Search

Objectives We sought to evaluate the impact of crossing strategy on the incidence of periprocedural myocardial infarction (PMI) during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Background: The optimal technique for crossing coronary CTOs remains controversial. Methods: We retrospectively examined the incidence of PMI among 184 consecutive patients who underwent CTO PCI at our institution between 2012 and 2015. Creatine kinase-myocardial band fraction (CK-MB) and troponin were measured before and after PCI in all patients. PMI was defined as CK-MB increase ≥3× upper limit of normal (ULN). Results: Mean age was 65 ± 8 years, 98% of patients were men, 57% had diabetes mellitus, 36% were current smokers, 38% had prior heart failure, 31% had prior coronary artery bypass graft surgery (CABG), and 55% had prior PCI. The retrograde approach was used in 38% of cases. As compared with antegrade wire escalation and antegrade dissection/re-entry, use of the retrograde approach was associated with higher J-CTO (Multicenter CTO Registry of Japan) scores (P

Summary Background Few studies have examined the efficacy of drug-eluting stents (DES) for reducing aortocoronary saphenous vein bypass graft (SVG) failure compared with bare-metal stents (BMS) in patients undergoing stenting of de-novo SVG lesions. We assessed the risks and benefits of the use of DES versus BMS in de-novo SVG lesions. Methods Patients were recruited to our double-blind, randomised controlled trial from 25 US Department of Veterans Affairs centres. Eligible participants were aged at least 18 years and had at least one significant de-novo SVG lesion (50–99% stenosis of a 2·25–4·5 mm diameter SVG) requiring percutaneous coronary intervention with intent to use embolic protection devices. Enrolled patients were randomly assigned, in a 1:1 ratio, by phone randomisation system to receive a DES or BMS. Randomisation was stratified by presence or absence of diabetes and number of target SVG lesions requiring percutaneous coronary intervention (one or two or more) within each participating site by use of an adaptive scheme intended to balance the two stent type groups on marginal totals for the stratification factors. Patients, referring physicians, study coordinators, and outcome assessors were masked to group allocation. The primary endpoint was the 12-month incidence of target vessel failure, defined as the composite of cardiac death, target vessel myocardial infarction, or target vessel revascularisation. The DIVA trial is registered with ClinicalTrials.gov, number NCT01121224. Findings Between Jan 1, 2012, and Dec 31, 2015, 599 patients were randomly assigned to the stent groups, and the data for 597 patients were used. The patients' mean age was 68·6 (SD 7·6) years, and 595 (>99%) patients were men. The two stent groups were similar for most baseline characteristics. At 12 months, the incidence of target vessel failure was 17% (51 of 292) in the DES group versus 19% (58 of 305) in the BMS group (adjusted hazard ratio 0·92, 95% CI 0·63–1·34, p=0·70). Between-group differences in the components of the primary endpoint, serious adverse events, or stent thrombosis were not significant. Enrolment was stopped before the revised target sample size of 762 patients was reached. Interpretation In patients undergoing stenting of de-novo SVG lesions, no significant differences in outcomes between those receiving DES and BMS during 12 months of follow-up were found. The study results have important economic implications in countries with high DES prices such as the USA, because they suggest that the lower-cost BMS can be used in SVG lesions without compromising either safety or efficacy. Funding US Department of Veterans Affairs Cooperative Studies Program.

Background As compared with bare metal stents, first-generation drug-eluting stents (DES) improved post-procedural outcomes in aortocoronary saphenous vein graft (SVG) lesions, but there is limited information on outcomes after use of second-generation DES in SVGs. Methods We compared the outcomes of patients who received first- (n = 81) with those who received second-generation (n = 166) DES in SVG lesions at our institution between 2006 and 2013. Major adverse cardiac events (MACE) were defined as the composite of all-cause death, myocardial infarction, and target vessel revascularization. Results Mean age was 66.0 ± 8.1 years and 97.6% of the patients were men. Mean SVG age was 11.1 ± 0.4 years. First-generation DES were sirolimus-eluting (n = 17) and paclitaxel-eluting (n = 64) stents. Second-generation DES were everolimus-eluting (n = 115) and zotarolimus-eluting (n = 51) stents. Median follow-up was 41 months. At 2-years post-procedure, patients with first- and second-generation DES had similar rates of death (20.91% vs. 20.27%, P = 0.916), target lesion revascularization (16.39% vs. 20.00%, P = 0.572), target vessel revascularization (20.97% vs. 23.16%, P = 0.747), myocardial infarction (26.15% vs. 23.00%, P = 0.644), and MACE (43.5% vs. 40.87%, P = 0.707), respectively. Conclusions Outcomes with first- and second-generation DES in SVGs are similar. Novel stent designs are needed to further improve the clinical outcomes in this challenging patient and lesion subgroup. © 2015 Wiley Periodicals, Inc.

