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Introduction: Antegrade dissection and re-entry (ADR) is an integral part of the hybrid algorithm, which has allowed for improved outcomes in chronic total occlusion (CTO) coronary intervention (PCI)., Methods: A new ADR method, Subintimal Antegrade FEnestration and Re-entry (SAFER), is described. The results of a first-in-man series are presented., Results: SAFER was performed on seven consecutive patients with angiographic and clinical success in all patients., Conclusions: This first-in-man study has shown that the SAFER technique is feasible and effective with the possibility of improving the antegrade PCI CTO success rate., (© 2023 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Background: The impact of occlusion length on the procedural techniques and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study., Methods: We examined the clinical and angiographic characteristics and procedural outcomes of 10,335 CTO PCIs at 42 US and non-US centers between 2012 and 2022. The cohort was divided into two groups based on lesion length (≥20 mm vs. <20 mm)., Results: Long lesions were present in 7208 (70%) patients. Comorbidities were more common in patients with long CTOs. Compared with short lesions, long lesions had higher J-CTO score (2.8 ± 1.1 vs. 1.3 ± 1; p < 0.001) and retrograde wiring was more often the initial (15.5% vs. 4.0%; p < 0.001) and successful (22.8% vs. 8.2%; p < 0.001) crossing strategy. Long lesions were more likely to require longer procedure (123 vs. 91 min; p < 0.001) and fluoroscopy (47.1 vs. 32.2 min; p < 0.001) time, larger contrast volume (218 vs. 200 mL; p < 0.001) and higher air kerma radiation dose (2.4 vs. 1.7 Gy; p < 0.001). After adjusting for potential confounders, long lesions were associated with lower technical success (odds ratio [OR]: 0.91 per 10 mm increase; 95% confidence interval [CI]: 0.88, 0.94) and higher major adverse cardiovascular events (MACE) (OR: 1.08 per 10 mm increase; 95% CI: 1.02, 1.15)., Conclusions: CTO PCI of long occlusions is independently associated with lower rates of technical success and higher rates of in-hospital MACE., (© 2023 Wiley Periodicals LLC.)

Objectives: The aim of this study was to evaluate the effect of the degree of severity of baseline thrombocytopenia (TCP) on outcomes after percutaneous coronary intervention (PCI) BACKGROUND: The association of TCP with clinical outcomes among patients undergoing coronary intervention has not been previously evaluated., Methods: Using data from the US Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) Program, we identified patients undergoing PCI between October 1, 2007, to September 30, 2017. The cohort was then stratified by platelet count, as no TCP (platelet count >150,000/mcl), mild TCP (100-150,000/mcl), or moderate-severe TCP (<100,000/mcl) and this was associated with clinical outcomes., Results: The cohort included 80,427 patients (98% male), of which 14.9% (13.2% mild, 1.7% moderate-severe) suffered from TCP at the time of PCI. Compared with mild or no TCP, moderate-severe TCP was associated with increased risk of post-PCI pericardiocentesis (0.6% vs. 0.2% vs. 0.2%, p = 0.018) and in-hospital mortality (1.5% vs. 0.7% vs. 0.7%) without a difference in postprocedure stroke (0.5% vs. 0.3% vs. 0.3%, p = 0.6). Over a median follow-up of 1729 days, time-to-repeat revascularization was significantly shorter in moderate-severe TCP (1080 vs. 1347 vs. 1467 days, p < 0.001) despite lower risk of revascularization. Both mild (adjusted HR: 1.11, 95% CI: 1.07-1.15, p < 0.001) and moderate-severe TCP (HR: 1.55, 95% CI: 1.43-1.69, p < 0.001) were associated with increased all-cause mortality compared with those without TCP., Conclusions: Thrombocytopenia was associated with increased short- and long-term adverse events among patients undergoing PCI. Any degree of TCP was associated with increased long-term all-cause mortality while moderate-severe TCP was also associated with increased risk of periprocedural adverse events., (© 2022 Wiley Periodicals LLC.)

