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Coronary artery perforation (CAP) is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI), however if recognized and managed promptly, its adverse consequences can be minimized. Risk factors for CAP include the use of advanced PCI technique (such as atherectomy and chronic total occlusion interventions) and treatment of severely calcified lesions. There are 3 major types of CAP depending on location: (a) large vessel perforation, (b) distal vessel perforation, and (c) collateral perforation. Large vessel perforation is usually treated with implantation of a covered stent, whereas distal and collateral vessel perforations are usually treated with coil or fat embolization. In this article we provide a state-of-the-art overview of the contemporary management of CAP.

© 2021 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC-BY-NC-ND license., The authors developed a global chronic total occlusion crossing algorithm following 10 steps: 1) dual angiography; 2) careful angiographic review focusing on proximal cap morphology, occlusion segment, distal vessel quality, and collateral circulation; 3) approaching proximal cap ambiguity using intravascular ultrasound, retrograde, and move-the-cap techniques; 4) approaching poor distal vessel quality using the retrograde approach and bifurcation at the distal cap by use of a dual-lumen catheter and intravascular ultrasound; 5) feasibility of retrograde crossing through grafts and septal and epicardial collateral vessels; 6) antegrade wiring strategies; 7) retrograde approach; 8) changing strategy when failing to achieve progress; 9) considering performing an investment procedure if crossing attempts fail; and 10) stopping when reaching high radiation or contrast dose or in case of long procedural time, occurrence of a serious complication, operator and patient fatigue, or lack of expertise or equipment. This algorithm can improve outcomes and expand discussion, research, and collaboration.

Dual lumen microcatheters (DLMC) have become indispensable tools in the setting of percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). Other than allowing preservation and treatment of bifurcated coronary branches within or in the proximity of the CTO-body, they enable the use of modified parallel wiring, antegrade dissection and re-entry, collateral selection and retrograde negotiation of the distal CTO-cap. This Euro-CTO consensus document describes current DLMCs and suggests a practical guide to anatomies and techniques in which these devices are applicable.

The aim of this randomized prospective study was to evaluate the quality of life (QoL) using the “Seattle Angina Questionnaire” (SAQ) in patients with chronic total occlusion (CTO) in coronary arteries treated with either percutaneous coronary intervention (PCI) or optimal medical therapy (OMT), or only with OMT. The potential benefits of recanalization of CTO by PCI have been controversial because of the scarcity of randomized controlled trials. A total of 100 patients with CTO were randomized (1:1) prospectively into the PCI CTO or the OMT group (50 patients in each group). There were no baseline differences in the SAQ scores between the groups, except for physical limitation scores (P = 0.03). During the mean follow-up (FUP) of 275 ± 88 days, patients in the PCI group reported less physical activity limitations (72.7 ± 21.3 versus 60.5 ± 27, P = 0.014), less frequent angina episodes (89.8 ± 17.6 versus 76.8 ± 27.1, P = 0.006), better QoL (79.9 ± 22.7 versus 62.5 ± 25.5, P = 0.001), greater treatment satisfaction (91.2 ± 13.6 versus 81.4 ± 18.4, P = 0.003), and borderline differences in angina stability (61.2 ± 26.5 versus 51.0 ± 23.7, P = 0.046) compared to patients in the OMT group. There were no significant differences in SAQ scores in the OMT group at baseline and during the FUP. There was a statistically significant increase in all five domains in the PCI group. Symptoms and QoL measured by the SAQ were significantly improved after CTO PCI compared to OMT alone.

