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Background Both stent length and stent overlap are associated with worse outcomes in the percutaneous treatment of diffuse coronary artery disease (dCAD). However, evidence comparing these issues is scarce. We aimed to compare the results between the use of single very long stent (VLS) and ≥2 overlapping stents (OS) in the treatment of dCAD. Methods Seven hundred twenty-four consecutive lesions were included: 275 treated with a single VLS (≥40 mm) and 449 with ≥2 OS. Procedural characteristics were assessed, and survival analysis was performed to compare the incidence of major adverse cardiovascular events (MACE; composite of cardiovascular death, nonfatal myocardial infarction, target lesion revascularization [TLR], or stent thrombosis) during a median follow-up of 31 months. Results Procedures with VLS required less contrast volume (268 ± 122 vs 302 ± 113 cm3; P < .01), fluoroscopy time (16 ± 8 vs 21 ± 16 minutes; P < .01), and procedure duration (37 ± 18 vs 47 ± 27 minutes; P < .01) than the OS procedures. The VLS group showed lower incidence of MACE (4.4% vs 10.7%; P < .01), driven mainly by lower TLR rate (1.1% vs 4.7%; P < .01). The use of OS was an independent predictor of MACE. Conclusions In this study, the use of VLS for the treatment of dCAD was associated with better outcomes compared to OS.

BACKGROUND The stent length as well as the stent overlap for the percutaneous treatment of diffuse coronary disease have been considered predictors of adverse events. However, there are no comparative data on the use of very long stents or overlapping stents in this scenario. OBJECTIVE To compare the clinical results of very long stents (≥40 mm) or overlapping stents in real clinical practice. METHODS We included 643 lesions in 628 consecutive patients treated with a single very long stent (≥40 mm) (251 lesions) or ≥2 overlapped stents (392 lesions). We analyzed the procedural characteristics and the presentation of the combined endpoint [cardiovascular death, non-fatal myocardial infarction, need for target lesion revascularization or stent thrombosis] after a follow-up of 20 months. RESULTS Total stent length was 54 ± 18 mm and minimum diameter was 2.9 ± 1.2 mm. At the end of follow-up, the rate of adverse events was 8.3% (cardiac death: 4.9%, myocardial infarction: 1.7%, target lesion revascularization: 3.1%, stent thrombosis: 0.7%). There were no significant differences between both groups in the presentation of the combined endpoint. Procedures with overlapping stents had more contrast volume (309 ± 115 vs 273 ± 127 ml; p = 0.002), longer duration (47 ± 22 vs 39 ± 18 min; p

Drug-eluting balloons currently constitute a therapeutic tool used in percutaneous coronary interventions (PCI). Long-term results remain unknown. We evaluated the prognosis of PCI using a second generation paclitaxel-eluting balloon (PEB) in real-world patients. We included all PCI with PEB in de novo or in-stent restenosis coronary lesions performed in our unit from March 2009 to March 2019. We assessed the composite of major adverse cardiovascular events (MACE) rate after a median follow-up of 42 months. Consecutive patients (n = 320) with 386 lesions were included; 46.9% presented with stable angina and 53.1% acute coronary syndromes; 52.6% of the lesions were in-stent restenosis and 47.3% de novo lesions with a mean diameter of 2.4 ± 0.5 mm. A bare metal stent was implanted in 6.7% and a drug-eluting stent in 8.5% of patients. The MACE rate was 8%: 10 (2.6%) cardiovascular deaths, 13 (3.4%) myocardial infarctions, and 16 (4.1%) target lesion revascularization. The all-cause death rate was 5.2%. No cases of thrombosis were recorded. In conclusion, PEB was a safe and effective tool to treat in-stent restenosis and de novo coronary lesions, especially small vessel disease, during long-term follow-up.

The clinical impact of percutaneous coronary intervention (PCI) and implantation of overlapping stents (OS) using platforms with the same versus different pharmacological characteristics is unknown. Our objective was to compare the outcomes of PCI with OS according to their pharmacological characteristics.In this observational single-center registry, we included all PCI performed from April 2014 to December 2018 in which overlapping drug-eluting stents were implanted. Two groups were created according to whether the stents release the same drug [homogeneous: (HO)] or different [heterogeneous: (HE)]. The primary endpoint was the need for target lesion revascularization (TLR). Clinical assessment was performed after the procedure, bianually and at the end of follow-up (June 2019).381 lesions with OS (HO: 209; HE: 172) were included (75.1% male, 66.7 ± 11.6 years). Clinical presentation was stable coronary artery disease in 49.9%. Syntax score was 23.7 ± 13.3. The number of OS implanted was 2.2 ± 0.5 and the total stent length was 59.5 ± 20.1 mm (HE: 61.5 ± 21.6 vs. HO: 57.8 ± 18.8 mm; p 0.01). After a median follow-up of 21 months, the HE group showed a lower TLR rate than the HO group (HE:2.3% vs HO:7.2%; p = 0.03). The rates of cardiac death (p = 0.44), myocardial infarction (p = 0.36) and stent thrombosis (p = 0.85) were similar between groups. In the multivariate analysis, the OS with homogeneous-drug devices was an independent predictor of a higher rate of TLR.PCI using OS with homogeneous pharmacological characteristics was associated with a higher rate of TLR in comparison with the implantation of OS with heterogeneous pharmacological characteristics.