Background: Measurement of post-percutaneous coronary intervention (PCI) fractional flow reserve (FFR) demonstrates residual ischemia in a large percentage of cases deemed angiographically successful which, in turn, has been associated with worse long-term outcomes. It has recently been shown that a resting pressure index, Pd/Pa, has prognostic value post stenting, however, its diagnostic value relative to FFR post-PCI has not been evaluated., Methods: The diagnostic accuracy of Pd/Pa in identifying ischemia (FFR≤0.80) pre- and post-PCI was evaluated. Three patient subsets were analyzed. A reference pre-PCI cohort of 1,255 patients (1,560 vessels) was used to measure the accuracy of pre-PCI Pd/Pa vs. FFR. A derivation post-PCI group of 574 patient (664 vessels) was then used to calculate the diagnostic accuracy of post-PCI Pd/Pa vs. FFR. A final prospective validation cohort of 230 patients (255 vessels) was used to test and validate the diagnostic performance of post-PCI Pd/Pa., Results: Median Pd/Pa and FFR were 0.90 (IQR 0.90-0.98) and 0.80 (IQR 0.71-0.88) in the reference pre-PCI model, 0.96 (IQR 0.93-1.00) and 0.87 (IQR 0.77-0.90) in the post-PCI derivation model, and 0.94 (IQR 0.89-0.97) and 0.84 (IQR 0.77-0.90) in the post-PCI validation model respectively. There was a strong linear correlation between Pd/Pa and FFR in all three models (p < 0.0001). Using ROC analysis, the optimal Pd/Pa cutoff value to predict a FFR ≤ 0.80 was ≤0.92 (AUC 0.87) in the pre-PCI model, ≤0.93 (AUC 0.85) in the post-PCI derivation model, and ≤ 0.90 (AUC 0.91) in the post-PCI validation model. Using a hybrid strategy of post-PCI Pd/Pa and post-PCI FFR when necessary (25% patients), overall diagnostic accuracy was improved to 95%., Conclusions: Pd/Pa has excellent diagnostic accuracy for identifying ischemia post-intervention. Using a hybrid strategy of post-PCI Pd/Pa first, and FFR afterwards, if required, adenosine administration can be avoided in over 75% of physiologic assessments post intervention., (© 2021 Wiley Periodicals LLC.)

Objectives: To demonstrate the feasibility and safety of performing elective percutaneous coronary intervention (PCI) during contrast reaction producing severe hypotension., Background: The development of profound hypotension due to a contrast reaction requires emergency treatment and usually signals procedure termination., Methods and Results: We report successful completion of planned PCI with blood pressure support with vasopressors during contrast-induced hypotension in nine procedures in three patients with previously known contrast reaction causing hypotension., Conclusions: This case series provides support for the feasibility and safety of performing successful planned PCI under blood pressure support in patients with contrast reaction causing severe hypotension. A management approach for considering intervention in the setting of contrast-induced hypotension is provided., (© 2021 Wiley Periodicals LLC.)

Objectives/background: Resting coronary blood flow approximates flow with maximal vasodilation in very severe coronary stenosis. We studied the incidence of exhausted vasodilatory reserve by FFR, its clinical characteristics and long-term prognosis after FFR guided percutaneous coronary intervention (PCI)., Methods: Consecutive patients undergoing FFR-guided PCI for coronary stenosis with reduced resting blood flow (baseline Pd/Pa < 0.8) were included. Basal maximal vasodilation (BMV) was defined as less than 5% difference between resting Pd/Pa and FFR, that is, FFR-baseline Pd/Pa < 0.05., Results: Of 658 vessels that underwent FFR-guided PCI in 602 patients, 151 vessels had resting blood flow in the ischemic range (baseline Pd/Pa ≤ 0.8) and were included in the analysis. Of these, 28 lesions in 28 patients met criteria for BMV (4.25% of the entire registry and 18.5% of those with the reduced basal coronary flow). Stenosis severity was a significant predictor of the presence of BMV. In long term follow-up (median 106 ± 3.6 months), BMV was not associated with increased target vessel revascularization (TVR) or major adverse cardiac event compared to non-BMV(OR 1.9, 95% CI 0.7-4.8, p-value 0.2 and OR 1.3, 95% CI 0.75-2.5, p = 0.3, respectively)., Conclusion: Low baseline Pd/Pa that approximates fractional flow reserve (exhausted vasodilatory reserve) defines a subgroup of patients with severe coronary artery stenosis. Prognosis, when treated with PCI along with medical therapy, appears similar to those with intact vasodilatory reserve., (© 2021 Wiley Periodicals LLC.)

Pseudoaneurysm (PSA) formation is a rare but well-known complication of coronary stenting. It develops after a procedural perforation disrupts the integrity of the vessel wall but is contained by a single wall layer, usually pericardium, extravascular thrombosis and later fibrosis. Medical literature of PSA consists primarily of case reports. A systematic review of pseudoaneurysm after coronary stenting was performed to summarize its presentation, diagnostic imaging modalities, natural history, and management approaches. Clinical presentations range from asymptomatic to hemodynamic collapse, size from small to "giant," and treatment approaches from surgical or percutaneous exclusion to "watchful waiting" and imaging surveillance. Based on current information, a management algorithm is provided recommending urgent to emergent exclusion for symptomatic PSA, elective exclusion for large and giant PSA, and "watchful waiting" and periodic imaging surveillance for small to moderate sized PSA., (© 2020 Wiley Periodicals LLC.)