Despite the use of anti-anginal drugs and/or percutaneous coronary interventions (PCI) or coronary artery bypass grafting, the proportion of patients with coronary artery disease who have daily or weekly angina ranges from 2% to 24%. Refractory angina refers to long-lasting symptoms (for >3 months) due to established reversible ischaemia, which cannot be controlled by escalating medical therapy with the use of 2nd- and 3rd-line pharmacological agents, bypass grafting, or stenting. While there is uncertain prognostic benefit, the treatment of refractory angina is important to improve the quality of life of the patients affected. This review focuses on conventional pharmacological approaches to treating refractory angina, including guideline directed drug combination and dosages. The symptomatic and prognostic impact of advanced and novel revascularization strategies such as chronic total occlusion PCI, transmyocardial laser revascularization, coronary sinus occlusion, radiation therapy for recurrent restenosis, and spinal cord stimulation are also covered and recommendations of the 2019 ESC Guidelines on the Diagnosis and Management of Chronic Coronary Syndromes discussed. Finally, the potential clinical use of current angiogenetic and stem cell therapies in reducing ischaemia and/or pain is evaluated.

Chronic total occlusion (CTO) of the coronary arteries are relatively common, observed in approximatively 15-25% of patients with coronary artery disease undergoing coronary angiography. The right coronary artery represents the most common CTO vessel, which represents about half of the CTO cases.The CTO prevalence is much higher ( 90%) among patients with prior coronary artery bypass graft (CABG), while a CTO is found in only one tenth of patients referred for ST-elevation myocardial infarction (STEMI)

Currently, there is no effective therapy for COVID-19, and several approaches are under investigation. Nevertheless, some drugs are used off-label despite the absence of clear data on their effectiveness. Among these, hydroxychloroquine suppresses SARS-CoV-2 replication in vitro,1 and clinical trials are ongoing to evaluate its use as an anti-COVID-19 agent. To date, the FDA and EMA allow its use only in hospitalized patients with severe COVID-19 or in those at high risk, in cases where other trials are not feasible. According to a small non-randomized study, hydroxychloroquine’s efficacy might be enhanced by azithromycin, as the combination of these two drugs appeared to accelerate viral clearance.2 However, these findings were not substantiated by another study performed in severe COVID-19 cases.3 In addition to the lack of consistent or conclusive efficacy data of these drugs, whether they are used individually or in combination, concern is increasing about potential safety issues. Both hydroxychloroquine and azithromycin may lead to QT prolongation-related life-threatening arrhythmias through the blockage of the rapid delayed rectifier potassium current (IKr). Their combination seems to be more harmful than their single use. Importantly, the risk of azithromycin-mediated QT prolongation is higher in males and in elderly groups,4 that represent a large proportion of the COVID-19 population. Data from a recent Chinese report showed that 16.7% of hospitalized COVID-19 patients and 44.4% of those in intensive care units had arrhythmias.5 The two main mechanisms involved could be hypoxia and electrolyte abnormalities, common features in the acute phase of severe illness. These factors may further enhance the risk of arrhythmic toxicity associated with hydroxychloroquine or azithromycin. Therefore, strategies to mitigate this potential risk have been proposed. The American College of Cardiology suggested QT monitoring in order to discontinue azithromycin (if used) and/or reduce the hydroxychloroquine dose in the case of QT prolongation. While drugs currently used against COVID-19 may seem crucial to treat the infection (in the absence of better options), it is imperative to mitigate toxicity to guarantee the maximum possible safety. According to 2019 international guidelines by the American Thoracic Society and Infectious Diseases Society of America, in pneumonia patients with QT prolongation, macrolides should be replaced by tetracyclines. While providing a broad-spectrum antibiotic activity, compared with other antibiotics tetracyclines also display additional properties that can be advantageous in COVID-19. In particular, the tetracycline derivative minocycline exerts anti-inflammatory effects by suppressing proinflammatory cytokines, including interleukin-6 (IL-6), which plays a key role in COVID-19, and may inhibit poly(ADP-ribose) polymerase-1 (PARP-1) which seems to be implicated in SARS-CoV-2 replication.6,7 Moreover, minocycline displays a synergistic effect when added to hydroxychloroquine.8 Compared with azithromycin, minocycline does not prolong the QT interval, and experimental evidence suggests that it may even be beneficial in conditions associated with increased risk of QT prolongation or arrhythmia. In an experimental model of epilepsy, intrathecal administration of minocycline, by antagonizing the action of microglia, reduced autonomic nervous system activity and seizure-induced QT prolongation.9 In other murine models, treatment with minocycline attenuated ischaemia-induced arrhythmias by blocking the mitochondrial K-ATP channel and inhibiting the PI3K/Akt signalling pathway mediated by L-type calcium channels both involved in myocardial ischaemia-induced arrhythmias.10 Although not proven in humans yet, it is reasonable to believe that minocycline may prevent (or at least mitigate) the increased risk of QT prolongation, and potentially fatal arrhythmias, due to hydroxychloroquine/azithromycin combination therapy, while having the same efficacy as azithromycin but a lower arrhythmogenic effect. For these reasons, until clinical trials prove the efficacy of azithromycin alone or in combination with hydroxychloroquine, we suggest that, whenever antibiotic prophylaxis is needed, azithromycin should be replaced by minocycline.

