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Contemporary practices for hemodynamically supported high-risk percutaneous coronary intervention have evolved over the last decade. This study sought to compare outcomes of the prospective, multicenter, PROTECT III study to historic patients treated with Impella in the PROTECT II randomized controlled trial.Of 1,134 patients enrolled in PROTECT III from March 2017 to March 2020, 504 were "PROTECT II-like" (met eligibility for PROTECT II randomized controlled trial) and are referred to as PROTECT III for comparative analysis. Major adverse cardiac and cerebrovascular events (MACCE), comprising all-cause mortality, stroke/transient ischemic attack, myocardial infarction, and repeat revascularization, were compared at hospital discharge and 90 days.Compared with PROTECT II (N = 216), PROTECT III patients were less often Caucasian (77.1% vs 83.8%, P = .045), with less prior CABG (13.7% vs 39.4%; P.001) and prior myocardial infarction (40.7% vs 69.3%; P.001). More PROTECT III patients underwent rotational atherectomy (37.1% vs 14.8%, P.001) and duration of support was longer (median 1.6 vs 1.3 hours; p0.001), with greater improvement achieved in myocardial ischemia jeopardy scores (7.0±2.4 vs 4.4±2.9; P.001) and SYNTAX scores (21.4±10.8 vs 15.7±9.5; P.001). In-hospital bleeding requiring transfusion was significantly lower in PROTECT III (1.8% vs 9.3%; P.001), as was procedural hypotension (2.2% vs 10.1%; P.001) and cardiopulmonary resuscitation or ventricular arrhythmia (1.6% vs 6.9%; P.001). At 90 days, MACCE was 15.1% and 21.9% in PROTECT III and PROTECT II, respectively (p=0.037). Following propensity score matching, Kaplan-Meier analysis showed improved 90-day MACCE rates in PROTECT III (10.4% vs 16.9%, P = .048).The PROTECT III study demonstrates improved completeness of revascularization, less bleeding, and improved 90-day clinical outcomes compared to PROTECT II for Impella-supported high-risk percutaneous coronary intervention among patients with severely depressed LVEF.

Background The use of drug-coated balloons (DCBs) in small-vessel coronary artery disease (SVD) remains controversial. Methods We performed a meta-analysis of all randomized controlled trials (RCTs) reporting the outcomes of DCB vs. DES in de-novo SVD. We included a total of 5 RCTs (1459 patients), with (DCB n = 734 and DES n = 725). Results Over a median follow-up duration of 6 months, DCB was associated with a smaller late lumen loss (LLL) compared with DES (mean difference − 0.12 mm (95% confidence interval (CI) [−0.21, −0.03 mm], p = 0.01). Over a median follow-up of 12 months, both modalities had a similar risk of major adverse cardiovascular events (MACE) (8.7% vs. 10.2%; odds ratio (OR): 0.94, 95% CI [0.49–1.79], p = 084), all-cause mortality (1.17% vs. 2.38%; OR: 0.53, 95% CI [0.16–1.75], p = 0.30), target lesion revascularization (TLR) (7.9% vs. 3.9%; OR: 1.26, 95% CI [0.51–3.14], p = 0.62), and target vessel revascularization (TVR) (8.2% vs. 7.8%; OR: 1.06, 95% CI [0.40–2.82], p = 0.91). DCBs were associated with a lower risk of myocardial infarction (MI) compared with DES (1.55% vs. 3.31%; OR: 0.48, 95% CI [0.23–1.00], p = 0.05, I2 = 0%). Conclusion PCI of SVD with DCBs is associated with a smaller LLL, a lower risk of MI, and a similar risk of MACE, death, TLR, and TVR compared with DES over one year. DCB appears as an attractive alternative to DES in patients with de-novo SVD, but long-term clinical data beyond are still needed.