Background: We examined guidewire and microcatheter utilization during chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We examined device utilization in 2,968 CTO PCIs performed in 2,936 patients at 19 US and two international center between January 2016 and January 2019., Results: The median number of antegrade guidewires used per case declined (5 in 2016 vs 3 in 2019) and was higher in higher complexity lesions (2 in J-CTO 0 vs. 8 in J-CTO 4 or 5 score). In antegrade-only procedures, the most frequently used guidewires were the Pilot 200 (Abbott Vascular, 37%), Fielder XT (Asahi Intecc, 25%) and Gaia third (Asahi Intecc, 18%), while the most commonly used microcatheters were the Turnpike Spiral (Vascular Solutions, 18%) and Turnpike (Vascular Solutions, 16%). Compared with 2012-2015, during 2016-2019 use of novel equipment such as the Gaia guidewires and the Turnpike microcatheters led to decreased use of Confianza Pro 12 (Asahi Intecc) wire and Corsair (Asahi Intecc) family of microcatheters. In retrograde cases, the guidewires most commonly used were the Sion (44%), Pilot 200 (27%) and Fielder FC (26%), while the Corsair/Corsair Pro, Turnpike LP (Vascular Solutions) and Caravel (Asahi Intecc) were the most frequently used microcatheters for collateral crossing (29%, 26% and 22%, respectively)., Conclusions: The most commonly used guidewires during CTO PCI are polymer-jacketed guidewires and the most commonly used microcatheters are torquable microcatheters., (© 2020 Wiley Periodicals LLC.)

Objectives: We aimed to evaluate the efficacy and safety of antegrade fenestration and reentry (AFR) for chronic total occlusion (CTO) recanalization in a multicenter registry., Background: Adoption of antegrade dissection/reentry (ADR) for CTO recanalization has been limited, and novel ADR techniques are needed., Methods: AFR involves the balloon-induced creation of multiple fenestrations between the false and true lumen. A targeted true lumen reentry is subsequently achieved with a low tip-load polymer-jacketed guidewire. Following the initial description and dissemination of AFR, patients undergoing AFR-based CTO recanalization at nine centers were included in the present registry. Study endpoints were AFR success, procedural success, and target-lesion failure (TLF) on follow-up., Results: We included 41 patients. Mean J-CTO score was 2.5 ± 1.4. In 80.5% of cases, AFR was performed after failed antegrade wire escalation. Another ADR technique was used before AFR in one-third of cases. AFR achieved distal true lumen reentry in n = 27/41 (65.9%) cases. In n = 14/41 (34.1%) cases with AFR failure, use of alternative techniques led to successful CTO recanalization in eight additional patients. The overall technical and procedural success rates were 85.4% and 82.9%, respectively. No AFR-related complications were observed. One-year TLF rate was 8.3% overall, with no differences between successful and failed AFR., Conclusions: We report on AFR feasibility in a multicenter registry of patients undergoing CTO recanalization. We observed a moderate success rate, coupled with the absence of complications. Moreover, even a failed AFR attempt did not preclude the use of alternative techniques to achieve recanalization. Further studies should confirm and extend our findings., (© 2020 Wiley Periodicals, Inc.)

Background: When crossing into the distal true lumen fails during chronic total occlusion (CTO) percutaneous coronary intervention (PCI), subintimal plaque modification (SPM) is often performed to restore antegrade flow and facilitate subsequent lesion recanalization., Methods: Between January 2012 and May 4, 2019, 4,659 CTO PCIs were included in the PROGRESS-CTO registry, of which 935 (20%) had a prior unsuccessful attempt. Of those 935 patients, 119 (13%) had prior SPM. We analyzed the outcomes of the 58 SPM procedures for which data were available, as well as the outcomes of the 60 subsequent CTO PCI attempts., Results: Mean patient age was 67 ± 9 years and 86% were men. Patients had high prevalence of cardiovascular risk factors such as dyslipidemia (91%), hypertension (93%) diabetes (48%), prior PCI (61%), and prior coronary artery bypass graft surgery (47%). The target CTO lesions often had proximal cap ambiguity (54%), moderate/severe calcification (73%), moderate/severe tortuosity (63%), and high J-CTO score (mean 3.2 ± 1.1). The technical and procedural success of subsequent CTO PCI were high (83% for both) with an acceptable rate of in-hospital major adverse cardiovascular events (3.3%). Technical and procedural success were higher for repeat attempts that were performed ≥60 days after the index CTO PCI (94% vs. 69%, p = .015). Median (interquartile range) subsequent procedure time was 147 (100, 215) min, contrast volume was 185 (150, 260) ml, and air kerma radiation dose was 2.5 (1.4, 4.2) Gray., Conclusion: Repeat CTO PCI attempts after SPM are associated with high likelihood for successful revascularization with acceptable risks., (© 2019 Wiley Periodicals, Inc.)