Introduction: Whether duration of chronic total occlusion (CTO) affects lesion and procedural characteristics remains largely unknown. Aim: To investigate whether CTO duration influences lesion characteristics and revascularization success. Material and methods: EuroCTO Registry data on patients who had CTO percutaneous coronary intervention between January 2015 and April 2017 were analyzed. Three groups were created based on occlusion age: 3 to 6 months (n = 1415), 7 to 12 months (n = 973), > 12 months (n = 1656). Results: Patients with greater CTO duration were older (63.0 (56.0–70.0); 63.0 (56.0–71.0); 66.0 (59.0–73.0) years respectively; p < 0.001), had more 3-vessel disease (32.2%; 30.9%; 46.1% respectively; p < 0.001) and more frequent prior coronary artery bypass grafting (8.2%; 9.9%; 29.4% respectively; p < 0.001). In multivariate analysis, occlusion duration was associated with moderate/ severe calcification (OR = 1.52; 95% CI: 1.28–1.80; p < 0.001), lesion length > 20 mm (OR 1.77; 95% CI 1.49–2.10; p < 0.001), and collateral circulation Werner type 2 (OR = 1.20; 95% CI: 1.01–1.43; p = 0.041). The CTO duration was associated with lower procedural success (OR for success 0.60; 95% CI: 0.46–0.79; p < 0.001). In multivariate analysis in-hospital adverse events did not differ according to duration of CTO. Conclusions: Coronary artery CTO duration is associated with greater extent of calcification, lesion length, development of collateral circulation and, most importantly, with lower procedural success.

© American Heart Association, Inc., 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.

Background: The study focuses on the evolution of practice, procedural outcomes, and in-hospital complications of chronic total occlusion percutaneous coronary intervention in Europe. Methods and Results: Data from 17 626 procedures enrolled in European Registry of Chronic Total Occlusion between January 2008 and June 2015 were assessed. The mean patient age was 63.9±10.9 years; 85% were men. Procedural success increased from 79.7% to 89.3% through the study period. Patients enrolled during the years had increasing comorbidities and lesion complexity (J-CTO score [Multicenter CTO Registry of Japan] increased from 1.76±1.03 in 2008 to 2.17±0.91 in 2015; P for trend, P for trend, P for trend, P for trend, 0.390). Conclusions: Chronic total occlusion percutaneous coronary intervention has shown a steady increase in procedural success rate over time, with unchanged complication rates, despite the increasing complexity of the lesions attempted. The J-CTO score predictive value for procedural success was low for the entire registry and had no predictive ability for the retrograde approach.