Percutaneous ventricular assist devices (pVAD) are frequently utilized in high-risk percutaneous coronary intervention (HR-PCI) to provide hemodynamic support in patients with complex cardiovascular disease and/or multiple comorbidities who are poor candidates for surgical revascularization. Using the National Inpatient Sample we identified pVAD-assisted PCI (excluding intra-aortic balloon pump) in patients without cardiogenic shock from January 2008 to December 2018. We evaluated the trends in patient and procedural characteristics, and complication rates across the 11-year study period. A total of 26,661 pVAD-PCI was performed. From 2008 to 2018 there has was a 27-fold increase in the number of pVAD-PCIs performed annually. There has also been an increase in the proportion of procedures performed in small to medium sized hospitals. The use of atherectomy, image-guided PCI, FFR/iFR, drug-eluting stents, and multi-vessel intervention has significantly increased. Patients undergoing pVAD-PCI had a higher burden of comorbidities, without a significant difference in mortality over time. There were decreased rates of acute stroke and blood transfusions over time, while vascular complications and acute kidney injury (AKI) requiring dialysis remained mostly unchanged. In conclusion, the use of pVAD for HR-PCI has increased significantly, along with adjunctive PCI techniques such as atherectomy, intravascular imaging, and physiologic lesion assessment. With increasing use of this device, there appeared to be lower rates of peri-procedural stroke, and blood transfusions. Despite a higher burden of comorbidities, adjusted mortality remained stable over time.

The use of mechanical circulatory devices to support high-risk elective percutaneous coronary intervention (PCI) has become more common as the group of patients considered inoperable or high risk for surgical revascularization has grown. Most of the data examining outcomes in high-risk PCI are observational and retrospective. Limited prospective randomized studies have been unable to show improved clinical outcomes with routine mechanical circulatory support (MCS) in patients with a high burden of coronary artery disease and reduced ejection fraction. The role for MCS in high-risk PCI continues to evolve as understanding of the appropriate groups for this therapy evolves.

Abstract: Coronary artery calcifications (CAC) has been known to be associated with worse Percutaneous Coronary Intervention (PCI) short- and long-term outcomes. Nowadays with the increased prevalence of the risk factors leading to CAC in the population and also more PCI procedures done in older patients and with the growing number of higher risk cases of chronic total occlusion (CTO) PCI and PCI after coronary artery bypass grafting(CABG), severe cases of CAC are now encountered on a daily basis in the catheterization lab and remain a big challenge to the interventional community, making it crucial to identify cases of severe CAC and plan a CAC PCI modification strategy upfront. Improved CAC detection with intravascular imaging helped identifying more of these severe CAC cases and predicting response to therapy and stent expansion based on CAC distribution in the vessel. Multiple available therapies for CAC modification has evolved over the years, familiarity with the specifics and special considerations and limitations of each of these tools is essential in the choice and application of these therapies when used in severe CAC treatment. In this review we discuss CAC pathophysiology, modes of detection, and different available therapies for CAC modification.

INTRODUCTION Intravascular imaging-guided percutaneous coronary intervention (PCI) has shown to improve outcomes in randomized controlled trials. However, there are little real-world data about intravascular imaging utilization during PCI and its outcomes in the United States. METHODS We conducted an observational analysis on the use of intravascular imaging (Intravascular Ultrasound or Optical Coherence Tomography)-guided PCI in 2,425,036 patients undergoing PCI between January 2010 and December 2014 from the Nationwide Inpatient Sample database. Utilizing propensity score matching, 83,988 matched pairs were identified. The primary outcome was in-hospital mortality. The secondary outcomes included cardiogenic shock and acute kidney injury. RESULTS Among the 2,425,036 patients, 161,808 (6.7%) underwent imaging-guided PCI. Use of imaging-guidance increased from 6% in 2010 to 6.6% in 2014 (Ptrend < 0.001). The in-hospital mortality was significantly different between imaging-guided PCI and angiography-guided PCI [1.0% vs. 1.5%; adjusted OR: 0.67; 95% confidence interval (CI): 0.54-0.83, P < 0.001]. The rates of cardiogenic shock (2.5% vs. 3.1%; adjusted OR: 0.78; 95% CI: 0.66-0.93; P = 0.005) were significantly lower in imaging-guided PCI group and acute kidney injury rates (7.0% vs. 7.1%; adjusted OR: 0.99; 95% CI: 0.89-1.12; P = 0.919) were not significantly different. CONCLUSIONS Imaging-guided PCI is associated with lower in-hospital mortality. Yet, a small proportion of patients undergoing PCI have imaging-guidance.

Background Gadolinium-based contrast agents have been used as an alternative to iodinated contrast agents for simple percutaneous coronary interventions (PCIs) in patients with obstructive coronary artery disease. Their use has been limited in complex PCI due to poor image quality with gadolinium contrast. Significant dilution of gadolinium is required in an effort to avoid malignant ventricular arrhythmias. Further, the recommended amount of gadolinium contrast that can be used is very limited. Case summary We describe a case of patient with severe anaphylaxis to iodinated contrast agents despite pre-exposure prophylaxis with steroids and histamine blockers who underwent intravascular imaging-guided PCI of chronic total occlusions (CTOs) of left anterior descending and dominant left circumflex arteries using gadolinium contrast. Discussion In patients with anaphylaxis to iodinated contrast agents (i) complex coronary interventions including CTO PCI can be successfully performed without use of iodinated contrast, and (ii) combination of intravascular ultrasound guidance and gadolinium-based contrast agents can be safely and effectively used to perform complex PCI.

