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Objectives: The purpose of this European survey was to describe current preprocedural planning, procedure techniques and post-implantation management of left atrial appendage closure (LAAC)., Design: Prospective survey regarding current practice for LAAC between March and August 2023., Setting: 357 participating European LAAC centres in 14 countries., Results: In 2022, the participating centres performed a total number of 9447 LAAC procedures, with a mean of 26 LAAC cases per centre (median 20; IQR 10-35). Preprocedure planning was performed with transoesophageal echocardiography (TOE) in 63% of centres, cardiac CT in 16%, or both in 21%. LAAC procedures were performed under general anaesthesia (59%), conscious sedation (36%) or with local anaesthesia only (5%). Device implantation was guided by conventional TOE (94%), intracardiac echocardiography (6%), miniaturised TOE probes (4%) or CT/fluoroscopy fusion (2%). The standard post-procedural antithrombotic regimen was dual antiplatelet therapy (73%), followed by single antiplatelet therapy (18%), conventional dose direct oral anticoagulant (DOAC) (7%) or half dose DOAC (1%), and no antithrombotic treatment (1%). There was a large heterogeneity between regions in terms of procedure volumes, hospital organisation, preprocedural planning, as well as procedural techniques and post-procedure management., Conclusions: The present survey indicates that LAAC has become a widespread procedure in Europe. The findings highlight considerable heterogeneity among European countries in terms of preprocedural planning, procedural techniques including guidance and the post-procedural antithrombotic regimen. There is a need to evaluate the outcomes of different practices., Competing Interests: Competing interests: PG has received speaker’s/advisory fees from Abbott, Boston Scientific, Biosensors, Edwards Lifesciences and Terumo. He is the Medical Director and shareholder of CERC (Cardiovascular European Research Center), a CRO dedicated to cardiovascular diseases. IC-G is a proctor for Abbott, Boston Scientific, Lifetech, Omega, Biosensors and Medtronic. LR has received research grants to the institution by Abbott, Biotronik, Boston Scientific, Heartflow, Infraredx, Sanofi and Regeneron and speaker/consultation fees by Abbott, Biotronik, Amgen, AstraZeneca, Canon, Medtronic, Novo Nordisk, Occlutech and Sanofi. J-EN-K is a proctor and received research grants from Abbott and Boston Scientific. The other authors have no conflict of interest to disclose with the present study., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Background: Results from the Distal vs Conventional Radial Access (DISCO RADIAL) trial confirmed distal radial access (DRA) as a valid alternative to conventional transradial access, with equally low rates of radial artery occlusion (RAO), yet higher crossovers but shorter hemostasis., Objectives: The purpose of the study was to investigate whether patient anthropometric measures influence the effect of randomized access on key secondary outcomes., Methods: DISCO RADIAL was an international, multicenter, randomized controlled trial in which patients with indications for percutaneous coronary procedure using a 6-F Slender sheath were randomized to DRA (n = 650) or transradial access (n = 657) implementing best practices to reduce RAO. The primary endpoint of the trial was incidence of forearm RAO, which was extremely uncommon. Secondary endpoints, including sheath insertion time, radial artery spasm, crossover (failure to obtain access through assigned access site), hemostasis time, and access site complications, were the focus of the current analysis. Regression models (linear for continuous and logistic for binary outcomes) were used to determine whether anthropometric measures (weight, height, body mass index, and body surface area) influenced the effect of randomized access on outcomes., Results: Across tertiles of weight, height, body mass index, and body surface area, both before and after adjustment for sex and age, the main effect of vascular access on radial artery spasm, crossover, hemostasis time, and access site complications remained, with no significant interaction effect., Conclusions: The results of this exploratory analysis are consistent with the main findings of the trial and support the use of DRA in all patients, regardless of anthropometric measures., Competing Interests: The trial was sponsored and funded by Terumo Europe. Drs Sgueglia and Leibundgut have received consulting and lecture fees from Terumo and Cordis outside of the submitted work. Drs Aminian and Ratib have received consulting and lecture fees from Terumo. Dr Iglesias has received an unrestricted research grant to the institution from Terumo, outside of the submitted work; is a consultant for and has received personal fees from Terumo, outside of the submitted work; has received research grants to the institution from Abbott Vascular, AstraZeneca, Biosensors, Biotronik, Concept Medical, and Philips Volcano; and has received personal fees from AstraZeneca, Biotronik, Bristol Myers Squibb/Pfizer, Cardinal Health, Medtronic, Novartis, and Philips Volcano, outside the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2025 The Authors.)

Background: In the era of first-generation drug-eluting stents and angiography-guided percutaneous coronary intervention (PCI), the presence of a bifurcation lesion was associated with adverse outcomes after PCI. In contrast, the presence of a bifurcation lesion had no impact on outcomes following coronary artery bypass grafting (CABG). Therefore, the presence of a coronary bifurcation lesion requires special attention when choosing between CABG and PCI. The aim of this study is to assess whether the presence of a bifurcation lesion still influences clinical outcomes after contemporary PCI using second-generation drug-eluting stent and fractional flow reserve (FFR) guidance versus CABG., Methods: The randomized FAME 3 trial (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) compared FFR-guided PCI using current drug-eluting stents with CABG in patients with 3-vessel coronary artery disease. The prespecified key end point at 3-year follow-up was the composite of death, myocardial infarction, or stroke. In this substudy, the impact of bifurcation lesions on outcomes after FFR-guided PCI and CABG was investigated., Results: The FAME 3 trial enrolled 1500 patients and 653 (45.2%) patients had at least 1 true bifurcation lesion. There was no difference in the composite of death, myocardial infarction, or stroke at the 3-year follow-up between patients with or without at least 1 true bifurcation lesion (11.6% versus 10.0%; hazard ratio, 1.17 [95% CI, 0.86-1.61]; P =0.32), regardless of revascularization strategy. The composite end point was not statistically different between FFR-guided PCI and CABG in patients with at least 1 true bifurcation lesion (hazard ratio, 1.27 [95% CI, 0.80-2.00]) or without a true bifurcation lesion (hazard ratio, 1.36 [95% CI, 0.87-2.12]), with no significant interaction ( P interaction =0.81)., Conclusions: In patients with 3-vessel coronary artery disease, the presence of a true bifurcation lesion was not associated with a different treatment effect after FFR-guided PCI with contemporary drug-eluting stent versus CABG., Competing Interests: Dr Pijls received institutional research grants from Abbott, has consulting relationships with and receives fees from Abbott and Coroventis, holds equity in ASML, General Electric, HeartFlow, and Philips, is a member of the Scientific Advisory Board of HeartFlow, and has patents pending in the fields of coronary microcirculation and aortic valve stenosis. Dr Fearon received institutional research grants from Abbott and Medtronic, had consulting relationships in the past with CathWorks, and holds stock options in HeartFlow. The other authors report no conflicts.

Objectives : to retrospectively evaluate the clinical relevance of the 1000/500 Hz inter-frequency amplitude ratio (IFAR) in cervical and ocular vestibular evoked myogenic potentials (cVEMPs and oVEMPs) in patients with unilateral definite Ménière's disease (MD) to identify the pathological ear. Method : cVEMPs and oVEMPs results obtained at 500 Hz and 1000 Hz were retrospectively analyzed in 28 patients with unilateral definite MD. 1000/500 Hz IFAR were calculated and compared for each ear. Spearman correlation tests between patient age and 1000/500 Hz IFAR were also performed. Results : No significant difference was observed between the 1000/500 Hz IFAR calculated in both pathological and healthy ears when the cVEMPs were performed ( p = 0.74; Wilcoxon signed-rank test). 1000/500 Hz IFAR results obtained in healthy and pathological ears were also not different for oVEMPs ( p = 0.73; Wilcoxon signed-rank test). Analysis of modified 1000/500 Hz IFARs for healthy and pathological ears showed no difference in both cVEMPs and oVEMPs ( p = 0.44; p = 0.95, respectively; Wilcoxon signed-rank test). There was a significant positive correlation between IFARs, modified IFARs, and patient age for cVEMPs ( p = 0.017; p = 0.012, respectively, Spearman's correlation test). A significant positive correlation was also found between modified IFARs and the subject age in oVEMPs ( p = 0.019, Spearman's correlation test). Conclusions : We did not observe any significant increase of 1000/500 Hz IFARs and 1000/500 Hz modified IFARs in ears affected by definite MD compared to healthy ears. Moreover, our research suggests that the age of the participants may influence IFAR results, which may lead to misdiagnosis in the elderly. It is, therefore, essential to conduct further prospective studies in larger cohorts, stratifying results by participant age, to better understand the role of 1000/500 Hz IFAR values in the diagnosis of MD.

