms, but it remains controversial whether it impacts subsequent clinical outcomes., Methods: In this systematic review and meta-analysis, we queried PubMed, ScienceDirect, Cochrane Library, Web of Science, and Embase databases (last search: September 15, 2021). We investigated the impact of CTO-PCI on clinical events including all-cause mortality, cardiovascular death, myocardial infarction (MI), major adverse cardiovascular event (MACE), stroke, subsequent coronary artery bypass surgery, target-vessel revascularization, and heart failure hospitalizations. Pooled analysis was performed using a random-effects model., Results: A total of 58 publications with 54,540 patients were included in this analysis, of which 33 were observational studies of successful vs failed CTO-PCI, 19 were observational studies of CTO-PCI vs no CTO-PCI, and 6 were randomized controlled trials (RCTs). In observational studies, but not RCTs, CTO-PCI was associated with better clinical outcomes. Odds ratios (ORs) and 95% confidence intervals (CIs) for all-cause mortality, MACE, and MI were 0.52 (95% CI, 0.42-0.64), 0.46 (95% CI, 0.37-0.58), 0.66 (95% CI, 0.50-0.86), respectively for successful vs failed CTO-PCI studies; 0.38 (95% CI, 0.31-0.45), 0.57 (95% CI, 0.42-0.78), 0.65 (95% CI, 0.42-0.99), respectively, for observational studies of CTO-PCI vs no CTO-PCI; 0.72 (95% CI, 0.39-1.32), 0.69 (95% CI, 0.38-1.25), and 1.04 (95% CI, 0.46-2.37), respectively for RCTs., Conclusions: CTO-PCI is associated with better subsequent clinical outcomes in observational studies but not in RCTs. Appropriately powered RCTs are needed to conclusively determine the impact of CTO-PCI on clinical outcomes.

Objectives: There are limited data on the association of operator volume with the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We analyzed the association between operator volume and procedural outcomes of 7035 CTO-PCIs performed between 2012 and February 2021 at 30 centers., Results: The study population was divided into 3 groups based on annual operator CTO-PCI volume: low-volume operators (LVO: &lt;30 cases/year; 39.7% of the cases); medium-volume operators (MVO: 30-60 cases/year; 25.7% of the cases); and high-volume operators (HVO: &gt;60 cases/ year; 34.6% of the cases). Mean patient age was 64.4 ± 10 years and 82% were men. Cases performed by HVOs were more complex, with higher J-CTO score compared with cases performed by MVOs and LVOs (2.72 ± 1.27 vs 2.39 ± 1.19 vs 2.12 ± 1.27, respectively; P&lt;.001). Moderate/severe proximal vessel tortuosity (35% vs 23% vs 20%; P&lt;.001) and proximal cap ambiguity (44% vs 34% vs 32%; P&lt;.001) was also more common in the HVO group. Cases performed by HVOs had higher technical success rates (87.9% vs 86.9% vs 82.6%; P&lt;.001), but also higher rates of periprocedural major cardiac adverse events compared with MVOs and LVOs (3.08% vs 2.71% vs 1.50%; P&lt;.01). On multivariable analyses, HVOs and MVOs were associated with higher technical success., Conclusions: In a contemporary, multicenter registry, 40% of CTO-PCI cases are performed by LVOs performing &lt;30 cases per year. Cases performed by HVOs were associated with higher technical and procedural success, but also higher periprocedural major complication rates, potentially due to higher lesion complexity.

Spontaneous coronary artery dissection (SCAD) has emerged as an important cause of acute coronary syndrome and sudden cardiac death. The triggers for SCAD often do not include traditional atherosclerotic risk factors. The most commonly reported triggers are extreme physical or emotional stress. The current study compared in-hospital and follow-up events in patients with SCAD with and without reported stress. Data from 83 patients with a confirmed diagnosis of SCAD were collected retrospectively from 30 centers in 4 Arab Gulf countries (KSA, UAE, Kuwait, and Bahrain) from January 2011 to December 2017. In-hospital myocardial infarction (MI), percutaneous coronary intervention (PCI), ventricular tachycardia/ventricular fibrillation, cardiogenic shock, death, ICD placement, dissection extension) and follow-up (MI, de novo SCAD, death, spontaneous superior mesenteric artery dissection) events were compared between those with and without reported stress. Emotional and physical stress was defined as new or unusually intense stress, within 1 week of their initial hospitalization. The median age of patients in the study was 44 (37-55) years. Foty-two (51%) were women. Stress (emotional, physical, and combined) was reported in 49 (59%) of all patients. Sixty-two percent of women with SCAD reported stress, and 51 % of men with SCAD reported stress. Men more commonly reported physical and combined stress. Women more commonly reported emotional stress (P < 0.001). The presence or absence of reported stress did not impact on overall adverse cardiovascular events (P = 0.8). In-hospital and follow-up events were comparable in patients with SCAD in the presence or absence of reported stress as a trigger., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI.  1. Ischemic symptom improvement is the primary indication for CTO-PCI.  2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI.  3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges.  4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs.  5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use.  6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation.  7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training.