Objective To compare long-term clinical outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using the retrograde and antegrade approach. Background There is limited long-term clinical outcomes data on the retrograde approach to CTO PCI. Methods We performed a retrospective analysis of the long-term clinical outcomes of 193 consecutive patients who underwent successful CTO PCI at our institution between March 2008 and December 2011. Results Mean age was 63.6 ± 8.3 years. The target vessel was right coronary artery in 52.6%, left anterior descending artery in 24.5% and circumflex in 21.4% of cases. The retrograde approach was used in 41 patients (21.2%). The mean stent length was longer in the retrograde group (83 ± 32 vs. 64 ± 32 mm, P = 0.001). Two major procedural complications occurred, both in the retrograde group (P = 0.012). During a median follow-up of 2.0 years compared to the antegrade CTO PCI group, patients who underwent retrograde CTO PCI were more likely to undergo target lesion revascularization (TLR) (45.6% vs. 25.7%, P = 0.006). No significant difference was observed in the incidence of all-cause mortality, myocardial infarction, non-target vessel revascularization, or coronary artery bypass graft surgery between the 2 groups. On multivariate analysis, stent length was the only independent predictor of TLR during follow-up. Conclusions Retrograde CTO PCI was associated with higher incidence of TLR, but similar incidence of death and myocardial infarction compared to antegrade CTO PCI. These findings likely reflect the higher complexity of CTO lesions treated with the retrograde approach. (J Interven Cardiol 2014;27:465–471)

Aortocoronary dissection can complicate percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs).We retrospectively examined the frequency and outcomes of aortocoronary dissection among 336 consecutive CTO PCIs performed at our institution between 2005 and 2012 and performed a systematic review of the published literature.Aortocoronary dissection occurred in six patients (1.8%, 95% confidence intervals 0.7%, 3.8%). All aortocoronary dissections occurred in the right coronary artery (CTO target vessel in five patients and donor vessel in one patient). The baseline clinical characteristics of patients with and without aortocoronary dissection were similar. Compared to patients without, those with aortocoronary dissection were more likely to undergo crossing attempts using the retrograde approach (25% vs. 67%, P = 0.036) and experience a major complication (2.4% vs. 33.3%, P = 0.008). Technical and procedural success rates were similar in both groups. Of the six patients with aortocoronary dissection one underwent emergency coronary bypass graft surgery (CABG), four were treated with ostial stenting, and one was treated conservatively without subsequent adverse clinical outcomes. Systematic literature review provided 107 published cases of aortocoronary dissection during PCI, that occurred mainly in the right coronary artery (74.8%) and were treated with stenting (49.5%), emergency CABG (29%), or conservatively (21.5%).Aortocoronary dissection is an infrequent complication of CTO PCI and although it can be treated with stents in most patients, it may infrequently require emergency CABG.

Objectives We sought to determine the contemporary prevalence and management of coronary chronic total occlusions (CTO) in a veteran population. Background The prevalence and management of CTOs in various populations has received limited study. Methods We collected clinical and angiographic data in consecutive patients that underwent coronary angiography at our institution between January 2011 and December 2012. Coronary artery disease (CAD) was defined as ≥50% diameter stenosis in ≥1 coronary artery. CTO was defined as total coronary artery occlusion of ≥3 month duration. Results Among 1,699 patients who underwent angiography during the study period, 20% did not have CAD, 20% had CAD and prior coronary artery bypass graft surgery (CABG), and 60% had CAD but no prior CABG. The prevalence of CTO among CAD patients with and without prior CABG was 89 and 31%, respectively. Compared to patients without CTO, CTO patients had more co-morbidities, more extensive CAD and were more frequently referred for CABG. Percutaneous coronary intervention (PCI) to any vessel was performed with similar frequency in patients with and without CTO (50% vs. 53%). CTO PCI was performed in 30% of patients without and 15% of patients with prior CABG with high technical (82 and 75%, respectively) and procedural success rates (80 and 73%, respectively). Conclusions In a contemporary veteran population, coronary CTOs are highly prevalent and are associated with more extensive co-morbidities and higher likelihood for CABG referral. PCI was equally likely to be performed in patients with and without CTO. © 2013 Wiley Periodicals, Inc.

Objectives: This study sought to compare and contrast use and radiation exposure using radial versus femoral access during cardiac catheterization of patients who had previously undergone coronary ...