Patients undergoing percutaneous coronary intervention (PCI) may experience bleeding events. Bleeding risk is increased in patients with comorbid peripheral arterial disease (PADs). To evaluate whether PCI patients with PADs have worse outcome after bleeding, we assessed pooled patient-level data of 5,989 randomized all-comer trial participants and identified those who had a bleeding (BIO-RESORT:NCT01674803, BIONYX:NCT02508714). Major adverse cardiac events (MACE) and mortality were assessed from bleeding until 3 years after PCI. Of all 313 PCI patients with bleeding events, patients with PADs (n = 34, 10.9%) were older and had more complex lesions than those without PADs (n = 279, 89.1%). In patients with PADs, bleeding occurred more often during the first year after PCI (79.4% vs. 57.3%, p = 0.013). The proportion of major bleeding, and the severity and location of bleeding were similar between both groups. Multivariate analysis found no statistically significant between-group difference in MACE (43.1% vs. 34.7%, p = 0.53; adj.HR:0.86, 95%CI 0.45-1.63, p = 0.64) and mortality (33.5% vs. 22.3%, p = 0.12; adj.HR:1.45, 95%CI 0.73-2.91, p = 0.29). Bleeding occurred significantly more often during the first year after PCI in all-comer patients with concomitant PADs than in those without PADs, while we observed no significant between-group difference in bleeding severity and location, and the risk of adverse events after bleeding., Competing Interests: Declarations. Conflict of interest: The Research Department of Thoraxcentrum Twente has received institutional research grants from Abbott Vascular, Biotronik, Boston Scientific, and Medtronic. RLA reports a teaching grant from Biotronik, a license from Sanofi, a speaking fee from Abiomed, and support from Amgen for attending a meeting, all outside the submitted work. All other authors declared that they have no relevant personal conflict of interest, related to the content of this study. All authors take responsibility for all aspects of the reliability and freedom from bias of the presented and their discussed interpretation., (© 2024. The Author(s) under exclusive licence to Japanese Association of Cardiovascular Intervention and Therapeutics.)

Background: Jailed wire (JW) in the side branch (SB) is recommended during coronary bifurcation provisional stenting, but there is uncertainty about the real benefit. Our objective was to evaluate the benefit of a JW technique in the Coronary Artery Bifurcation Revascularization Without kIssing ballOon infLation by rEpoT (CABRIOLET) registry., Methods: In CABRIOLET, which included 500 patients, we compared the primary composite end point of a poor final SB angiographic result (of Thrombolysis in Myocardial Infarction (TIMI) flow < III, dissection grade > B, thrombosis, residual stenosis > 70%, or additional SB stenting) whether JW was performed or not. On the basis of the usual operator practice, we also compared a systematic JW strategy: operators known to place JW frequently (> 75% performed), to a conditional strategy: selective JW practices (< 20% of JW)., Results: JW was performed in 251 patients (50.2%), without significant baseline clinical and angiographic differences compared with those who received no JW. JW was associated with higher primary end point (15.1% vs 8.4%; P < 0.05), and increased fluoroscopy time and contrast volume (15.9 ± 7.3 minutes and 181 ± 62 mL vs 13.3 ± 6.5 minutes and 161 ± 74 mL; P < 0.05). JW was performed in 12.1% of patients (26 of 214) in the conditional JW group and 78.7% (225 of 286) in systematic group. The primary end point was similar in both strategies (11.2% and 12.2%; P = 0.78), although with greater fluoroscopy time and contrast volume for systematic JW (180 ± 57 mL and 15.3 ± 7.5 minutes vs 162 ± 79 mL and 13.7 ± 6.1 minutes; P < 0.05). There was no difference in 1-year major adverse cardiovascular events depending on whether JW was performed or not and between conditional or systematic strategies., Conclusions: In a large registry, JW was associated with poorer final SB angiographic results than no JW. Final SB angiographic results were similar between conditional or systematic JW strategies., (Copyright © 2024 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Distal radial artery access (DRA) has been emerged as an alternative for conventional transradial arterial access. While palpation of radial artery is mandatory prior coronary angiography, it remains unknown the clinical impact of palpation in DRA success. Aim of our study is to explore whether the palpability of distal radial artery is linked with higher rates of successful arterial access., Methods: We conducted a post-hoc analysis using data from two randomized-controlled trials on DRA. All patients with available data on distal radial artery palpability and cannulation's success were included in our analysis. No procedure was performed with ultrasound guidance., Results: Data on the palpability of the distal radial artery and the DRA success were available for 435 patients. Successful distal radial artery cannulation was attempted in 255 and 98 of patients with and without palpable distal radial artery, respectively. No significant difference between the two groups was observed (81.5% vs 80.3%, p  = 0.786). Univariate analysis revealed statistically significant difference in gender, height, known CAD, valvular disease as indication for angiography and number of skin punctures. Multivariate analysis included these variables, as well as palpability of the distal radial artery and found that number of skin punctures and valvular disease as indication are significantly associated with DRA success., Conclusion: According our post-hoc analysis, the palpability of the distal radial artery is not associated with higher rates of DRA success. Further studies are required for the validation of these results., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction and Objectives: The optimal antithrombotic therapy (AT) after left atrial appendage closure (LAAC) is debated. We assessed the impact of intensive vs nonintensive AT on the incidence of device-related thrombus (DRT) based on whether the device implantation was classified as optimal or suboptimal., Methods: This study included patients who underwent successful LAAC in 9 centers. Patients were classified according to the quality of device implantation: optimal (proximal implant without ≥3mm peridevice leak) or suboptimal (distal implant and/or ≥3mm peridevice leak). Postimplant AT was classified as either intensive (dual antiplatelet therapy, anticoagulants, or a combination of both) or nonintensive (no AT or a single antiplatelet therapy). The primary endpoint was the incidence of DRT between the 6th and 12th weeks postprocedure., Results: A total of 1225 patients underwent LAAC, with 757 (61.8%) achieving optimal device implantation and 468 (38.2%) classified as suboptimal. After a median follow-up of 20 months, the incidence of DRT in the optimal implant group was 2.6% with intensive AT and 3.7% with nonintensive AT (P=.38). In the suboptimal implant group, the incidence of DRT increased to 11.2% with intensive AT and 15.5% with nonintensive AT (P=.19). On multivariate analysis, suboptimal implantation (HR, 4.51; 95%CI, 2.70-7.54, P<.001) but not intensive AT (HR, 0,66; 95%CI, 0.40-1.07, P=.09) emerged as an independent predictor of DRT., Conclusions: The incidence of DRT after LAAC was higher in patients with suboptimal device implantation. In patients with optimal implantation, the incidence of DRT was low and similar between nonintensive and intensive AT strategies. Large, randomized trials are warranted to confirm these results., (Copyright © 2024 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Due to the late-stage diagnosis of head and neck squamous cell carcinoma (HNSCC), treatment remains a significant clinical challenge. The metalloproteinases MMP-9 and MT1-MMP play a pivotal role in extracellular matrix remodeling, thereby facilitating tumor growth and metastasis. Tumor progression requires the degradation of the basement membrane. The principal components of this structure, namely collagen IV and laminin, are the main targets of both MMP-9 and MT1-MMP. However, they can also exert influence over the expression of these enzymes. Oxidative stress plays an instrumental role in tumor development, functioning as a key inducer of metalloproteinase expression. The present study investigates the distribution of MMP-9 and MT1-MMP within tumor nests and along the basement membrane, comparing these with the distributions of collagen IV, laminin-332, and the antioxidant MnSOD. Biopsies from 12 patients with HNSCC and poor prognostic factors were subjected to immunofluorescence analysis. MMP-9 and MT1-MMP were found to be predominantly present in tumor cells, with a significant decrease in expression from the periphery to the center of tumor nests. Co-localization studies with laminin-332 and collagen IV, revealed substantial overlap, in accordance with the role of MMPs in basal membrane degradation. The cellular expression of laminin-332 associated with MMP-9 expression suggests an intricate relationship between metalloproteinases and their targets. While the previously observed pattern of glutathione-producing enzyme was similar to the metalloproteinases pattern, MnSOD expression was homogeneously distributed within tumor nests. Our findings reveal various distribution patterns of oxidative stress regulators, suggesting a complicated interplay in the development of HNSCC., (©The Author(s) 2024. Open Access. This article is licensed under a Creative Commons CC-BY International License.)