Percutaneous coronary intervention (PCI) in the elderly is a major hospital burden since this group of patients exhibits high mortality rates and many comorbidities. The aim of this study was to analyze the impact of a transradial intervention (TRI) approach for PCI on bleeding complications in octogenarians. We retrospectively analyzed a consecutive cohort of 2530 patients who underwent PCI at a tertiary care center in Japan. Octogenarians constituted 12 % (291 cases) of the total PCI cases during the study period. Bleeding complications and all-cause mortality were observed at 30 days after PCI. Average age was 83 ± 3 years and female gender was 32 %. Stable coronary artery disease was 59 %. TRI was performed in 218 patients (75 %) and transfemoral intervention (TFI) in 73 (25 %). Bleeding Academic Research Consortium (BARC) major bleeding unrelated to bypass surgery were observed in 7.6 %, which were significantly lower in TRI than TFI (5.1 vs. 15.1 %, P = 0.005). The 30-day mortality rate was significantly low in patients without bleeding (4.9 vs. 31 %, p < 0.0001). In octogenarians, major bleeding complication was significant at 30 days after PCI. TRI had lower bleeding complication rate than TFI in this population. Octogenarians may be a subgroup of patients who derive benefits from TRI.

Background: Factors of restenosis after percutaneous coronary intervention (PCI) for chronic total coronary occlusion (CTO) have not been fully explored. In particular, although the last ACC/AHA guidelines on PCI suggest that a minimum diameter stenosis of 10% with an optimal goal of as close to 0% as possible should be the new benchmark for lesions treated by stenting, angiographic success of PCI for CTO remains in the literature most often defined as a <30% residual diameter stenosis. Whether an optimized immediate post-PCI angiographic result (OAR) defined by a minimal diameter stenosis as close to 0% is associated with a lower restenosis rate in this subset of coronary lesions remains unknown., Methods: Therefore, we assessed by quantitative coronary analysis (QCA) both the immediate post-PCI and 6-month follow-up angiographic results of 170 successfully treated true CTO., Results: Post-PCI QCA immediate residual diameter stenosis was <30% in all 170 CTOs and OAR defined as a ≤10% residual stenosis was achieved in 133 (78%). Global binary restenosis rate was 21% in the 170 lesions. Restenosis rates were 46% and 14% in the non-OAR group and in the OAR group, respectively (p<0.0001). Multivariate analysis showed that a non-OAR, a younger age and a retrograde approach were independent factors of restenosis., Conclusion: Thus, an optimized immediate angiographic result with a minimal diameter stenosis as close to 0% as possible appears to be associated with a lower rate of restenosis after CTO PCI., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objectives: The aim of this study was to analyze the effectiveness of drug-eluting stents (DES) in small vessels in patients with non-insulin-dependent (NIDDM) and insulin-dependent diabetes mellitus (IDDM)., Background: Several randomized trials have shown DES to significantly reduce the angiographic and clinical events in diabetic patients. However, there is insufficient data on similar outcomes in diabetics with small vessels., Methods: We studied 258 consecutive diabetic patients (173 NIDDM and 85 IDDM) who underwent coronary stenting with DES, divided into 2 cohorts: group A (vessels<2.7mm): 163 patients, and group B (vessels≥2.7mm): 95 patients. We analyzed the major adverse cardiac events (MACE) [death, nonfatal myocardial infarction MI, and target lesion revascularization (TVR)] over a mean follow-up of 78.4±14.8months., Results: Group A patients had: smaller reference diameter (2.4±0.31 versus 3.14±0.2mm, p=0.0001), longer lesions (19.3±9.5 versus 16.7±7.1mm, p=0.023), more complex lesions: (B2/C) (80.7 versus 52.6%, p<0.033), bifurcation lesions (25.8 versus 11.6%, p=0.007), diffuse disease (42.9 versus 26.3%, p=0.008), multivessel (32.5 versus 18.9%, p=0.019), eccentric lesions (57.1 versus 43.2%, p=0.031), more stents implanted (1.99±1.6 versus 1.7±1.3, p<0.0001), more overlapping stents (29.4 versus 13.7%, p=0.004) and more stents length (25.7±4.9 versus 20.2±2.6, p<0.003). During the follow-up, both groups had overall similar MACE (10.4 versus 11.7%, p=0.9) with insignificant higher restenosis (9.2 versus 8.4%, p=0.832) and TVR (7.4 versus 6.4%, p=0.75) in group A. There was no difference in death (p=0.111) or MI (p=0.858). Both groups had similar stent thrombosis rate (1.2 versus 1.1%, p=0.899), angina events (10.4 versus 16.8%, p=0.137), abnormal stress thallium (14.1 versus 14.7%, p=0.890), and hospital days (2.91 versus 3.57, p=0.886)., Conclusion: Despite complex angiographic characteristics, the use of DES in diabetic patients with small vessels showed favorable clinical outcomes and similar low TVR compared to those with large vessels., (Copyright © 2015 Elsevier Inc. All rights reserved.)