Introduction: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been advancing due to improvement of equipment, operator experience, and techniques. Methods: We examined contemporary outcomes of CTO PCI by analyzing the clinical, angiographic, and procedural characteristics of 7,031 CTO interventions performed in 6,984 patients at 35 participating centers between 2012 and 2020. Results: Mean age was 64.5 ± 10 years and 82% of the patients were men. The patients had high prevalence of comorbidities, such as diabetes (42%), prior coronary artery bypass graft surgery (29%), prior myocardial infarction (45%), and prior heart failure (29%). The most common CTO target vessel was the right coronary artery (53%), followed by the left anterior descending artery (26%), and left circumflex artery (20%). The mean J-CTO and PROGRESS scores were 2.41 ± 1.28 and 1.09 ± 1.01, respectively. The overall technical and procedural success rates were 85.9% and 83.8% and the rate of in-hospital major cardiac adverse events (MACE) was 2.06%. Technical success and procedural success rates were lower for higher values of J-CTO and PROGRESS scores, and MACE rate was higher ( Figure 1 ). The final successful crossing strategy was antegrade wire escalation in 53.7%, retrograde in 19.9%, and antegrade dissection reentry in 14.6%. The overall median air kerma radiation dose, contrast volume, procedure and fluoroscopy time were 2.30 (1.30, 3.90) Gray, 225 (160, 305) ml, 115 (75, 170) and 43 (26, 70) minutes, respectively. Conclusions: Using a combination of crossing strategies, high success and acceptable complication rates can be achieved in CTO PCI among various centers and patient populations.

Objectives This study sought to compare outcomes of patients enrolled in the NCSI (National Cardiogenic Shock Initiative) trial who were treated using a revascularization strategy of percutaneous coronary intervention (PCI) of multivessel PCI (MV-PCI) versus culprit-vessel PCI (CV-PCI). Background In patients with multivessel disease who present with acute myocardial infarction and cardiogenic shock (AMICS), intervening on the nonculprit vessel is controversial. There are conflicting published reports and lack of evidence, particularly in patients treated with early mechanical circulatory support (MCS). Methods From July 2016 to December 2019, patients who presented with AMICS to 57 participating hospitals were included in this analysis. All patients were treated using a standard shock protocol emphasizing early MCS, revascularization, and invasive hemodynamic monitoring. Patients with multivessel coronary artery disease (MVCAD) were analyzed according to whether CV-PCI or MV-PCI was undertaken during the index procedure. Results Of 198 patients with MVCAD, 126 underwent MV-PCI (64%) and 72 underwent CV-PCI (36%). Demographics between the cohorts were similar with respect to age, sex, history of diabetes, prior PCI or coronary artery bypass grafting, and prior history of myocardial infarction. Patients who underwent MV-PCI had a trend toward more severe impairment of cardiac output and worse lactate clearance on presentation, and cardiac performance was significantly worse at 12 h. However, 24 h from PCI, the hemometabolic derangements were similar. Survival and rates of acute kidney injury were not significantly different between groups (69.8% MV-PCI vs. 65.3% CV-PCI; p = 0.51; and 29.9% vs. 34.2%; p = 0.64, respectively). Conclusions In patients with MVCAD presenting with AMICS treated with early MCS, revascularization of nonculprit lesions was associated with similar hospital survival and acute kidney injury when compared with culprit-only PCI. Selective nonculprit PCI can be safety performed in AMICS in patients supported with mechanical circulatory support.