Introduction: Patients with coronary artery disease (CAD) remain vulnerable to future major atherosclerotic events after revascularization, despite effective secondary prevention strategies. Inflammation plays a central role in the pathogenesis of CAD and recurrent events. To date, there is no specific anti-inflammatory medicine available with proven effective, cost-efficient, and favorable benefit-risk profile, except for colchicine. Initial studies with colchicine have sparked major interest in targeting atherosclerotic events with anti-inflammatory agents, but further studies are warranted to enforce the role of colchicine role as a major treatment pillar in CAD. Given colchicine's low cost and established acceptable long-term safety profile, confirming its efficacy through a pragmatic trial holds the potential to significantly impact the global burden of cardiovascular disease., Methods: The COL BE PCI trial is an investigator-initiated, multicenter, double-blind, event-driven trial. It will enroll 2,770 patients with chronic or acute CAD treated with percutaneous coronary intervention (PCI) at 19 sites in Belgium, applying lenient in- and exclusion criteria and including at least 30% female participants. Patients will be randomized between 2 hours and 5 days post-PCI to receive either colchicine 0.5 mg daily or placebo on top of contemporary optimal medical therapy and without run-in period. All patients will have baseline hsCRP measurements and a Second Manifestations of Arterial Disease (SMART) risk score calculation. The primary endpoint is the time from randomization to the first occurrence of a composite endpoint consisting of all-cause death, spontaneous non-fatal myocardial infarction, non-fatal stroke, or coronary revascularization. The trial is event-driven and will continue until 566 events have been reached, providing 80% power to detect a 21 % reduction in the primary endpoint taking a premature discontinuation of 15% into account. We expect a trial duration of approximately 44 months., Conclusion: The COL BE PCI Trial aims to assess the effectiveness and safety of administering low-dose colchicine for the secondary prevention in patients with both chronic and acute coronary artery disease undergoing PCI., Trial Registration: ClinicalTrials.gov: NCT06095765., Competing Interests: Conflict of Interest The authors have no conflict of interest related to the content of this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The clinical impact of a chronic total occlusion (CTO) in patients with 3-vessel coronary artery disease undergoing fractional flow reserve-guided percutaneous coronary intervention (PCI) with current-generation drug-eluting stents or coronary artery bypass grafting (CABG) is unclear., Methods: The FAME 3 trial (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation 3) compared fractional flow reserve-guided PCI with CABG in patients with 3-vessel coronary artery disease. The primary end point was major adverse cardiac and cerebrovascular events, a composite of death, myocardial infarction, stroke, or repeat revascularization at 1 year. In this substudy, the 3-year outcomes were analyzed in patients with or without a CTO., Results: Of the patients randomized to PCI or CABG in the FAME 3 trial, 305 (21%) had a CTO. In the PCI arm, revascularization of the CTO was attempted in 61% with a procedural success rate of 88%. The incidence of major adverse cardiac and cerebrovascular events at 3 years was not significantly different between those with or without a CTO in both the PCI (15.2% versus 20.1%; adjusted hazard ratio, 0.62 [95% CI, 0.38-1.03]; P =0.07) and the CABG (13.0% versus 12.9%; adjusted hazard ratio, 0.96 [95% CI, 0.55-1.66]; P =0.88) arms. In those without a CTO, PCI was associated with a significantly higher risk of major adverse cardiac and cerebrovascular events compared with CABG (adjusted hazard ratio, 1.61 [95% CI, 1.20-2.17]; P <0.01) but not in those with a CTO (adjusted hazard ratio, 1.21 [95% CI, 0.64-2.28]; P =0.56; P interaction =0.31)., Conclusions: The presence of a CTO did not significantly impact the treatment effect of PCI versus CABG at 3 years in patients with 3-vessel coronary artery disease., Clinical Trial Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02100722., Competing Interests: Dr Otsuki has received research grants from the Uehara Memorial Foundation, Abbott, Medtronic, Boston Scientific, and Terumo. Dr Fearon has received institutional research grants from Abbott Vascular and Medtronic, had a consulting relationship with CathWorks, and has stock options with HeartFlow. Dr Mavromatis reported that his institution (Atlanta Research Education Foundation) has received grant support from Stanford University. The other authors report no conflicts.

Background: In the management of acute ischemic stroke with large vessel occlusion (LVO-AIS), current data are conflicting as to whether a mothership model of management (MS) is associated with better functional recovery than a drip-and-ship model (DS)., Method: Files from LVO-AIS patients treated with MT at CHU Charleroi were analyzed between 01/01/2017 and 12/31/2022. Consecutive patients with a LVO-AIS of the anterior circulation and a prestroke modified Rankin Scale (mRS) ≤2 were included. The study's primary endpoint was the functional independence, defined as a mRS of 0-2 at 3 months post-stroke. Times metrics of MT and thrombolysis application, safety outcome including symptomatic intracranial hemorrhage and death were recorded. We conducted similar analyses by dividing DS patients, depending of their transfer time (less or >20 min). Logistic regression was used to assess if differences in baseline characteristics affected the primary outcome., Results: 366 patients were included: 229 in the DS group and 137 in the MS group. Demographic data showed a higher rate of tobacco use and lower functional status prestroke in the MS population. The MS group demonstrated better performance in time metrics related to thrombolysis and MT administration. The proportion of patients achieving an mRS of 0-2 at 3 months was similar in the DS and MS groups (50.22 % vs. 48.17 %, p = 0.706). The same conclusions were drawn from the subgroup analysis. Logistic regression analysis showed no impact of baseline characteristic differences on the primary outcome., Conclusion: Despite faster access to MT in the MS model, our study did not find any significant differences in functional recovery at three months post-stroke between the MS and DS management models. Our data suggest further that the prestroke health status was an important factor influencing functional outcomes after LVO-AIS., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2024. Published by Elsevier Inc.)

Inferior nasal turbinates play a crucial role in conditioning inhaled air. While hypertrophy of these turbinates is a common cause of nasal obstruction in adults, congenital malformations are extremely rare. Only a few cases of unilateral agenesis have been reported. This report presents the first documented case of bilateral inferior head turbinate agenesis (BITHA). A 22-year-old woman with a history of chronic nasal obstruction, sneezing, and nasal itching was diagnosed with BITHA. Her medical history included trisomy 14 mosaicism and other comorbidities. Clinical examination revealed mild facial dysmorphic features and agenesis of both inferior turbinate heads. Nasal endoscopy showed compensatory hypertrophy of the middle and posterior portions of the inferior turbinates. Following a one-month treatment with nasal corticosteroids and antihistamines, her nasal symptoms improved. Trisomy 14 mosaicism is a rare genetic condition often associated with unspecific dysmorphic features. To our knowledge, BITHA has not been previously reported in such patients. This case suggests that BITHA could be a clinical feature for trisomy 14 mosaicism. Additionally, the absence of empty nose syndrome (ENS) in this patient, despite BITHA, provides insights into the potential iatrogenic origin of ENS. BITHA is an exceptional congenital anomaly and may serve as a specific sign of trisomy 14 mosaicism. The lack of ENS in this case supports the hypothesis that ENS may arise from acquired rather than congenital anatomical changes., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Drabkin et al.)