The intraplaque injection of contrast media in the recanalization of coronary chronic total occlusions (CTO) has witnessed a dynamic journey since its initial formulation. Contrast-guided subintimal tracking and re-entry (STAR) was the first contrast modulation technique for CTO percutaneous coronary intervention (PCI). With this technique, a forceful injection of a large volume of contrast (3-4 mL) was performed in order to achieve hydraulic recanalization of the vessel. This approach was associated with extensive vessel injury and unpredictable true lumen re-entry, which were in turn linked to high rates of restenosis on follow-up. In the subsequent iteration, called the "microchannel technique", a smaller amount of contrast media (1 mL) was gently injected inside the plaque to modify its compliance by softening and recruiting loose tissue, which facilitated subsequent true-to-true lumen crossing with a polymer-jacketed wire along paths of least resistance. The microchannel technique has later evolved into what is currently known as the "Carlino technique", where a minimal volume of contrast media (<0.5 mL) is gently injected inside the occlusion, with the goal of modifying plaque compliance to facilitate guidewire and microcatheter advancement through a fibrocalcific plaque. The Carlino technique is now widely utilized to allow negotiation of difficult-to-cross occlusions, particularly by the "hybrid operators", with high success rates and low incidence of complications. The purpose of this article is to provide a historical perspective on the use of contrast modulation in CTO PCI, its pathophysiological basis, as well as technical recommendations on how and when to perform these maneuvers., (© 2018 Wiley Periodicals, Inc.)

Background: Despite evidence from individual studies suggesting that prolonged inflation improves coronary stent expansion, relatively shorter inflation times are commonly employed in clinical practice., Methods: We performed an electronic search of PubMed, Web of Science, Cochrane, and CINAHL databases to retrieve outcome studies comparing prolonged versus short inflation times during stent deployment. Outcomes studied included minimal stent diameter (MSD) and minimal stent area (MSA). Standardized mean difference (SMD) was used to estimate the effect sizes for these continuous variables., Results: Seven studies with a total of 341 patients (415 lesions; mean age 67.6 years; 82% male) were included. Drug-eluting stents were used in 89 ± 15% of coronary lesions. Prolonged stent inflation was associated with increased minimal stent diameter (2.93 ± 0.34 mm vs. 2.72 ± 0.28 mm; SMD = 0.42; 95% CI 0.25-0.59; P < 0.001) and minimal stent area (5.99 ± 1.21 mm 2 vs. 5.17 ± 0.87 mm 2 ; SMD = 0.46; 95% CI 0.19-0.73; P = 0.001) compared with shorter duration stent inflation. This difference remained significant in sensitivity analyses that excluded studies with very prolonged inflation duration or multiple stent balloon inflations., Conclusion: Despite differences in duration and methodology, prolonged stent inflation is associated with improved expansion compared with shorter duration. The effect of this optimization recommends randomized trials to determine whether long-term outcomes can be improved by this simple technical modification., (© 2018 Wiley Periodicals, Inc.)

Despite improvements in guidewire technologies, the traditional antegrade wire escalation approach to chronic total occlusion (CTO) recanalization is successful in only 60-80% of selected cases. In particular, long, calcified, and tortuous occlusions are less successfully approached with a true-to-true lumen approach. Frequently, the guidewire tracks into the subadventitial space, with no guarantee of distal re-entry into the true lumen. The ability to manage the subadventitial space has been a key step in the tremendous improvement in success rates of contemporary CTO percutaneous coronary intervention (PCI), whether operating antegradely or retrogradely. A modern approach to CTO PCI involves understanding the concept of "vessel architecture," which is based on the distinction between coronary structures (occlusive plaque, comprising the disrupted intima and media, and the outer adventitia) and extravascular space. The vessel architecture represents a safe work environment for guidewire and device manipulation. This review provides an anatomy-based description of the concept of vessel architecture, along with a historical perspective of subadventitial techniques for CTO PCI, and outcome data of CTO PCI utilizing the subadventitial space. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Background: The prevalence, treatment and outcomes of balloon undilatable chronic total occlusions (CTOs) have received limited study., Methods: We examined the prevalence, clinical and angiographic characteristics, and procedural outcomes of percutaneous coronary interventions (PCIs) for balloon undilatable CTOs in a contemporary multicenter US registry., Results: Between 2012 and 2017 data on balloon undilatable lesions were available for 425 consecutive CTO PCIs in 415 patients in whom guidewire crossing was successful: 52 of 425 CTOs were balloon undilatable (12%). Mean patient age was 65 ± 10 years and most patients were men (84%). Patients with balloon undilatable CTOs were more likely to be diabetic (67 vs. 41%, P < 0.001) and have heart failure (44 vs. 28%, P = 0.027). Balloon undilatable CTOs were longer (40 mm [interquartile range, IQR 20-50] vs. 30 [IQR 15-40], P = 0.016), more likely to have moderate/severe calcification (87 vs. 54%, P < 0.001), and had higher J-CTO score (3.2 ± 1.1 vs. 2.5 ± 1.3, P < 0.001) and PROGRESS-CTO complications score (3.9 ± 1.7 vs. 3.1 ± 2.0, P < 0.005). They were associated with lower technical and procedural success (92 vs. 98%, P = 0.024; and 88 vs. 96%, P = 0.034, respectively) and higher risk for in-hospital major adverse events (8 vs. 2%, P = 0.008) due to higher perforation rates. The most frequent treatments for balloon undilatable CTOs were high pressure balloon inflations (64%), rotational atherectomy (31%), laser (21%), and cutting balloons (15%)., Conclusions: Balloon undilatable CTOs are common and are associated with lower success and higher complication rates., (© 2018 Wiley Periodicals, Inc.)