Background Debulking and ablative techniques are sometimes used for the treatment of in-stent restenosis (ISR) secondary to resistant stent under-expansion (SU). The safety and effectiveness of orbital atherectomy (OA) in this cohort of patients has not been reported. Methods We retrospectively evaluated consecutive patients treated with OA for ISR secondary to balloon undilatable SU at two academic tertiary care centers between October 2016 and June 2019. Angiographic or intravascular imaging identified SU. Technical success was defined as residual 0% stenosis with TIMI III flow. Results A total of 41 patients were included in the study. Patients had an average age of 65 ± 12 years; 73% male, 61% diabetic, 41% with prior coronary artery bypass grafting, 61% with a prior incident of ISR, 51% presented with stable angina, 17% unstable angina, and 32% non-ST elevation myocardial infarction (MI). Implantation of the under-expanded stents occurred between 2 months and 22 years prior to the index procedure. A total of 27% of patients had multiple layers of stents in the target lesion and 32% of patients had in-stent chronic total occlusion. Technical success was achieved in 40 (98%) patients. There were 2 (5%) major adverse cardiovascular events; both of them were periprocedural MI from the no-reflow phenomenon. There were 2 (5%) Ellis type II coronary perforations that required no intervention. Conclusions OA can be effectively performed as an adjunctive tool in the treatment of ISR with balloon undilatable SU. The use of OA for SU is not approved by the U.S. Food and Drug Administration and is "off label" and caution must be used to limit any device/stent interaction.

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.

We examined the procedural outcomes of chronic total occlusions (CTO) percutaneous coronary interventions in patients with prior coronary artery bypass graft surgery (CABG).We compared the clinical, angiographic characteristics and outcomes of 3486 CTO interventions performed in patients with (n=1101) and without (n=2317) prior CABG at 21 centers. Prior CABG patients (32% of total cohort) were older (67±9 versus 63±10 years; P0.001) and had more comorbidities and lower left ventricular ejection fraction (50% [40-58] versus 55% [45-60]; P0.001). The CTO target vessel in prior CABG patients was the right coronary artery (56%), circumflex (26%), and left anterior descending artery (17%). The mean J-CTO (2.9±1.2 versus 2.2±1.3; P0.001) and PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention; 1.5±1.1 versus 1.2±1.0; P0.001) score was higher in prior CABG patients. Retrograde (53% versus 30%, P0.001) and antegrade dissection reentry (35% versus 28%; P0.001) techniques were used more frequently in prior CABG patients. Prior CABG patients had lower technical (84% versus 89%; P0.001) and procedural (82% versus 87%, P0.001) success, but similar incidence of in-hospital major complications (3.1% versus 2.5%; P=0.287). In-hospital mortality (1% versus 0.4%; P=0.016) and coronary perforation (7.1% versus 3.1%; P0.001) occurred more frequently in prior CABG patients, however, CABG patients had a lower incidence of pericardial tamponade (0.1% versus 1.0%; P=0.002) and pericardiocentesis (0% versus 1.3%; P0.001).In a large multicenter CTO percutaneous coronary interventions registry, prior CABG patients had lower success rate but similar overall risk for complications, although mortality was higher and the incidence of tamponade was lower.URL: https://www.clinicaltrials.gov . Unique identifier: NCT02061436.

Objectives We sought to describe contemporary guidewire and microcatheter utilization for antegrade wire escalation (AWE) during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Background Equipment utilization for AWE has been variable and evolving over time. Methods We examined device utilization during 694 AWE attempts in 679 patients performed at 15 experienced US centers between May 2012 and April 2015. Results Mean age was 65.6 ± 9.7 years, and 85% of the patients were men. Successful wiring occurred in 436 AWE attempts (63%). Final technical and procedural success was 91% and 89%, respectively. The mean number of guidewire types used for AWE was 2.2 ± 1.4. The most frequently used guidewire types were the Pilot 200 (Abbott Vascular, 56% of AWE procedures), Fielder XT (Asahi Intecc, 45%), and the Confianza Pro 12 (Asahi Intecc, 28%). The same guidewires were the ones that most commonly crossed the occlusion: Pilot 200 (36% of successful AWE crossings), Fielder XT (20%), and Confianza Pro 12 (11%). A microcatheter or over-the-wire balloon was used for 81% of AWE attempts; the Corsair microcatheter (Asahi Intecc) was the most commonly used (44%). No significant association was found between guidewire type and incidence of major adverse cardiac events (MACE). Conclusions Our contemporary, multicenter CTO PCI registry demonstrates that the most commonly used wires for AWE are polymer-jacketed guidewires. "Stiff" and polymer-jacketed guidewires appear to provide high crossing rates without an increase in MACE or perforation, and may thus be considered for upfront use. © 2016 Wiley Periodicals, Inc.