Background: Cervicitis, an infectious or noninfectious inflammation of the cervix, encompasses a wide range of clinical conditions, from asymptomatic infections to severe lesions, making its diagnosis difficult. Acute cervicitis may develop into pelvic inflammatory disease. In patients with cervicitis, current guidelines recommend testing for herpes simplex virus when external genital lesions are present. Here, we present the case of a patient with an atypical primary herpes simplex virus 2 infection manifesting as cervicitis without genital lesions., Case Presentation: A 29-year-old Caucasian woman was hospitalized for pelvic inflammatory disease. The patient complained of severe suprapubic pain, fever, and heavy vaginal discharge. The external genitalia were unremarkable, so empirical antibiotic treatment was initiated. Despite 48 hours of well-administered antibiotic therapy, her complaints persisted. Polymerase chain reaction for possible microbial causes was negative for Chlamydia trachomatis and Neisseria gonorrhoeae. There was no bacterial vaginosis. Repeat gynecological examinations with endovaginal ultrasound revealed an enlarged cervix, and pelvic magnetic resonance imaging supported a diagnosis of cervicitis. At this point, additional screening for other sexually transmitted infections and infectious disease-related etiologies of cervicitis was performed, and the polymerase chain reaction analysis of newly isolated samples was positive for herpes simplex virus 2. No antiviral treatment was initiated given the delay in diagnosing herpes simplex virus 2 infection and the slow but spontaneous abatement of symptoms., Conclusion: Herpes simplex virus infection should be considered as a possible cause of cervicitis, even in the absence of typical genital lesions. Early detection of herpes simplex virus allows early treatment, helping to reduce the duration and severity of symptoms and therefore potentially reducing recurrences and improving disease control. These data and data from future cases might spur changes in the guidelines on cervicitis testing and treatment., (© 2024. The Author(s).)

Background: Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a complication of adenoviral-based vaccine against SARS-CoV-2 due to prothrombotic immunoglobulin (Ig) G antibodies to platelet factor 4 (PF4) and may be difficult to distinguish from heparin-induced thrombocytopenia (HIT) in patients treated with heparin., Objectives: We assessed the usefulness of competitive anti-PF4 enzyme immunoassays (EIAs) in this context., Methods: The ability of F(ab')2 fragments of 1E12, 1C12, and 2E1, 3 monoclonal anti-PF4 antibodies, to inhibit the binding of human VITT or HIT antibodies to PF4 was evaluated using EIAs. Alanine-scanning mutagenesis was performed to define the amino acids involved in the interactions between the monoclonal antibodies and PF4., Results: A strong inhibition of VITT IgG binding to PF4 was measured with 1E12 (median inhibition, 93%; n = 8), whereas it had no effect on the binding of HIT antibodies (median, 6%; n = 8). In contrast, 1C12 and 2E1 inhibited VITT (median, 74% and 76%, respectively) and HIT antibodies (median, 68% and 53%, respectively) binding to PF4. When a competitive anti-PF4 EIA was performed with 1E12 for 19 additional VITT samples, it strongly inhibited IgG binding to PF4, except for 1 patient, who had actually developed HIT according to the clinical history. Epitope mapping showed that 1E12 interacts with 5 key amino acids on PF4, of which 4 are also required for the binding of human VITT antibodies, thus explaining the competitive inhibition., Conclusion: A simple competitive anti-PF4 EIA with 1E12 could help confirm VITT diagnosis and distinguish it from HIT in patients when both diagnoses are possible., Competing Interests: Declaration of competing interests C.V. reports honorarium from Viatris. J.R. reports research grant from Stago. H.G. reports transport fees from Stago. F.M. reports speaker fees from Fresenius, Technoclone, and Werfen, all outside the submitted work. Y.G. reports research grant and symposium fees from Stago. C.P. reports research grant from Stago. All other authors of this paper have no conflicts of interest., (Copyright © 2024 International Society on Thrombosis and Haemostasis. Published by Elsevier Inc. All rights reserved.)

Background: Transfemoral access is often used when large-bore guide catheters are required for percutaneous coronary intervention (PCI) of complex coronary lesions, especially when large-bore transradial access is contraindicated. Whether the risk of access site complications for these procedures may be reduced by ultrasound-guided puncture is unclear., Aims: We aimed to show the superiority of ultrasound-guided femoral puncture compared to fluoroscopy-guided access in large-bore complex PCI with regard to access site-related Bleeding Academic Research Consortium 2, 3 or 5 bleeding and/or vascular complications requiring intervention during hospitalisation., Methods: The ULTRACOLOR Trial is an international, multicentre, randomised controlled trial investigating whether ultrasound-guided large-bore femoral access reduces clinically relevant access site complications compared to fluoroscopy-guided large-bore femoral access in PCI of complex coronary lesions., Results: A total of 544 patients undergoing complex PCI mandating large-bore (≥7 Fr) transfemoral access were randomised at 10 European centres (median age 71; 76% male). Of these patients, 68% required PCI of a chronic total occlusion. The primary endpoint was met in 18.9% of PCI with fluoroscopy-guided access and 15.7% of PCI with ultrasound-guided access (p=0.32). First-pass puncture success was 92% for ultrasound-guided access versus 85% for fluoroscopy-guided access (p=0.02). The median time in the catheterisation laboratory was 102 minutes versus 105 minutes (p=0.43), and the major adverse cardiovascular event rate at 1 month was 4.1% for fluoroscopy-guided access and 2.6% for ultrasound-guided access (p=0.32)., Conclusions: As compared to fluoroscopy-guided access, the routine use of ultrasound-guided access for large-bore transfemoral complex PCI did not significantly reduce clinically relevant bleeding or vascular access site complications. A significantly higher first-pass puncture success rate was demonstrated for ultrasound-guided access., Clinicaltrials: gov identifier: NCT04837404.