Background Optical coherence tomography (OCT) coronary imaging requires displacement of red blood cells from the vessel lumen. This is usually accomplished using radiographic contrast. Low molecular weight dextran has low cost and is safe in low volumes. In the present study, we compared dextran with contrast for coronary OCT imaging. Methods Fifty-one vessels in 26 patients were sequentially imaged using manual injection of radiographic contrast (iodixanol) and dextran. OCT images were analyzed at 1 mm intervals to determine the image clarity (defined as a visible lumen border > 270°) and to measure the lumen area and lumen diameter. To correct for the refractive index of dextran, the dextran area measurements were multiplied by 1.117 and the dextran length measurements were multiplied by 1.057. Results A total of 3,418 cross-sections (1,709 with contrast and 1,709 with dextran) were analyzed. There were no complications related to OCT imaging or to contrast or dextran administration. Clear image segments were observed in 97.0% vs. 96.7% of the cross-sections obtained with contrast and dextran, respectively (P = 0.45). The mean lumen areas were also similar: 6.69 ± 1.95 mm2 with iodixanol vs. 7.06 ± 2.06 mm2 with dextran (correlation coefficient 0.984). Conclusions The image quality and measurements during OCT image acquisition are similar for dextran and contrast. Dextran could be used instead of contrast for OCT imaging, especially in patients in whom contrast load minimization is desired. © 2013 Wiley Periodicals, Inc.

Chronic Kidney Disease (CKD) prevalence rate among veterans has risen in the past decade. The CKD associations with long term mortality and cardiovascular adverse event risks after stented PCI are unknown among veterans population. This study extracted data from VA national Corporate Data Warehouse

Successful percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has been associated with clinical benefit. There are no randomized controlled trials on long-term clinical outcomes after CTO PCI, limiting the available evidence to observational cohort studies. We sought to perform a weighted meta-analysis of the long-term outcomes of successful versus failed CTO PCI. A total of 25 studies, published from 1990 to 2014, with 28,486 patients (29,315 CTO PCI procedures) were included. We analyzed data on mortality, subsequent coronary artery bypass grafting (CABG), myocardial infarction, major adverse cardiac events, angina pectoris, stroke, and target vessel revascularization using random-effects models. Procedural success was 71% (range 51% to 87%). During a weighted mean follow-up of 3.11 years, compared with unsuccessful, successful CTO PCI was associated with lower mortality (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.43 to 0.63), less residual angina (OR 0.38, 95% CI 0.24 to 0.60), lower risk for stroke (OR 0.72, 95% CI 0.60 to 0.88), less need for subsequent coronary artery bypass grafting (OR 0.18, 95% CI 0.14 to 0.22), and lower risk for major adverse cardiac events (0.59, 95% CI 0.44 to 0.79). There was no difference in the incidence of target vessel revascularization (OR 0.66, 95% CI 0.36 to 1.23) or myocardial infarction (OR 0.73, 95% CI 0.52 to 1.03). Outcomes were similar in patients who underwent balloon angioplasty only or stenting with bare metal or drug-eluting stents. Compared with failed procedures, successful CTO PCIs are associated with a lower risk of death, stroke, and coronary artery bypass grafting and less recurrent angina pectoris.

Background: In percutaneous coronary intervention (PCI) of coronary chronic total occlusions (CTOs), inability to cross the lesion with a balloon is the second most common cause of technical failure following inability to cross the lesion with a guidewire. While various techniques have been reported for such "balloon uncrossable" CTOs, the frequency and outcomes of these techniques have received limited study. Methods: We retrospectively examined 373 consecutive CTO PCIs performed at our institution between 2005 and 2013 to determine the frequency and outcomes of “balloon uncrossable” CTOs. Results: Mean age was 63.7 ± 8.3 years and 98.9% of the patients were men. Twenty four patients (6.4%) were found to have a "balloon uncrossable" CTO. These patients had similar clinical and angiographic characteristics compared to the other CTO PCI patients (Table). Successful crossing of the lesion was achieved in 22 of 24 patients (91.7%) using a variety of techniques, such as successive balloon inflations (43.5%), microcatheter advancement (21.7%), laser (8.7%), increased guide catheter support (13.0%), and subintimal lesion crossing (13.0%) (Figure). Patients with “balloon uncrossable” CTOs had longer procedure time (184.5 ± 77.9 vs. 134.0 ± 69.0 min, p Conclusion: “Balloon uncrossable” CTOs occur in 6.4% of contemporary CTO PCIs and can be successfully treated in most patients using a variety of techniques.

Cardiologist Jerry Grodin, MD (Figure ​(Figure1),1), volunteered for the US Army Reserve soon after the terrorist attacks on September 11, 2001. He spent a tour of duty in 2004 with the 67th Combat Support Hospital in Mosul, Iraq. More recently, Major Grodin was reactivated and sent to the US Army's Landstuhl Regional Medical Center in Ramstein, Germany. He periodically writes letters to his colleagues. Baylor University Medical Center Proceedings will reprint occasional letters to inform the Baylor community of a perspective on the war and our soldiers. Dr. Grodin can be reached at jerrold.m.grodin@us.army.mil.

a complete coronary revascularization as compared to patients with incomplete revascularization (96% 3% vs. 78% 7%; p1⁄40.002); completeness of revascularization was inversely related to the risk of death (HR 0.10; p1⁄40.029). Conclusions: In patients with multiple CTOs a successful PCI of all CTOs was associated with increased cardiac survival, and completeness of revascularization was a strong predictor of survival.