Aims: The clinical value of percutaneous coronary intervention (PCI) for chronic coronary total occlusions (CTOs) is not established by randomized trials. This study should compare the benefit of PCI vs. optimal medical therapy (OMT) on the health status in patients with at least one CTO.Method and results: Three hundred and ninety-six patients were enrolled in a prospective randomized, multicentre, open-label, and controlled clinical trial to compare the treatment by PCI with OMT with a 2:1 randomization ratio. The primary endpoint was the change in health status assessed by the Seattle angina questionnaire (SAQ) between baseline and 12 months follow-up. Fifty-two percent of patients have multi-vessel disease in whom all significant non-occlusive lesions were treated before randomization. An intention-to-treat analysis was performed including 13.4% failed procedures in the PCI group and 7.3% cross-overs in the OMT group. At 12 months, a greater improvement of SAQ subscales was observed with PCI as compared with OMT for angina frequency [5.23, 95% confidence interval (CI) 1.75; 8.71; P = 0.003], and quality of life (6.62, 95% CI 1.78-11.46; P = 0.007), reaching the prespecified significance level of 0.01 for the primary endpoint. Physical limitation (P = 0.02) was also improved in the PCI group. Complete freedom from angina was more frequent with PCI 71.6% than OMT 57.8% (P = 0.008). There was no periprocedural death or myocardial infarction. At 12 months, major adverse cardiac events were comparable between the two groups.Conclusion: Percutaneous coronary intervention leads to a significant improvement of the health status in patients with stable angina and a CTO as compared with OMT alone.Trial registration: NCT01760083.

Background Through contemporary literature, the optimal strategy to manage coronary chronic total occlusions (CTOs) remains under debate. Objectives The aim of the Italian Registry of Chronic Total Occlusions (IRCTO) was to provide data on prevalence, characteristics, and outcome of CTO patients according to the management strategy. Methods The IRCTO is a prospective real world multicentre registry enrolling patients showing at least one CTO. Clinical and angiographic data were collected independently from the therapeutic strategy [optimal medical therapy (MT), percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG)]; a comparative 1-year clinical followup was performed. Results A total of 1777 patients were enrolled for an overall CTO prevalence of 13.3%. The adopted therapeutic strategies were as follows: MT in 826 patients (46.5%), PCI in 776 patients (43.7%), and CABG in the remaining 175 patients (9.8%). At 1-year follow-up, patients undergoing PCI showed lower rate of major adverse cardiac and cerebrovascular events (MACCE) (2.6% vs. 8.2% and vs. 6.9%; P < 0.001 and P < 0.01) and cardiac death (1.4% vs. 4.7% and vs. 6.3%; P < 0.001 and P < 0.001) in comparison with those treated with MT and CABG, respectively. After propensity scorematching analysis, patients treated with PCI showed lower incidence of cardiac death (1.5 vs. 4.4%; P < 0.001), acute myocardial infarction (1.1 vs. 2.9%; P = 0.03), and re-hospitalization (2.3 vs. 4.4% P = 0.04) in comparison with those managed by MT. Conclusions Our data showed how CTO PCI might significantly improve the survival and decrease MACCE occurrence at 1 year follow-up in comparison with MT and/or CABG.

Coronary chronic total occlusions (CTOs) are commonly encountered in patients undergoing coronary angiography. Several observational studies have demonstrated that successful CTO revascularization is associated with better cardiovascular outcomes and enhanced quality of life (QOL). However, in the absence of randomized trials, its prognostic benefit for patients remains debated. Over the past decade, the interest of the interventional community in CTO percutaneous coronary intervention (PCI) has exponentially grown due to important developments in dedicated equipment and techniques, resulting in high success and low complication rates. Both European and American guidelines have assigned a class IIa (level of evidence B) recommendation for CTO PCI. In the current review, we focus on the impact of CTO revascularization on clinical outcomes and QOL and on appropriate patient selection, and we provide a critical assessment of the current guidelines and recommendations on CTO PCI.