Background: The BIONYX randomized trial is the first study to evaluate the Resolute Onyx durable polymer-coated zotarolimus-eluting stent (ZES) in all-comers. Furthermore, it is the first trial to assess safety and efficacy of this stent versus the Orsiro biodegradable-polymer sirolimus-eluting stent (SES) in all-comers, paying particular attention to patients with diabetes. It has previously shown promising results until 3 years of follow-up., Aims: We aimed to assess long-term clinical outcome after percutaneous coronary intervention (PCI) with Onyx ZES versus Orsiro SES at 5-year follow-up., Methods: The main composite endpoint was target vessel failure (TVF): cardiac death, target vessel myocardial infarction, or target vessel revascularization. Time to primary and secondary endpoints was assessed using Kaplan-Meier methods, applying the log-rank test for between-group comparison., Results: Follow-up was available in 2414/2488 (97.0%) patients. After 5 years, TVF showed no significant difference between Onyx ZES and Orsiro SES (12.7% vs. 13.7%, hazard ratio [HR] 0.94, 95% confidence interval [CI] [0.75-1.17], p log-rank  = 0.55). Landmark analysis between 3- and 5-year follow-up found a lower target lesion revascularization rate for Onyx ZES (1.1% vs. 2.4%, HR 0.47, 95% CI [0.24-0.93], p log-rank  = 0.026). A prespecified subgroup analysis showed no significant between-stent difference in clinical outcome among patients with diabetes. After treatment with Onyx ZES, patients aged ≥75 years had significantly lower rates of TVF (13.8% vs. 21.9%, HR 0.60, 95% CI [0.39-0.93], p log-rank  = 0.023)., Conclusions: The final 5-year analysis of the randomized BIONYX trial showed favorable and similar long-term outcomes of safety and efficacy for Onyx ZES and Orsiro SES in both all-comers and patients with diabetes., (© 2024 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Background: Left atrial appendage (LAA) occluder embolization is an infrequent but serious complication., Objectives: We aim to describe timing, management and clinical outcomes of device embolization in a multi-center registry., Methods: Patient characteristics, imaging findings and procedure and follow-up data were collected retrospectively. Device embolizations were categorized according to 1) timing 2) management and 3) clinical outcomes., Results: Sixty-seven centers contributed data. Device embolization occurred in 108 patients. In 70.4 % of cases, it happened within the first 24 h of the procedure. The device was purposefully left in the LA and the aorta in two (1.9 %) patients, an initial percutaneous retrieval was attempted in 81 (75.0 %) and surgery without prior percutaneous retrieval attempt was performed in 23 (21.3 %) patients. Two patients died before a retrieval attempt could be made. In 28/81 (34.6 %) patients with an initial percutaneous retrieval attempt a second, additional attempt was performed, which was associated with a high mortality (death in patients with one attempt: 2.9 % vs. second attempt: 21.4 %, p < 0.001). The primary outcome (bailout surgery, cardiogenic shock, stroke, TIA, and/or death) occurred in 47 (43.5 %) patients. Other major complications related to device embolization occurred in 21 (19.4 %) patients., Conclusions: The majority of device embolizations after LAA closure occurs early. A percutaneous approach is often the preferred method for a first rescue attempt. Major adverse event rates, including death, are high particularly if the first retrieval attempt was unsuccessful., Condensed Abstract: This dedicated multicenter registry examined timing, management, and clinical outcome of device embolization. Early embolization (70.4 %) was most frequent. As a first rescue attempt, percutaneous retrieval was preferred in 75.0 %, followed by surgical removal (21.3 %). In patients with a second retrieval attempt a higher mortality (death first attempt: 2.9 % vs. death second attempt: 24.1 %, p < 0.001) was observed. Mortality (10.2 %) and the major complication rate after device embolization were high., Competing Interests: Declaration of competing interest A. Aminian is a consultant and proctor for Boston Scientific and Abbott. I. Akin received lecture and proctoring fees from Boston Scientific for the Watchman Okkluder. J. Lund discloses a clinical advisor (proctor) role in LAAC (Abbott) and lecture fees (Abbott, Boston scientific). E. Guerios serves as proctor for LAA closure for Abbott and Lifetech Scientific. N. Amabile has received proctoring and consulting fees from Abbott Vascular and Boston Scientific. C. Skurk has received proctor honoraria from Boston Scientific and speaker fees from Boston Scientific and Lifetech Scientific. J. Harvey is proctor for Abiomed, Boston Scientific and Medtronic and part of the Speaker's bureau for Abiomed, Boston Scientific and Medtronic. He also is part of the advisory board for Avail, Boston Scientific and Medtronic. H. Sievert has received study honoraria to institution, travel expenses and consulting fees from 4tech Cardio, Abbott, Ablative Solutions, Adona Medical, Akura Medical, Ancora Heart, Append Medical, Axon, Bavaria Medizin Technologie GmbH, Bioventrix, Boston Scientific, Cardiac Dimensions, Cardiac Success, Cardimed, Cardionovum, Celonova, Contego, Coramaze, Croivalve, CSL Behring LLC, CVRx, Dinova, Edwards, Endobar, Endologix, Endomatic, Esperion Therapeutics, Inc., Hangzhou Nuomao Medtech, Holistick Medical, Intershunt, Intervene, K2, Laminar, Lifetech, Magenta, Maquet Getinge Group, Metavention, Mitralix, Mokita, Neurotronic, NXT Biomedical, Occlutech, Recor, Renal Guard, Shifamed, Terumo, Trisol, Vascular Dynamics, Vectorious Medtech, Venus, Venock, Vivasure Medical, Vvital Biomed and Whiteswell. M. Kühne received personal fees from Bayer, Böhringer Ingelheim, Pfizer BMS, Daiichi Sankyo, Medtronic, Biotronik, Boston Scientific, Johnson & Johnson, and F. Hoffmann-La Roche Ltd., as well as grants from Bayer, Pfizer, Boston Scientific, BMS, Biotronik, and Daiichi Sankyo. S. Sabir is part of the Boston Scientific WATCHMAN advisory board. J. Kim has received proctoring fees from Abbott Vascular. M. Montorfano received consultant fees from Abbott, Boston Scientific, Kardia. M. Ancona received consultant fees from Abbott. Relevant research funding went to Vanderbilt University Medical Center from Boston Scientific, Boehringer-Ingelheim, Medtronic and Atricure, where C. Ellis is practicing. He also reseves a consultant and advisor fee from Abbott Medical, Atricure, Boston Scientific, Medtronic. L. Nombela-Franco is proctor for Abbott Vascular and has received lectures fees from Boston Scientific. A. Natale has received speaker honoraria from Boston Scientific, Biosense Webster, St. Jude Medical, Biotronik, and Medtronic. He also is a consultant for Biosense Webster, St. Jude Medical, and Janssen. All other authors declare that they have no competing interests., (Copyright © 2024. Published by Elsevier Inc.)

Background: Several ethnic minorities have an increased risk of cardiovascular events, but previous European trials that investigated clinical outcome after coronary stenting did not assess the patients' ethnic background., Aims: To compare ethnic minority and Western European trial participants in terms of both cardiovascular risk profile and 1‑year clinical outcome after percutaneous coronary intervention., Methods: In the BIO-RESORT and BIONYX randomised trials, which assessed new-generation drug-eluting stents, information on patients' self-reported ethnic background was prospectively collected. Pooled patient-level data of 5803 patients, enrolled in the Netherlands and Belgium, were analysed in this prespecified analysis. The main endpoint was target vessel failure after 1 year., Results: Patients were classified as belonging to an ethnic minority (n = 293, 5%) or of Western European origin (n = 5510, 95%). Follow-up data were available in 5772 of 5803 (99.5%) patients. Ethnic minority patients were younger, less often female, more often current smokers, more often medically treated for diabetes, and more often had a positive family history of coronary artery disease. The main endpoint target vessel failure did not differ between ethnic minority and Western European patients (3.5% vs 4.9%, hazard ratio 0.71, 95% confidence interval 0.38-1.33; p = 0.28). There was also no difference in mortality, myocardial infarction, and repeat revascularisation rates., Conclusions: Despite the unfavourable cardiovascular risk profile of ethnic minority patients, short-term clinical outcome after treatment with contemporary drug-eluting stents was highly similar to that in Western European patients. Further efforts should be made to ensure the enrolment of more ethnic minority patients in future coronary stent trials., (© 2024. The Author(s).)

Background: Helicobacter pylori (Hp) infection predisposes to malignant and non-malignant diseases warranting eradication. In Belgium, resistance rates for clarithromycin demonstrate regional variations making the use of standard triple therapy (STT) borderline acceptable. According to a recent Belgian survey, STT and bismuth-based quadruple therapy (BQT), are equally frequent prescribed as first line treatment for treatment naïve Hp positive patients. This study aims to evaluate the eradication rates (ER) of BQT versus STT., Methods: Multicentre, non-blinded randomized, prospective study comparing ER in treatment-naïve Hp positive patients. ER were compared by intention to treat (ITT) and per protocol (PP) analysis., Results: Overall 250 patients were included (STT 126, BQT 124). Seventeen patients were lost to follow-up (6,8%). No significant difference in ER between BQT and STT was observed in ITT (73% vs 68%, p= 0,54) neither in PP analysis (81% vs 75%, p= 0,33). Side effects and endoscopic findings were comparable between groups. Post-hoc analysis showed no differences according to gender or site allocation., Conclusion: The numerical advantage of BQT did not translate in a significant improvement of ER when compared with STT. These results question the cost-effectiveness of BQT, while confirming the suboptimal eradication rates on STT. A nationwide monitoring of resistance patterns, maximal investments in treatment adherence as well as a detailed follow-up of the changing treatment landscape are mandatory to continuously optimise Hp ER in Belgium., Competing Interests: The authors declare that they have no conflict of interest, (© Acta Gastro-Enterologica Belgica.)