Aims: To elucidate causes and extent of strut malapposition in angiographically optimized stenting., Methods and Results: Using a new classification system for strut malapposition, the mechanisms of stent strut malapposition were classified as localized lumen enlargement, vessel asymmetry, stent undersizing, strut underexpansion and stent deployment issue. Stent implantations (n = 110) in 100 consecutive patients undergoing optical coherence tomography (OCT) after the operator considered the stent as optimally deployed angiographically were reviewed to determine if strut apposition was complete. 127,894 stent struts in 110 stents were analyzed. There were 6,644 struts malapposed (5.2% ±7.3%), with strut malapposition found in 82 of 110 stents (74.5%). Localized lumen enlargement was the most common cause of malapposition (74.4% of malapposition clusters). Stent undersizing was the second most common cause (46.3%) followed by strut under-expansion in 29.3%, stent deployment issue in 18.2%, and vessel asymmetry in 9.7%., Conclusion: Malapposition of any degree is common after angiographic stent optimization, occurring in up to three-quarters of stents. The most frequent mechanism was localized lumen enlargement. The second most common cause of strut malapposition was stent undersizing, which was angiographically invisible. Whether performing OCT after angiographic optimization improves short- and long-term outcomes requires further study. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Background: High-pressure inflation for coronary stent deployment is universally performed. However, the duration of inflation is variable and does not take into account differences in lesion compliance. We developed a standardized "pressure optimization protocol" (POP) using inflation pressure stability rather than an arbitrary inflation time or angiographic balloon appearance for stent deployment. Whether this approach improves long-term outcomes is unknown., Methods and Results: 792 patients who underwent PCI using either rapid inflation/deflation (n = 376) or POP (n = 416) between January 2009 and March 2014 were included. Exclusion criteria included PCI for acute myocardial infarction, in-stent restenosis, chronic total occlusion, left main, and saphenous vein graft lesions. Primary endpoint was target vessel failure [TVF = combined end point of target vessel revascularization (TVR), myocardial infarction, and cardiac death]. Outcomes were analyzed in the entire cohort and in a propensity analysis. Stent implantation using POP with a median follow-up of 1317 days was associated with lower TVF compared with rapid inflation/deflation (10.1 vs. 17.8%, P < 0.0001). This difference was driven by a decrease in TVR (7 vs. 10.6%, P = 0.0016) and cardiac death (2.9 vs. 5.8%, P = 0.017) while there was no difference in myocardial infarction (1 vs. 1.9%, P = 0.19). In the Cox regression model, deployment using POP was the only independent predictor of reduced TVF (HR 0.43; 0.29-0.64; P < 0.0001). In the propensity analysis (330 patients per group) TVF remained lower with POP vs. rapid inflation/deflation (10 vs. 18%, P < 0.0001)., Conclusions: Stent deployment using POP led to reduced TVF compared to rapid I/D. These results recommend this method to improve long-term outcomes. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Objectives: To assess the efficacy and safety of the modified contrast microinjection technique to facilitate chronic total occlusion recanalization., Background: The success rate of chronic total occlusion percutaneous coronary intervention (CTO-PCI) does not exceed 90% even in the most experienced centres. We have previously demonstrated that a large volume of contrast injected into the subintimal space can facilitate recanalization but is limited by a risk of serious complication. The aim of this study was to assess the application, efficacy and safety of a modified contrast microinjection technique that utilizes the injection of a much smaller volume of contrast in CTO-PCI., Methods: A retrospective analysis of patients in whom the modified microinjection technique was utilised in patients undergoing CTO-PCI at five tertiary centres was conducted., Results: Of 1,192 patients who underwent CTO-PCI, the microinjection technique was used in 59 patients (4.7%). The majority of CTOs treated were in the right coronary artery (79.7%), were of high complexity and 35.6% of lesions had a least one previously failed PCI attempt. The modified microinjection technique was used for more than one indication in 7 (11.9%) of patients. The success rate was 81.4%. There were no procedural complications related to the use of the reported modified microinjection., Conclusion: Initial experience with the modified microinjection demonstrates that it can be performed safely, is reproducible, and is broadly applicable. Whilst not required for all CTO procedures it can be a helpful adjunctive tool to increase the likelihood of success especially in complex, or refractory cases, without compromising the safety of the procedure. © 2015 Wiley Periodicals, Inc., (© 2015 Wiley Periodicals, Inc.)