Aims To analyse systematic isolated post-dilatation of the side branch as a part of provisional stent technique. Methods 1960 angioplasties performed in two centres were prospectively registered, of which 382 were coronary bifurcations with a side branch > 2 mm. In centre A, isolated post-dilatation of the side branch was performed regardless its impairment after main vessel stenting. In centre B, side branch post-dilatation was performed only if it was severely affected after stent implantation. Results There was no difference between the two centres in the rate of side branch affection after stent implantation (A: 44.6 vs B: 49.3%, p = 0.48) nor in the procedural success rate (A: 98.6% vs B: 96.7%, p = 0.45). After one-year follow-up, a reduction of cardiovascular events was observed in centre A (A: 4.4% vs B: 10.4%, p = 0.043) with a trend towards lower cardiac mortality (A: 2.2% vs B: 6.5%, p = 0.093) and stent thrombosis (A: 0% vs B: 2.6%, p = 0.077). There were no differences in the rate of myocardial infarction related to the treated artery (A: 1.4% vs B: 3.9%, p = 0.29), or target lesion revascularization (A: 1.4% vs. B: 3.2%, p = 0.45). Conclusions Systematic isolated post-dilatation of the side branch in the provisional stent technique was associated with a high angiographic success rate, and a low rate of cardiovascular events during follow-up. Although the study design does not allow definitive conclusions, this strategy could be considered a valid option in some cases or even as part of the provisional stent technique.

Risk awareness of no-reflow is mandatory, especially in patients with cardiovascular risk factors, long door-to-balloon time, and in the presence of angiographic evidence of a large thrombus burden. Some preventive strategies have been described. Nevertheless, in clinical practice, is difficult to avoid no-reflow. Interventional cardiologists have no guidelines or recommendations for this situation. We suggest that a conservative management with dual antiplatelet therapy and slow intravenous infusion of nitroglycerine over 12 to 24 hours and abciximab, followed by deferred [...]

A 50-year-old man with an inferior myocardial infarction was admitted after successful fibrinolysis. Coronary angiography showed 2 giant coronary aneurysms in series in the right coronary artery with high thrombus burden ([Figure 1A][1], [Online Video 1][2]), a severe ostial lesion, and ecstatic

A 73-year-old woman with a severely calcified critical stenosis in the midleft anterior descending coronary artery ([Figure 1A][1]) was referred for percutaneous coronary intervention. Pre-dilatation with a 2.5-mm noncompliant balloon at 20 atm pressure did not achieve adequate balloon expansion

Severe stenosis of the subclavian artery is a rare clinical finding, even more so for bilateral existence of the condition. Subclavian artery stenosis leads to erroneously normal or even low blood pressure values when measured at the brachial artery on the ipsilateral side. The poor control of blood pressure may cause cardiovascular complications such as heart failure and acute pulmonary edema without the patient having high blood pressure in the arms. Widespread clinical reliance on a sole brachial measurement of blood pressure, particularly in the emergency room setting, may result in inappropriate clinical management in patients with conditions that alter brachial blood pressure. We report a case of acute diastolic heart failure secondary to hypertensive emergency hidden due to bilateral stenosis of both subclavian arteries in a patient with severe atherosclerosis, cerebrovascular disease, and symptoms of subclavian steal syndrome.

We have carefully read the article by Jolly et al.1 We congratulate the authors for the effort of pooling individual data from the most important trials regarding thrombus aspiration (TA). It confirms that routine TA should not be performed in this context. However, we would like to make some considerations. We agree that after the TAPAS trial (Thrombus Aspiration During Primary Percutaneous Coronary Intervention),2 TA became part of routine practice, and was probably overused. However, results of the TASTE (Thrombus Aspiration During ST-Segment Elevation Myocardial Infarction)3 and TOTAL (Randomized Trial of Primary PCI With or Without Routine Manual Thrombectomy)4 trials, which drive the bulk of the overall effect …

Nickel is the most frequent allergen in patients with allergic contact dermatitis and nickel allergy has been associated with recurrent in-stent restenosis. However, it is often misdiagnosed because of a low suspicion threshold. It should be discarded in patients with recurrent in-stent restenosis, especially if their medical history reveals prior contact dermatitis. It is also noteworthy and rarely specified that even newer generation stents that use novel metal alloys also contain low amounts of nickel. To avoid the implantation of new stents containing this metal, when percutaneous coronary intervention is indicated, drug eluting balloons or bioresorbable vascular scaffolds associated with small doses of steroids could provide good alternatives of treatment. To the best of our knowledge, this is the first description of this therapeutic alternative in such an exceedingly rare clinical scenario.

A reduction in radiation doses at the catheterization laboratory, maintaining the quality of procedures is essential. Our objective was to analyze the results of a simple radiation reduction protocol at a high-volume interventional cardiology unit.We analyzed 1160 consecutive procedures: 580 performed before the implementation of the protocol and 580 after it. The protocol consisted in: the reduction of the number of ventriculographies and aortographies, the optimization of the collimation and the geometry of the X ray tube-patient-receptor, the use of low dose-rate fluoroscopy and the reduction of the number of cine sequences using the software "last fluoroscopy hold".There were no significant differences in clinical baseline features or in the procedural characteristics with the exception of a higher percentage of radial approach (30.7% vs 69.6%; p0.001) and of percutaneous coronary interventions of chronic total occlusions after the implementation of the protocol (2.1% vs 6.7%; p=0,001). Angiographic success was similar during both periods (98.3% vs 99.2%; p=0.2). There were no significant differences between both periods regarding the overall duration of the procedures (26.9 vs 29.6min; p=0.14), or the fluoroscopy time (13.3 vs 13.2min; p=0.8). We observed a reduction in the percentage of procedures with ventriculography (80.9% vs 7.1%; p0.0001) or aortography (15.4% vs 4.4%; p0.0001), the cine runs (21.8 vs 6.9; p0.0001) and the dose-area product (165 vs 71 Gyxcm(2); p0.0001).With the implementation of a simple radiation reduction protocol, a 57% reduction of dose-area product was observed without a reduction in the quality or the complexity of procedures.