Aims: A substantial proportion of the patients undergoing percutaneous coronary intervention (PCI) have none of the of standard modifiable cardiovascular risk factors (SMuRFs): hypertension, diabetes, hypercholesterolaemia and smoking. The aim of this analysis was to compare clinical outcomes after PCI according to the number of SMuRFs., Methods: Patients with an indication for a PCI were stratified based upon the number of SMuRFs: 0, 1, 2 or 3-4. The primary outcome was target lesion failure (TLF), a composite of cardiac death, target vessel-related myocardial infarction or clinically driven target lesion revascularization at 1-year. Inverse weighted propensity score (IWPS) adjustment was performed to adjust for differences in baseline characteristics., Results: The prevalence of SMuRFs was: 0 SMuRF 16.4 %; 1 SMuRF 27.8 %; 2 SMuRFs 34.7 % and 3-4 SMuRFs 21.1 %. Patients without SMuRFs were younger, more likely to be male and had less complex coronary artery disease. The incidence of TLF increased with the number of SMuRFs: 2.65 %, 2.75 %, 3.23 %, and 4.24 %, P trend  < 0.001. The relative risk (RR) for a TLF was 60 % higher (95 % confidence interval 1.32-1.93, p < 0.01) for patients with 3-4 SMuRFs compared to patients without SMuRFs. The trend remained (P trend  < 0.01) after IWPS with TLF rates of 2.88 %, 2.64 %, 2.88 % and 3.65 %. The RR for a TLF was 27 % higher (95 % CI 1.05-1.53, p < 0.01)., Conclusion: The incidence of clinical events at 1-year increased with the number of SMuRFs. While patients without SMuRFs have a relatively favourable risk profile, more research is needed to optimize therapeutic management in the majority of patients., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)

Objective: To explore clinical effect modifiers of systemic hydrocortisone in ventilated very preterm infants for survival and neurodevelopmental outcome at 2 years' corrected age (CA)., Design: Secondary analysis of a randomised placebo-controlled trial., Setting: Dutch and Belgian neonatal intensive care units., Patients: Infants born <30 weeks' gestational age (GA), ventilator-dependent in the second week of postnatal life., Intervention: Infants were randomly assigned to systemic hydrocortisone (cumulative dose 72.5 mg/kg; n=182) or placebo (n=190)., Main Outcome Measures: The composite of death or neurodevelopmental impairment (NDI) at 2 years' CA and its components. Candidate effect modifiers (GA, small for GA, respiratory index, sex, multiple births, risk of moderate/severe bronchopulmonary dysplasia or death) were analysed using regression models with interaction terms and subpopulation treatment effect pattern plots., Results: The composite outcome was available in 356 (96.0%) of 371 patients (one consent withdrawn). For this outcome, treatment effect heterogeneity was seen across GA subgroups (<27 weeks: hydrocortisone (n=141) vs placebo (n=156), 54.6% vs 66.2%; OR 0.61 (95% CI 0.38 to 0.98); ≥27 weeks: hydrocortisone (n=30) vs placebo (n=31), 66.7% vs 45.2%; OR 2.43 (95% CI 0.86 to 6.85); p=0.02 for interaction). This effect was also found for the component death (<27 weeks: 20.1% vs 32.1%; OR 0.53 (95% CI 0.32 to 0.90); ≥27 weeks: 28.1% vs 16.1%; OR 2.04 (95% CI 0.60 to 6.95); p=0.049 for interaction) but not for the component NDI. No differential treatment effects were observed across other subgroups., Conclusion: This secondary analysis suggests that in infants <27 weeks' GA, systemic hydrocortisone may improve the outcome death or NDI, mainly driven by its component death. There was insufficient evidence for other selected candidate effect modifiers., Competing Interests: Competing interests: AHvK reports grants from the Netherlands Organization for Health Research and Development (ZonMW) during the conduct of the study. No other disclosures were reported., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Re-POT (proximal optimization technique (POT)) is a simple provisional sequential technique for percutaneous coronary bifurcation revascularization with better arterial geometry respect compared to classical techniques. Re-POT has demonstrated excellent mechanical and short-term clinical results. The multicenter CABRIOLET registry (NCT03550196) evaluate the long-term clinical benefit of the re-POT sequence in non-selected patients., Methods: All consecutive patients presenting a coronary bifurcation lesion for which provisional stenting was indicated were included in 5 european centers. Re-POT strategy was systematically attempted. The primary endpoint was target lesion failure (TLF), comprising cardiac death, myocardial infarction, stent thrombosis and target lesion revascularization (TLR) at 12 months' follow-up. The secondary endpoints were the individual components of the primary endpoint, all-cause death, target vessel failure (TVF) and target vessel revascularization (TVR). Complex bifurcation was defined as Medina 0.1.1 or 1.1.1., Results: A total of 500 patients aged 67.7 ± 11.7 years, 78.4% male, were included from 2015 to 2019, 174 of whom (34.8%) were considered having complex bifurcation lesions. Bifurcations involved the left main in 35.2% of cases. The full re-POT sequence was systematically performed in all cases. At 1 year, TLF was 2.0% (1.7% in complex vs. 2.1% in non-complex bifurcation; p = NS), and TLR was 1.6%, (1.1% vs. 1.8% respectively; p = NS). TVF and TVR rates were 3.2% and 2.8%. On multivariate analysis, only multivessel disease was predictive of TLF at 1 year (OR = 1.66 (1.09-2.53), p = 0.02)., Conclusions: In this large prospective all-comer registry, provisional stenting with re-POT technique appeared safe and effective at 1 year, without anatomical bifurcation restriction., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Competing Interests: Disclosures Dr Meneveau reports grants and personal fees from Bayer Healthcare, BMS Pfizer, and Abbott, as well as personal fees from Astra Zeneca and Terumo, outside the submitted work. Dr De Marco reports consultancies and paid expert testimonies from Abbott and Boston-Scientific. Dr Aminian is a proctor and consultant for Abbott and Boston-Scientific. Dr Chalkou reports a research grant from Janssen Switzerland (Johnson & Johnson). Dr Gräni reports funding from the Swiss National Science Foundation, InnoSuisse, CAIM foundation, GAMBIT foundation and Novartis foundation, outside of the submitted work. Dr Vranckx reports personal fees from AstraZeneca, Bristol Myers Squibb-Janssen, Bristol Myers Squibb-Pfizer, CSL Behring, and Daiichi-Sankyo, outside the submitted work. Dr Fischer reports grants from Medtronic and other from Medtronic, Stryker, and CSL-Behring, outside the submitted work. Dr Bedogni is a proctor for Abbott, Boston-Scientific, and Medtronic; he reports consultancies from Terumo and Meril. Dr Räber reports research grants to his institution from Abbott-Vascular, Boston-Scientific, Biotronik, Heartflow, and Sanofi, Regeneron. He reports speaker/consultation fees from Abbott-Vascular, Amgen, AstraZeneca, CSL-Behring, Canon, Occlutech, Sanofi, and Vifor. Dr Valgimigli has received grants and/or personal fees from AstraZeneca, Terumo, Alvimedica/CID, Abbott-Vascular, Daiichi-Sankyo, Opsens, Bayer, CoreFLOW, Idorsia-Pharmaceuticals-Ltd, Universität Basel Department Klinische Forschung, Vifor, Bristol-Myers-Squibb-SA, iVascular, and Medscape. The other authors report no conflicts.

Background: Evidence-based recommendations for antithrombotic treatment in patients who have an indication for oral anticoagulation (OAC) after transcatheter edge-to-edge mitral valve repair (TEER) are lacking., Aims: To compare bleeding and thrombotic risk for different antithrombotic regimens post-TEER with MitraClip in an unselected population with the need for OACs., Methods: Bleeding and thrombotic complications (stroke and myocardial infarction) up to 3 months after TEER with mitraclip were evaluated in 322 consecutive pts with an indication for OACs. These endpoints were defined by the Mitral Valve Academic Research Consortium criteria and were compared between two antithrombotic regimens: single antithrombotic therapy with OAC (single ATT) and double/triple ATT with a combination of OAC and aspirin and/or clopidogrel (combined ATT)., Results: Collectively, 108 (34%) patients received single ATT, 203 (63%) received double ATT and 11 (3%) received triple ATT. Bleeding events occurred in 67 patients (20.9%), with access site related events being the most frequent cause (37%). Bleeding complications were observed more frequently in the combined ATT group than in the single ATT group: 24% versus 14% [p = 0.03, adjusted RR: 0.55 (0.3-0.98)]. Within the combined group, the bleeding risk was 23% in the double ATT and 45% in the triple ATT group. Thrombotic complications occurred in only three patients (0.9%), and all belonged to the combined ATT group., Conclusions: In patients with an indication for OACs, withholding of antiplatelet therapy post-TEER with Mitraclip was associated with a 45% reduction in bleeding and without a signal of increased thrombotic risk., (© 2023 Wiley Periodicals LLC.)