Objectives: To identify predictors of restenosis after recanalization of chronic total occlusions (CTOs) with the Subintimal Tracking And Reentry (STAR) technique., Background: STAR is associated with high rates of restenosis but the associated factors are not clear. Understanding the underlying mechanisms may be important to improve STAR outcomes and possibly other contemporary CTO recanalization techniques utilizing extensive subintimal dissection and stenting., Methods: We retrospectively analyzed 211 lesions that underwent a STAR procedure (between 2002 and 2013) with a final Thrombolysis in Myocardial Infarction (TIMI) flow grade 2 or 3. One-hundred and nineteen lesions that received drug eluting stents (DES) and underwent follow-up angiography were included in the final analysis., Results: Of the 119 lesions treated with DES following STAR, 75 restenoses were observed (63.0%). Utilizing multivariate analysis, TIMI flow grade in the recanalized artery following stent implantation at the end of the index procedure was the only independent predictor of restenosis., Conclusions: Following recanalization of a CTO with STAR, final TIMI flow predicted future restenosis or reocclusion. As a bailout technique, STAR resulted in a high acute success rate with good safety and acceptable long-term results. When poor flow is observed following recanalization, and prior to stent implantation, a two-step strategy whereby a second procedure is performed at an interval to maximize coronary flow at the end of the procedure may be considered with the goal to reduce the risk of future restenosis or total vessel occlusion following STAR., (© 2015 Wiley Periodicals, Inc.)

Background: High-pressure inflation is the universal standard for stent deployment but a specific protocol for its use is lacking. We developed a standardized "pressure optimization protocol" (POP) using time to inflation pressure stability as an endpoint for determining the required duration of stent inflation., Objectives: The primary study purpose was to determine the stent inflation time (IT) in a large patient cohort using the standardized inflation protocol, to correlate various patient and lesion characteristics with IT, and ascertain in an in vitro study the time for pressure accommodation within an inflation system., Methods: Six hundred fifteen stent implants in 435 patients were studied. Multivariate analysis was performed to determine predictors of longer ITs. In an in vitro study, various stents and balloons were inflated in air to determine the pressure accommodation time of the inflation system., Results: The mean stent IT was 104 ± 41 sec (range 30-380 sec). Stent length was the only predictor of prolonged stent inflation. The "accommodation time" in vitro of the stent inflation system itself was 33 ± 24 sec. The protocol was safe requiring premature inflation termination in <3% of stent implants. No serious adverse events occurred., Conclusions: Achieving stable inflation pressure requires on average over 100 sec and may require several minutes in individual cases. Stent length increases IT. These results suggest that the widespread practice of rapid inflation/deflation may not be sufficient to fully expand the stent and that the use of a pressure stability protocol will allow for safe, predictable, and more complete stent deployment. © 2015 Wiley Periodicals, Inc., (© 2015 Wiley Periodicals, Inc.)

The patient with acute coronary syndrome, particularly with myocardial infarction, from an unprotected left main coronary stenosis represents one of the highest risk subgroups with mortality exceeding 25-50%. Once a patient develops cardiogenic shock, the risk of death during index hospitalization is exceedingly high. Percutaneous coronary intervention may improve short- and long-term outcome, particularly if performed prior to shock development. Should the patient survive index hospitalization, survival tends to be rather good. This review summarizes current knowledge and proposes a clinical algorithm for evaluation and treatment. © 2015 Wiley Periodicals, Inc., (© 2015 Wiley Periodicals, Inc.)

Perforation of a left internal mammary artery (LIMA) graft during percutaneous coronary intervention is a rare event. We report a case of mid-LIMA perforation treated by a polytetrafluoroethylene-covered stent using a modification of the dual catheter ("ping pong") technique. We propose that use of this modification when possible will further improve safety of treating a perforation., (© 2015 Wiley Periodicals, Inc.)