Objectives The aims of this study were to describe the 10-year experience of a single operator dedicated to chronic total occlusion (CTO) and to establish a model for predicting technical failure. Background During the last decade, the interest in percutaneous coronary interventions (PCIs) of chronic total occlusions (CTOs) has increased, allowing the improvement of success rate. Methods One thousand nineteen patients with CTO underwent 1,073 CTO procedures performed by a single CTO-dedicated operator. The study population was subdivided into 2 groups by time period: period 1 (January 2005 to December 2009, n = 378) and period 2 (January 2010 to December 2014, n = 641). Observations were randomly assigned to a derivation set and a validation set (in a 2:1 ratio). A prediction score was established by assigning points for each independent predictor of technical failure in the derivation set according to the beta coefficient and summing all points accrued. Results Lesions attempted in period 2 were more complex in comparison with those in period 1. Compared with period 1, both technical and clinical success rates significantly improved (from 87.8% to 94.4% [p = 0.001] and from 77.6% to 89.9% [p < 0.001], respectively). A prediction score for technical failure including age ≥75 years (1 point), ostial location (1 point), and collateral filling Rentrop grade

BACKGROUND A retrograde approach improves the success rate of percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs). OBJECTIVES The authors describe the European experience with and outcomes of retrograde PCI revascularization for coronary CTOs. METHODS Follow-up data were collected from 1,395 patients with 1,582 CTO lesions enrolled between January 2008 and December 2012 for retrograde CTO PCI at 44 European centers. Major adverse cardiac and cerebrovascular events were defined as the composite of cardiac death, myocardial infarction, stroke, and further revascularization. RESULTS The mean patient age was 62.0 +/- 10.4 years; 88.5% were men. Procedural and clinical success rates were 75.3% and 71.2%, respectively. The mean clinical follow-up duration was 24.7 +/- 15.0 months. Compared with patients with failed retrograde PCI, successfully revascularized patients showed lower rates of cardiac death (0.6% vs. 4.3%, respectively; p < 0.001), myocardial infarction (2.3% vs. 5.4%, respectively; p = 0.001), further revascularization (8.6% vs. 23.6%, respectively; p < 0.001), and major adverse cardiac and cerebrovascular events (8.7% vs. 23.9%, respectively; p < 0.001). Female sex (hazard ratio [HR]: 2.06; 95% confidence interval [CI]: 1.33 to 3.18; p = 0.001), prior PCI (HR: 1.73; 95% CI: 1.16 to 2.60; p = 0.011), low left ventricular ejection fraction (HR: 2.43; 95% CI: 1.22 to 4.83; p = 0.011), J-CTO (Multicenter CTO Registry in Japan) score >= 3 (HR: 2.08; 95% CI: 1.32 to 3.27; p = 0.002), and procedural failure (HR: 2.48; 95% CI: 1.72 to 3.57; p < 0.001) were independent predictors of major adverse cardiac and cerebrovascular events at long-term follow-up. CONCLUSIONS The number of retrograde procedures in Europe has increased, with high percents of success, low rates of major complications, and good long-term outcomes. (C) 2015 by the American College of Cardiology Foundation.

We report a case of apical thrombus formation among a group of 15 patients with takotsubo cardiomyopathy who were referred for a suspected acute coronary syndrome over a 2.5-year period. To the best of our knowledge, no data are available regarding the treatment of this syndrome. According to current literature and our reported experience, the use of anticoagulant therapy administered until complete resolution of wall motion abnormalities appears to be appropriate to treat apical thrombus formation and any possible subsequent embolism. © 2008 Italian Federation of Cardiology.