We sought to examine the prevalence and management of coronary chronic total occlusions (CTO) within a contemporary veteran population. We collected clinical and angiographic data on 1,699 consecutive patients that underwent coronary angiography at our institution between January 2011 and December

Background The efficacy and safety profile of retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We sought to perform a weighted meta-analysis of the success and complication rates of retrograde CTO PCI. Methods We conducted a meta-analysis of 26 studies published between 2006 and April 2013 reporting in-hospital outcomes of retrograde CTO PCI. Data on procedural success, frequency of death, emergent coronary artery bypass graft surgery (CABG), stroke, myocardial infarction (MI), perforation, tamponade, stent thrombosis, major vascular or bleeding events, contrast nephropathy, and radiation skin injury were collected. Results A total of 26 studies with 3482 patients and 3493 target CTO lesions were included. Primary retrograde CTO PCI was attempted in 52.4%. Pooled estimates of outcomes were as follows: procedural success 83.3% [95% confidence interval (CI): 79.0% to 87.7%]; death 0.7% (95% CI: 0.5% to 1.2%); urgent CABG 0.7% (95% CI: 0.4% to 1.2%); tamponade 1.4% (95% CI: 1.0% to 2.2%); collateral perforation 6.9% (95% CI: 4.6% to 10.4%); coronary perforation 4.3% (95% CI: 1.2% to 15.4%); donor vessel dissection 2% (95% CI: 0.9% to 4.5%); stroke 0.5% (95% CI: 0.2% to 1.0%); MI 3.1% (95% CI: 0.2% to 5.0%); Q wave MI 0.6% (95% CI: 0.4% to 1.1%); vascular access complications 2% (95% CI: 0.9% to 4.5%); contrast nephropathy 1.8% (95% CI: 0.8% to 3.7%); and wire fracture and equipment entrapment 1.2% (95% CI: 0.6% to 2.5%). Conclusions Retrograde CTO PCI is associated with high procedural success rate and acceptable risk for procedural complications.

There is ongoing controversy about the optimal crossing strategy selection for chronic total occlusion (CTO) percutaneous coronary intervention (PCI), especially regarding the relative merits of antegrade dissection/re-entry and the retrograde approach.We retrospectively examined the clinical outcomes of 173 consecutive patients who underwent successful CTO PCI at our institution between January 2012 and March 2015.The mean age was 65 ± 8 years, and 98% of the patients were men with a high prevalence of diabetes (60%), previous coronary artery bypass grafting (CABG) (31%), and previous PCI (54%). The successful CTO crossing strategy was antegrade wire escalation in 79 patients (45.5%), antegrade dissection/re-entry in 58 patients (33.5%), retrograde wire escalation in 11 patients (6.4%), and retrograde dissection and re-entry in 25 patients (14.5%). The retrograde approach was more commonly used in lesions with interventional collaterals (P0.0001), moderate/severe calcification (P = 0.02), blunt stump (P = 0.01), and a higher Japan Chronic Total Occlusion score (P = 0.0002). Use of dissection and re-entry (both antegrade and retrograde) was associated with bifurcation and the distal cap (P = 0.004), longer CTO occlusion length (P0.0001), and longer stent length (P0.0001). Median follow-up was 11 months. The 12-month incidence of death, myocardial infarction, and the composite of acute coronary syndrome/target lesion revascularization/target vessel revascularization was 2.5%, 4.9%, and 24.4%, respectively, and was similar with intimal and subintimal crossing strategies.Antegrade dissection/re-entry and retrograde approaches are frequently used during CTO PCI and were associated with similarly favorable intermediate-term outcomes as antegrade wire escalation.

We evaluated the use of Google Glass for remote transthoracic echocardiography (TTE) video capture and interpretation. Google Glass was used to record 17 TTE studies with 25 key findings. Ten physicians (3 faculty and 7 fellow cardiologists) interpreted recordings on a) desktop, b) iPhone, c) iPad

Saphenous vein grafts (SVG) are used in most coronary artery bypass graft surgeries (CABG), but have high rates early and late occlusion. We sought to examine the pathogenesis of early SVG failure using serial optical coherence tomography (OCT) imaging. OCT was performed in 10 SVGs in 9 patients at

There is limited data on outcomes after implantation of second generation drug-eluting stents in coronary chronic total occlusions (CTOs). Our study's aim is to evaluate the frequency of angiographic restenosis and clinical outcomes after implantation of the everolimus-eluting stent (EES) in CTOs