There is substantial evidence that recanalization of a chronic total occlusion is beneficial; nonetheless, it is generally underutilized in clinical practice. We consider the Aesop's fable of the "Fox and the Grapes" as analogous to the current situation in interventional cardiology. The technical challenges in achieving CTO recanalization has led interventionalists, clinical cardiologists, and sometimes even patients to believe that CTO recanalization is not effective, and, therefore, not needed. This perspective reviews available data regarding efficacy and safety of CTO percutaneous coronary intervention (PCI) in the current drug-eluting stent era, discusses areas where more studies are required, and encourages the interventional community to utilize CTO PCI where appropriate based on current evidence., (© 2014 Wiley Periodicals, Inc.)

Background: Percutaneous coronary intervention of a chronic total occlusion to a saphenous vein graft is currently not recommended because the benefit/risk ratio is considered unfavorable. However, there is a patient subset with clinical ischemia, and PCI of the native chronic total occlusion (CTO) is unfavorable. In this setting, PCI to the saphenous vein graft (SVG) may have utility. We reviewed our experience to determine its value in the modern era., Methods and Results: This was a single-center retrospective study of all patients undergoing PCI to SVG CTO. Of 161 patients undergoing SVG PCI during the study period, 27 patients underwent 28 SVG CTO PCI, which was technically successful in 79% (22/28). There were 2 intra-procedural Q wave myocardial infarctions. At 30 days there were no adverse events after hospital discharge. Angina relief was significantly better at 30 days in successful (n = 21) vs. unsuccessful (n = 6) PCI(90% vs. 33% P < 0.01). At the last available follow-up (591 ± 407 days), angina improvement persisted (80.1% vs. 33%, P < 0.01). Long-term adverse events were not significantly different between the two groups., Conclusion: PCI to SVG CTO is feasible with a reasonable success rate, safety profile, and improvement in angina in contemporary practice. This approach may be considered in highly selected patients where revascularization to the ischemic territory is appropriate and the native CTO is technically difficult to recanalize., (Copyright © 2013 Wiley Periodicals, Inc.)

Bridging for antiplatelet therapy remains a subject of debate with data favoring GP blockers but at a risk of bleeding. This Conversation in Cardiology addresses a key and often asked question about use of alternatives to P2Y12 agents in patients requiring surgery within 6 months after drug eluting stent implantation., (Copyright © 2013 Wiley Periodicals, Inc.)

Aims: Optimizing stent deployment is important for both acute- and long-term outcomes. High-pressure balloon inflation is the standard for coronary stent implantation. However, there is no standardized inflation protocol. We hypothesized that prolonged high-pressure balloon inflation until stabilization of inflation pressure is superior to a rapid inflation/deflation sequence for both stent expansion and strut apposition., Methods and Results: A high-pressure rapid inflation/deflation sequence was deployed followed by angiography to assure no residual stenosis. Optical coherence tomography (OCT) was then performed followed by prolonged inflation until balloon pressure was stabilized for 30 sec using the same balloon at the same pressure as the rapid sequence. A second OCT run was then done. Thirteen thousand nine hundred thirteen stent struts were evaluated by OCT in 12 patients undergoing successful stenting. Stent expansion improved with prolonged (206 ± 115 sec) vs. rapid (28 ± 17 sec) inflation for both minimal stent diameter (3.0 ± 0.5 vs. 2.75 ± 0.44 mm, P < 0.0001) and area (7.83 ± 2.45 vs. 6.63 ± 1.85 mm(2) , P = 0.0003). The number of malapposed struts decreased (45 ± 41 vs. 88 ± 75, P = 0.005) as did the maximal malapposed strut distance (0.31 ± 0.2 vs. 0.43 ± 0.2 mm, P = 0.0001). Factors related to strut malapposition after rapid inflation included localized asymmetry in 67%, stent underexpansion in 75%, and stent undersizing in 67%., Conclusions: These data demonstrate that prolonged inflation is superior to a rapid inflation/deflation technique for both stent expansion and strut apposition. We recommend for routine stent deployment a prolonged inflation protocol as described above to optimize stent deployment., (Copyright © 2012 Wiley Periodicals, Inc.)

Unlabelled: Well-developed collaterals to a myocardial segment supplied by a chronic total occlusion (CTO) and/or left ventricular dysfunction in the CTO regions in patients with chronic stable angina suggest that severe ischemia is unlikely to be present. We evaluated the presence and severity of ischemia using fractional flow reserve (FFR) of the myocardium supplied by a CTO in patients and compared the results with a non-CTO control group., Methods: Patients undergoing FFR and successful percutaneous coronary intervention (PCI) of a CTO were evaluated and compared to a matched non-CTO control group., Results: One hundred patients were included (50 CTO/50 controls). CTO lesions were longer (31.6 ± 18.9 vs 20.2 ± 14.9 mm, P = 0.004) and required more stents (2.2 ± 0.8 vs 1.2 ± 0.5, P = 0.001). FFR was lower (P = 0.0003) with CTO (0.45 ± 0.15) than controls (0.58 ± 0.17) prior to intervention but similar after PCI (CTO 0.91 ± 0.05 vs non-CTO 0.90 ± 0.08). All CTO patients demonstrated an ischemic FFR, even with severe regional dysfunction or well-developed collaterals. Resting ischemia was present in 78% (39/50) of CTO patients as evidenced by a resting Pd /Pa of <0.80., Conclusion: In symptomatic patients, a CTO, even with regional left ventricular impairment and/or excellent collateral development, reveals an ischemic zone. This ischemic zone can be normalized by PCI with outcomes appearing to be comparable to non-CTO patients., (Copyright © 2013 Wiley Periodicals, Inc.)