Objectives: To evaluate the prognostic value of exercise myocardial scintigraphy in patients undergoing incomplete revascularization by means of percutaneous coronary intervention (PCI) with at least a residual chronic total occlusion (CTO) left untreated. Methods: Of 569 consecutive patients with multivessel disease undergoing myocardial scintigraphy after incomplete revascularization by PCI between March 1997 and December 2004, 126 (79% male, 64 ± 10 years) with ≥ 1 residual CTO fulfilled the eligibility criteria and entered in the study. Hard events defined as cardiac death and myocardial infarction, soft events defined as incidence of unstable angina and PCI procedures, and their composite were assessed at a median follow-up period of 44 months. Results: Hard events were observed in six patients (4.8%). All of them had severely abnormal perfusion defects detected by myocardial scintigraphy. Soft events occurred in 0 (0%), 10 (7.9%), and 15 (11.9%) patients with normal, mildly abnormal, and severely abnormal perfusion, respectively. In the Kaplan-Meier analysis, the log-rank test was statistically significant across patients stratified by summed stress score either in terms of hard, soft and hard, or soft events. Univariate and multivariate Cox proportional-hazards showed an incremental significant information when the scintigraphic variables were added to clinical, angiographic, left ventricular ejection fraction, and Duke treadmill score, for prediction of the composite of hard and soft cardiac events (P < 0.006). Conclusions: Among patients with a residual CTO left untreated after PCI, myocardial perfusion imaging provides significant independent information concerning the subsequent risk of cardiac events. (J Interven Cardiol 2010;23:139-148) © 2010, Wiley Periodicals, Inc.

Background: Several studies have illustrated the safety and the procedural outcome of high-frequency vibrational energy in guidewire refractory chronic total occlusions (CTOs). Aim: To evaluate the advantage of high-frequency vibrational energy device (CROSSER Catheter) use in coronary complex CTO revascularization as primary strategy. Methods: CROSSER was used as a primary approach if four or more unfavorable angiographic features were observed in the CTO lesions. Results: From May 2007 to February 2009, a CTO percutaneous intervention attempt was performed in 178 lesions of 171 patients (60.1 ± 8.9 age with 49.4 ± 7.2% in ejection fraction). Among these, the CROSSER was used in 46 complex CTO lesions of 45 patients (25.8% of cases) and in the remaining cases, typical CTO percutaneous coronary intervention techniques were employed. Clinical success was 84.8% in CROSSER group. Moreover, in the CROSSER group, no periprocedural myocardial infarction, perforation, or 30 days MACE was observed. In addition, the use of CROSSER was associated with lower time of procedure, time of fluoroscopy, and contrast load administration as compared with conventional techniques [88 ± 27 minutes vs 109 ± 38 minutes (P = 0.045), 39 ± 12 minutes vs 50 ± 27 minutes (P = 0.032), and 334 ± 122cc vs 408 ± 198cc (P = 0.05), respectively]. Conclusion: In the present study, the CROSSER System was safe and obtained a high rate of success in complex CTO similar to conventional dedicated guidewire techniques for noncomplex CTO; however, the CROSSER Catheter obtained CTO recanalization with lower contrast load administration, less time of procedure, and lower fluoroscopy exposure. (J Interven Cardiol 2010;23:130-138)

Background: Conventional two-dimensional angiography lacks the ability to properly image the true bifurcation geometry, and its percutaneous coronary intervention-induced changes in the clinical setting. Methods and Results: A novel three-dimensional reconstruction system was investigated by retrospectively analyzing 39 lesions in 35 consecutive patients with coronary bifurcation disease treated with the mini-crush technique. At baseline, significant correlations were proved between two- and three-dimensional systems in terms of either reference vessel diameter (R 2 = 0.68 and 0.29 for main and side branches, respectively), minimum lumen diameter (R 2 = 0.73 and 0.36), stenosis diameter (R 2 = 0.69 and 0.29), and lesion length (R 2 = 0.48 and 0.58). These results were consistent with those observed after the procedure and at 8-month follow-up. Lesion length was significantly longer with the three-dimensional compared to the two-dimensional system for both main and side branches (P < 0.001, and P = 0.007, respectively). Conclusions: The three-dimensional quantitative reconstruction system may provide accurate evaluation of the complex curvilinear structure of bifurcation lesions when using a double stent technique. © 2009, Wiley Periodicals, Inc.