Competing Interests: Stijn Lochy, Adel Aminian, Edgard Prihadi, and Philippe Unger have received consultancy fees from Abbott. The other authors had no conflicts to declare.

The management of patients with severe aortic valve stenosis and an abdominal aortic aneurysm is a real therapeutic challenge. Minimally invasive treatment is more beneficial than open surgery for treating both aortic valve stenosis and abdominal aortic aneurysm. We present a case of a 77-year-old male initially treated with a 26 mm Sapien 3 transcatheter aortic valve replacement. Subsequently, using the same femoral access points, a custom fenestrated endoprosthesis and stents in digestive trunks and renal arteries were implanted. Follow-up imaging revealed no dysfunction of the valve, endoprosthesis, or stents. This is the first reported successful concomitant management of significant aortic valve stenosis and infrarenal abdominal aortic aneurysm through transcatheter aortic valve replacement and fenestrated endovascular aortic aneurysm repair., (© 2023 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Aims: Patients with premature coronary artery disease (CAD) have a higher incidence of myocardial infarction (MI) than patients with non-premature CAD. The aim of the present study is to asess differences in clinical outcome after a first acute MI, percutaneously treated with new-generation drug-eluting stents between patients with premature and non-premature CAD., Methods and Results: We pooled and analysed the characteristics and clinical outcome of all patients with a first MI (and no previous coronary revascularization) at time of enrolment, in four large-scale drug-eluting stent trials. Coronary artery disease was classified premature in men aged <50 and women <55 years. Myocardial infarction patients with premature and non-premature CAD were compared. The main endpoint was major adverse cardiac events (MACE): all-cause mortality, any MI, emergent coronary artery bypass surgery, or clinically indicated target lesion revascularization. Of 3323 patients with a first MI, 582 (17.5%) had premature CAD. These patients had lower risk profiles and underwent less complex interventional procedures than patients with non-premature CAD. At 30-day follow-up, the rates of MACE [hazard ratio (HR): 0.22, 95% confidence interval (CI): 0.07-0.71; P = 0.005), MI (HR: 0.22, 95% CI: 0.05-0.89; P = 0.020), and target vessel failure (HR: 0.30, 95% CI: 0.11-0.82; P = 0.012) were lower in patients with premature CAD. At 1 year, premature CAD was independently associated with lower rates of MACE (adjusted HR: 0.50, 95% CI: 0.26-0.96; P = 0.037) and all-cause mortality (adjusted HR: 0.24, 95% CI: 0.06-0.98; P = 0.046). At 2 years, premature CAD was independently associated with lower mortality (adjusted HR: 0.16, 95% CI: 0.05-0.50; P = 0.002)., Conclusions: First MI patients with premature CAD, treated with contemporary stents, showed lower rates of MACE and all-cause mortality than patients with non-premature CAD, which is most likely related to differences in cardiovascular risk profile. TWENTE trials: TWENTE I, clinicaltrials.gov: NCT01066650), DUTCH PEERS (TWENTE II, NCT01331707), BIO-RESORT (TWENTE III, NCT01674803), and BIONYX (TWENTE IV, NCT02508714)., Competing Interests: Conflict of interest: C.v.B. reports that the research department of Thoraxcentrum Twente has received research grants provided by Abbott Vascular, Biotronik, Boston Scientific, and Medtronic. R.L.A. reports a teaching grant from Biotronik, a license from Sanofi, a speaking fee from Abiomed and support from Amgen for attending a meeting, all outside the submitted work. All other authors declared that they have no conflict of interest., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Objective: Incorrect inhaler use and poor treatment adherence have a negative impact on COPD outcomes. This multi-centre, single arm, non-interventional, phase IV study investigated whether inhalation technique, treatment adherence and patient outcomes change in patients who evolve from dual therapy or multiple inhaler triple therapy to single inhaler extrafine triple therapy (beclomethasone dipropionate (BDP, 87 μg), formoterol fumarate (FF, 5 μg) and glycopyrronium (G, 9 μg)) in combination with inhalation technique training., Methods: A total of 126 COPD patients were included in the per protocol set. Inhalation technique and treatment adherence were assessed at baseline and at two visits at approximately 3 and 6 months of treatment with extrafine BDP/FF/G. In addition, lung function, symptom score, patient satisfaction and exacerbations (exploratory) were followed up., Results: Before switching to single inhaler extrafine BDP/FF/G (baseline), any device errors and critical errors were detected for 28.8% and 9.6% of patients, respectively. After switching to BDP/FF/G, the percentage of patients with any device errors decreased to 14.0% (visit 2) and 16.3% (visit 3), without critical errors at the two follow-up visits. Treatment adherence increased from 67.5% at baseline to 75.8% (visit 2) and 80% (visit 3). In addition, lung function, symptom and patient satisfaction scores improved, whilst exacerbation rates substantially decreased., Conclusions: This observational study demonstrates that in eligible COPD patients in a real-life setting, the switch from dual therapy or multiple inhaler triple therapy to single inhaler extrafine BDP/FF/G in combination with inhalation technique training is associated with improved inhalation technique and adherence., Competing Interests: Declaration of competing interest Brusselle G. has, within the last 5 years, received honoraria for lectures from AstraZeneca, Boehringer-Ingelheim, Chiesi, GlaxoSmithKline, Novartis, Pfizer, Teva, UCB and Zambon; he is a member of advisory boards for AstraZeneca, Boehringer-Ingelheim, Chiesi, GlaxoSmithKline, Novartis, Sanofi/Regeneron and Teva. He reports financial support as principal investigator during the study from Chiesi sa/nv. Himpe U. received honoraria for lectures from AstraZeneca, Chiesi, GlaxoSmithKline, MSD, BMS; she is a member of advisory boards for GlaxoSmithKline. She reports financial support as principal investigator during studies from Chiesi, Astra Zeneca. She reports financial support as investigator during the study from Chiesi sa/nv. Fievez P. has no declaration of interest. Leys M. received honoraria for lectures from AstraZeneca, Chiesi, GlaxoSmithKline, Novartis, Pfizer, Janssen, Bayer, MSD; he is a member of advisory boards for AstraZeneca, Chiesi, GlaxoSmithKline, Novartis,. He reports financial support as investigator during the study from Chiesi sa/nv. Perez Bogerd S. was a member of advisory boards for AstraZeneca and has received, within the last 5 years, grants from Chiesi. She reports financial support as investigator during the study from Chiesi sa/nv. Peché R. has, within the last 5 years, received honoraria for lectures from AstraZeneca, Boehringer-Ingelheim, Chiesi, GlaxoSmithKline. He is a member of advisory boards for AstraZeneca, Boehringer-Ingelheim, Chiesi and GlaxoSmithKline. Vanderhelst E has, within the last 5 years, received honoraria for lectures from Vertex Pharmaceuticals, Boehringer-Ingelheim, Chiesi, GlaxoSmithKline. She is a member of advisory boards for Vertex Pharmaceuticals, Boehringer-Ingelheim, GlaxoSmithKline and received scientific grants from Chiesi and Boehringer-Ingelheim. Lins M. has, within the last 5 years, received honoraria for lectures from AstraZeneca, Boehringer-Ingelheim, Chiesi, GlaxoSmithKline, Novartis, Pfizer and Nyxoah. She is a member of advisory boards for AstraZeneca, GlaxoSmithKline, Novartis, Biophytis. She reports financial support as principal investigator during studies from Novartis, Chiesi, Astra Zeneca, Biophytis, Sanofi, Bayer, GSK, Johnson & Johnson. Capiau P. is a full-time employee of Chiesi sa/nv., (Copyright © 2023 Chiesi Pharmaceuticals. Published by Elsevier Ltd.. All rights reserved.)