Retrograde recanalization of a chronic coronary total occlusion has become an increasingly utilized method to increase success from percutaneous coronary intervention (PCI). Retrograde wire passage using a septal collateral is the preferred route as the consequences of vessel perforation are more benign than epicardial collateral perforation which may produce cardiac tamponade. Tamponade risk is thought to be lessened by previous coronary bypass surgery due to adhesions preventing free flow of blood throughout the pericardial space. We report the first case of the retrograde approach producing epicardial collateral perforation resulting in a localized epicardial hematoma, which in turn, produced left atrial (LA) inflow and outflow obstruction, with the former producing localized pulmonary edema and pleural effusion. We review reported cases of LA hematoma as a consequence of the antegrade PCI approach and describe a unified explanation for the development of this phenomenon., (Copyright © 2012 Wiley Periodicals, Inc.)

Background: Case reports have shown that an intermediate stenosis in the donor artery collateralizing the myocardium of a chronic total occlusion (CTO) can produce an ischemic fractional flow reserve (FFR) value which may revert to non-ischemic with CTO revascularization., Methods: A consecutive series of patients with severe angina in which a donor artery with intermediate stenosis (30-70%) had FFR measured before and after successful CTO recanalization were studied., Results: Fourteen of 50 consecutive CTO patients with successful PCI fulfilled the study criteria. Eight had CTO of the right coronary artery (RCA), three circumflex (LCx), and three RCA and LCx. Left anterior descending artery was the donor artery in 13 and LCx in 1 patient. Of nine donor ischemic FFR patient's pre-PCI, six reverted to non-ischemic (FFR pre-PCI 0.76 ± 0.04 and 0.86 ± 0.03 post-PCI). Five patients had normal FFR in the donor artery pre- and post-CTO PCI., Conclusions: In patients with a CTO and an intermediate donor artery stenosis, the frequency of ischemia in the donor artery territory is relatively high and often normalized by successful CTO recanalization. These data recommend recanalizing the CTO first whenever possible as a preferred therapeutic strategy to avoid the need for PCI to the donor artery or multivessel bypass surgery., (Copyright © 2013 Wiley Periodicals, Inc.)

Stable angina pectoris owing to isolated right ventricular ischemia from a critical stenosis in a nondominant right coronary artery is a rare entity and documentation of isolated right ventricular ischemia even rarer. We present a case of isolated right ventricular ischemia documented by fractional flow reserve (FFR) and resolution of symptoms after percutaneous coronary intervention., (Copyright © 2012 Wiley Periodicals, Inc.)

Chronic total occlusion (CTO) of the coronary artery represents a difficult group of lesions for percutaneous interventions. Conventionally, antegrade approach has been used to open these lesions, but recent literature provides evidence for the utility of retrograde approach in cases where initial antegrade approach is either not feasible or fails to recanalize the target vessel. This report illustrates retrograde CTO recanalization of saphenous vein graft (SVG) with fractional flow reserve utilization to determine ischemia in the territory of occluded SVG., (Copyright © 2012 Wiley Periodicals, Inc.)

Evaluation of ischemia and the extent of viable myocardium is required prior to consideration of revascularizing a lesion after a myocardial infarction in which there is hypo- or akinesis. We present a case in which we utilized fractional flow reserve (FFR) of a lesion in a patient whose nuclear study 7 days after infarction suggested minimal viability in the infarct zone. After FFR was positive, stenting was performed with recovery of a large amount of viable myocardium at 1 month as shown on nuclear study. This case illustrates that if ischemia is demonstrated by FFR in an infarct-related artery even with minimal viability by nuclear study, revascularization may result in significant myocardial recovery., (Copyright © 2011 Wiley Periodicals, Inc.)

With the advent of new tools and techniques including the retrograde approach, success rates for recanalization of chronic total occlusion (CTO) have improved. Numerous cardiac and extracardiac complications during retrograde CTO recanalization have been described. To date the development of ST-segment elevation myocardial infarction (STEMI) with retrograde recanalization as a result of atheroembolization has not been reported. We report such a case following retrograde recanalization of a totally occluded right coronary artery., (Copyright © 2011 Wiley Periodicals, Inc.)