Objective: To investigate long-term outcomes of unprotected left main coronary artery (ULMCA) disease treatment using drug-eluting stents (DES). Background: In several studies, DES implantation in ULMCA appeared safe and effective at mid-term; however, to date, there is limited long-term data. Methods: All consecutive patients undergoing sirolimus- or paclitaxel-eluting stent implantation in ULMCA disease at a single institution were evaluated. The primary endpoint was long-term major adverse cardiac events (MACE) defined as cardiac death, nonfatal myocardial infarction, or target lesion revascularization (TLR). Stent thrombosis (ST), according to Academic Research Consortium definitions, was also evaluated. Results: A total of 210 patients were assessed. In-hospital MACE rate was 1%. During a mean follow-up of 28.0 ± 14.5 months, MACE occurred in 26 patients (12.5%): cardiac death in nine patients (4.3%) and TLR in 17 patients (8.2%). The cumulative MACE-free survival rate was 89.0, 87.4, and 85.4% at 1, 2, and 3 years, respectively. ST occurred in three patients (1.4%): one case was definite and the other two were probable/possible ST; there were no cases of very late ST. Binary restenosis occurred in 8.3%. The EuroScore >6 was the only independent predictor of MACE [hazard ratio (HR) 2.24, 95% confidence interval (CI) 1.05-4.77, P = 0.04]. There was a trend toward an increased risk of MACE associated with distal ULMCA location (HR 2.14, 95% CI 0.87-5.29, P = 0.10). Conclusions: Our study showed DES implantation in ULMCA to be feasible, safe, and effective at long term. Randomized trials comparing percutaneous versus surgical revascularization are warranted to define the treatment of choice for ULMCA disease. © 2009 Wiley-Liss, Inc.

Background: Percutaneous coronary intervention (PCI) of coronary bifurcation lesions remains a subject of debate. Many studies have been published in this setting. They are often small scale and display methodological flaws and other shortcomings such as inaccurate designation of lesions, heterogeneity, and inadequate description of techniques implemented. Methods: The aim is to propose a consensus established by the European Bifurcation Club (EBC), on the definition and classification of bifurcation lesions and treatments implemented with the purpose of allowing comparisons between techniques in various anatomical and clinical settings. Results: A bifurcation lesion is a coronary artery narrowing occurring adjacent to, and/or involving, the origin of a significant side branch. The simple lesion classification proposed by Medina has been adopted. To analyze the outcomes of different techniques by intention to treat, it is necessary to clearly define which vessel is the distal main branch and which is (are) the side branche(s) and give each branch a distinct name. Each segment of the bifurcation has been named following the same pattern as the Medina classification. The classification of the techniques (MADS: Main, Across, Distal, Side) is based on the manner in which the first stent has been implanted. A visual presentation of PCI techniques and devices used should allow the development of a software describing quickly and accurately the procedure performed. Conclusion: The EBC proposes a new classification of bifurcation lesions and their treatments to permit accurate comparisons of well described techniques in homogeneous lesion groups. (c) 2008 Wiley-Liss, Inc. Udgivelsesdato: 2007-Nov-5

Aims Recanalisation rates of coronary chronic total occlusions (CTO) remain sub-optimal. The retrograde technique was recently introduced to improve success rates. Methods and results From February 2005 until December 2007, 175 patients were treated with this technique in seven European centres by highly experienced operators: in 84 (48%) as primary strategy, in 41 (23.5%) immediately after antegrade failure and in 50 (28.5%) as a repeat procedure after previous antegrade failure. Baseline characteristics revealed a mean age 61.4 +/- 10.8 years with 29.5% and 39% of patients having diabetes and a prior history of MI, respectively. The mean occlusion duration was 50.8 months (determined in 32% of patients). The target vessel was: LAD 21%, LCX 6.3%, RCA 71.4%. Epicardial collaterals were accessed in 20.6% and septal in 79.4% of the patients. Overall success rate was 83.4%. In 80.6% a wire crossed the collaterals and successfully delivered distal to the occlusion; success rate in this group was 91.5%. The technique implemented in the retrograde facilitated successful recanalisation was: retrograde wire/balloon crossing in 28%, CART in 34% and marker wire/"knuckle" technique in 48%. There was a great diversity between centres referring to the retrograde technique used. According to the initial strategy success rates were: primary 89.3%, immediately after antegrade failure 65.9% and repeat procedure after antegrade failure in 88%. In patients with failure to cross the collaterals success rate was 50%. Septal rupture/haematoma occurred in 6.9% of the patients, periprocedural myocardial infarction (CK-MB rise) in 4% and TIA in 0.6% and wire entrapment in 0.6%. Mean fluoroscopy time was 59.3 mn and the mean contrast used was 420.9 ml. Drug eluting stents were implanted in all successfully recanalised vessels. Conclusions There is great diversity amongst European centres with respect to how the retrograde strategy has been adopted and adapted. The retrograde approach was used with high degree of success and safety and can thus be regarded as a valid contributor to the armamentarium of the modern day interventional cardiologist.