Objectives\ud \ud The aim of the Hybrid Video Registry (HVR) is to assess the acute safety and efficacy of the Hybrid Approach in comparison to other contemporary methods of CTO‐PCI. Background: Recently, multiple techniques in Percutaneous Coronary Intervention (PCI) for coronary Chronic Total Occlusions (CTO) have been synthesized into a method referred to as the “Hybrid Approach”.\ud \ud Methods\ud \ud About 194 video‐taped timed live cases from CTO‐PCI training workshops were analyzed by independent data abstractors and compared to three contemporary CTO‐PCI registries stratified by case complexity based on the J‐CTO score.\ud \ud Results\ud \ud Overall procedural success was 95% of all cases attempted with an excellent safety profile. In the most complex lesion subset, which made up 45% of all HVR cases, success was 92.8%, which was significantly higher than either the Royal Bromptom (78.9%), or Japanese‐CTO (73.3%) registries, P = 0.04 Hybrid vs. Royal Brompton, P = 0.006 Hybrid vs. Japanese‐CTO). The Hybrid Approach was also associated with shorter procedure times and lower contrast utilization.\ud \ud Conclusions\ud \ud In a real world angiographic registry of complex CTOs, the Hybrid Approach to CTO‐PCI is safe, and may be superior to other contemporary approaches to CTO intervention with respect to procedural success and efficiency among a diverse group of operators and lesion complexity.

Currently, there are no data on the use of mechanical circulatory support (MCS) in patients without severely depressed left ventricular ejection fraction (LVEF) during high-risk percutaneous coronary intervention (PCI). We analyzed data from the global catheter-based ventricular assist device (cVAD) registry on the clinical use of MCS in high-risk PCI in patients without severely depressed LVEF, defined as LVEF 35%. Patients without cardiogenic shock from the catheter-based ventricular assist device registry, who underwent elective or urgent PCI with an Impella 2.5 or Impella CP, were included. Patients who received MCS after the start of the PCI were excluded. A total of 891 patients were included, of whom 661 had LVEF ≤ 35% and 230 had LVEF 35%. Patients with LVEF 35% compared with patients with LVEF ≤ 35% were older (72.12 ± 11.70 years vs 68.68 ± 11.01 years; p 0.001), had more extensive coronary artery disease with more diseased vessels (1.90 ± 0.71 vs 1.73 ± 0.79; p = 0.005), more multivessel intervention (1.74 ± 0.69 vs 1.55 ± 0.73; p 0.001), and more use of rotational atherectomy (21.21% vs 14.90%; p = 0.046), respectively. Additionally, they had a high prevalence of high-risk clinical features such as renal failure (24.89%) and diabetes mellitus (45.37%). Despite these high-risk features, the major adverse cardiovascular and cerebral event rates were favorable overall, with no differences between the 2 groups (3.48% vs 4.54%; p = 0.574). Despite having LVEF 35%, this selected group of patients had severe co-morbidities and complex angiographic features; hence, PCI with hemodynamic support was deemed necessary. In addition, PCI with elective MCS was feasible and safe in this patient population.

Objective To assess the spatial distribution of chronic total occlusions (CTOs) within the coronary arteries and describe procedural strategies and outcomes during CTO percutaneous coronary intervention (PCI). Background Acute occlusions due to plaque rupture tend to cluster within the proximal third of the coronary artery. Methods We examined the clinical and procedural characteristics of 1,348 patients according to lesion location within the coronary tree. Results A total of 1,369 lesions in 1,348 patients (mean age 66 ± 10 years, 85% male) were included. CTO PCI of proximal segments (n = 633, 46%) was more common than of mid (n = 557, 41%) and distal segments (n = 179, 13%). Patients undergoing CTO PCI of proximal segments were more likely to be smokers (P

AIMS The goal of this study was to describe the procedural characteristics, strategy selection and associated technical and efficiency outcomes for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) of the right coronary artery (RCA). METHODS AND RESULTS We examined the clinical and angiographic characteristics of patients who underwent RCA CTO PCI between 2012 and 2015 at 11 centres in the USA. The RCA was the CTO target vessel in 739 of 1,308 CTO PCIs (56%). Overall technical and procedural success rates were 90% and 88%, respectively. A major adverse cardiovascular event (MACE) occurred in 19 patients (2.6%). Technical success was most frequently achieved using antegrade wire escalation (38% of successful procedures) followed by retrograde (36%) and antegrade dissection/re-entry (26%). Technical success was similar between various locations of RCA CTOs (p=0.11). Compared with antegrade-only procedures, utilisation of any retrograde approach was associated with lower technical (85% vs. 95%, p