OBJECTIVE - It is still controversial whether sirolimus-eluting stent (SES) and paclitaxel-eluting stent (PES) are equally effective in patients with diabetes. In these patients, multiple individual variables may be responsible for neointimal hyperplasia, thus making difficult the comparison of the two drug-eluting stents (DES). RESEARCH DESIGN AND METHODS - We designed a prospective, randomized study to compare the efficacy in prevention of restenosis of SES and PES, both implanted in the same diabetic patient with multiple de novo coronary artery lesions undergoing elective percutaneous coronary intervention. We enrolled 60 patients with diabetes with at least two significant de novo angiographic stenoses in different coronary segments. The primary end point was in-stent late luminal loss (LLL) at 8-month angiographic follow-up. RESULTS - A total of 120 lesions were successfully treated with the randomly assigned DES (SES, n=60; PES, n=60). In-stent LLL was lower in the SES than in the PES group (0.26 ± 0.4 vs. 0.50 ± 0.6 mm; P = 0.01). Coronary lesions treated with SES presented a reduced in-stent LLL in 40 (68%) patients, while PES resulted in a lower in-stent LLL in 19 (32%) patients (P = 0.0002). At multivariable analysis, the type of DES implanted was the only independent predictor of in-stent LLL (odds ratio 2.3 [95% CI 1.1-5.0]; P = 0.03). CONCLUSIONS - SES directly compared with PES in the same diabetic patient is associated with a decrease in the extent of in-stent LLL at 8 months, suggesting a reduced risk of restenosis. © 2008 by the American Diabetes Association.

Aims. Radiation exposure is a limiting factor for percutaneous coronary interventions (PCI) of chronic total coronary occlusion (CTO) lesions. This study was designed to analyze changes in patient radiation dose for CTO-PCI and parameters associated with radiation dose. Methods and Results. We analyzed a cohort of 12,136 procedures performed by 23 operators between 2012 and 2017 from the European Registry of CTO-PCI. Radiation exposure was recorded as air kerma (AK) and dose area product (DAP). A dose rate index (DRI) was calculated as AK per fluoroscopy time to normalize for individual differences in fluoroscopy time. The lesion complexity increased from Japanese-CTO (J-CTO) score of 2.19 +/- 1.44 to 2.46 +/- 1.28, with an increase of retrograde procedures from 31.1% to 40.7%; still, procedural success improved from 87.7% to 92.1%. Fluoroscopy time remained similar, but AK decreased by 14.9%, from 2.35 Gy (interquartile range [IQR], 1.29-4.14 Gy) to 2.00 Gy (IQR, 1.08-3.45 Gy) and DAP decreased by 21.5%, from 130 Gy.cm(2) (IQR, 70-241 Gy.cm(2)) to 102 Gy.cm(2) (IQR, 58-184 Gy.cm(2)). Radiation exposure was determined by the lesion complexity (J-CTO score) and procedural complexity (antegrade or retrograde). DRI was determined by fluoroscopy frame rate and type of equipment used, but the major influence remained interoperator differences. Conclusions. Radiation exposure decreased during the observation period despite an increase in lesion and procedural complexity. While many operators already achieved a goal of low radiation exposure, there were considerable interoperator differences in radiation management, indicating further potential for improvement.