Background: Previous studies comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with multivessel coronary disease not involving the left main have shown significantly lower rates of death, myocardial infarction (MI), or stroke after CABG. These studies did not routinely use current-generation drug-eluting stents or fractional flow reserve (FFR) to guide PCI., Methods: FAME 3 (Fractional Flow Reserve versus Angiography for Multivessel Evaluation) is an investigator-initiated, multicenter, international, randomized trial involving patients with 3-vessel coronary artery disease (not involving the left main coronary artery) in 48 centers worldwide. Patients were randomly assigned to receive FFR-guided PCI using zotarolimus drug-eluting stents or CABG. The prespecified key secondary end point of the trial reported here is the 3-year incidence of the composite of death, MI, or stroke., Results: A total of 1500 patients were randomized to FFR-guided PCI or CABG. Follow-up was achieved in >96% of patients in both groups. There was no difference in the incidence of the composite of death, MI, or stroke after FFR-guided PCI compared with CABG (12.0% versus 9.2%; hazard ratio [HR], 1.3 [95% CI, 0.98-1.83]; P =0.07). The rates of death (4.1% versus 3.9%; HR, 1.0 [95% CI, 0.6-1.7]; P =0.88) and stroke (1.6% versus 2.0%; HR, 0.8 [95% CI, 0.4-1.7]; P =0.56) were not different. MI occurred more frequently after PCI (7.0% versus 4.2%; HR, 1.7 [95% CI, 1.1-2.7]; P =0.02)., Conclusions: At 3-year follow-up, there was no difference in the incidence of the composite of death, MI, or stroke after FFR-guided PCI with current-generation drug-eluting stents compared with CABG. There was a higher incidence of MI after PCI compared with CABG, with no difference in death or stroke. These results provide contemporary data to allow improved shared decision-making between physicians and patients with 3-vessel coronary artery disease., Registration: URL: https://www., Clinicaltrials: gov; Unique identifier: NCT02100722., Competing Interests: Disclosures Dr Pijls receives research funding from Abbott, has consulting relationships with Abbott and Opsens, and has stock or stock options with ASML, General Electric, HeartFlow, Hexacath, and Philips. Dr Mansour has consulting relationships with Abbott Vascular, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Novartis, Pfizer, and Servier Affaires, and received a research grant from Opsens Inc and Abbott Vascular. Dr Kala has a consulting relationship with Boston Scientific, Medtronic, and Servier Affaires, and receives honoraria from AstraZeneca and Bayer. Dr Angeras receives research funding from Abbott Vascular and AstraZeneca and has a consulting relationship with Abbott Vascular and Boston Scientific. Dr Miner has a consulting relationship with Abbott, Amgen, Astra Zeneca, Bayer, Boehringer, Novartis, Opsens, Pfizer, and Servier Affaires Medicales. Dr Engstrøm has a consulting relationship with Abbott Vascular, Bayer, and Novo Nordisk. Dr Christiansen has a consulting relationship with Abbott Vascular and has received research grants from Abbott Vascular. Dr Tonino has received research grants from Biosensors and Opsens. Dr Reardon has a consulting relationship with Boston Scientific and W.L. Gore & Associates. Dr Otsuki has received research grants from the Uehara Memorial Foundation, Abbott, Medtronic, Boston Scientific, and Terumo. Dr Kobayashi has a consulting relationship with Abbott Vascular. Dr Hlatky has a consulting relationship with Blue Cross and Blue Shield and research support from HeartFlow. Dr Mahaffey has received research grants or contracts from the American Heart Association, Apple, Inc, Bayer, California Institute Regenerative Medicine, Eidos, Ferring, Gilead, Google (Verily), Idorsia, Johnson & Johnson, Luitpold, PAC-12, Precordior, and Sanifit; has provided consulting or other services for Amgen, Applied Therapeutics, AstraZeneca, Bayer, CSL Behring, Elsevier, FibroGen, Inova, Johnson & Johnson, Lexicon, MyoKardia, Novartis, Novo Nordisk, Otsuka, PhaseBio, Portola, Quidel, Sanofi, and Theravance; and has equity in Precordior. Dr Yeung has a consulting relationship with Medtronic. Dr De Bruyne has an institutional consulting relationship with Boston Scientific, Abbott Vascular, CathWorks, Siemens, GE Healthcare, and Coroventis Research; receives institutional research grants from Abbott Vascular, Coroventis Research, CathWorks, and Boston Scientific; and holds minor equities in Philips, Siemens, GE Healthcare, CathWorks, Edwards Life Sciences, HeartFlow, Opsens, Celyad, Xenter, Medyria, Bayer, and Sanofi. Dr Fearon receives research funding from Abbott, Medtronic, and Boston Scientific and has a consulting relationship with Siemens and CathWorks and stock options with HeartFlow. The other authors report no conflicts of interest.

Background: Device-related thrombus (DRT) remains one of the main concerns after left atrial appendage occlusion (LAAO). Several risk factors have been proposed, but most cannot be modulated. A modifiable factor such as device implantation depth is a potential target to adjust the risk for DRT., Objectives: The aim of this study was to assess the impact of LAAO device implantation depth as a predisposing factor for DRT., Methods: The study included patients who underwent successful LAAO at 9 centers in Europe and Canada. Patients were classified into 2 groups: proximal device implantation (covered pulmonary ridge [PR] in the lobe and disc cohort or <5 mm from the PR in the single-lobe cohort) and distal device implantation (uncovered PR in the disc and lobe cohort and ≥5 mm in the single-lobe cohort)., Results: A total of 1,317 patients were included. Among these, proximal and distal device implantation was achieved in 732 (55%) and 585 (45%) patients, respectively. No differences in procedural outcomes were observed between the groups. At follow-up, patients with proximal implantation had a lower incidence of DRT (2.3%) than those with distal implantation (12.2%) (P < 0.001). Deeper device implantation and a larger uncovered left atrial appendage area were associated with a higher incidence of DRT (P < 0.001), regardless of device type. In multivariable analysis, distal implant (HR: 5.92; 95% CI: 3.39-10.36) and no or single antiplatelet therapy (HR: 1.62; 95% CI: 0.99-2.62) emerged as independent predictors of DRT., Conclusions: LAAO device implantation depth is an independent risk factor for DRT. Deeper device implantation and larger uncovered left atrial appendage areas were associated with a higher incidence of DRT., Competing Interests: Funding Support and Author Disclosures Dr De Backer has received institutional research grants and consulting fees from Abbott and Boston Scientific. Dr Sanchis is a proctor for Abbott Medical. Dr Garot has received speaker and advisory fees from Abbott, Biosensors, Boston Scientific, Edwards Lifesciences, GE Healthcare, and Terumo; and serves as medical director for and is a shareholder in the Cardiovascular European Research Center. Dr Aminian is a proctor and consultant for Abbott and Boston Scientific. Dr Rodés-Cabau has received an institutional research grant from Boston Scientific. Dr Freixa is a proctor for Abbott Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: We assessed differences in risk profile and 3-year outcome between patients undergoing percutaneous coronary intervention (PCI) for premature and non-premature coronary artery disease (CAD)., Background: The prevalence of CAD increases with age, yet some individuals develop obstructive CAD at younger age., Methods: Among participants in four randomized all-comers PCI trials, without previous coronary revascularization or myocardial infarction (MI), we compared patients with premature (men <50 years; women <55 years) and non-premature CAD. Various clinical endpoints were assessed, including multivariate analyses., Results: Of 6,171 patients, 887 (14.4%) suffered from premature CAD. These patients had fewer risk factors than patients with non-premature CAD, but were more often smokers (60.7% vs. 26.4%) and overweight (76.2% vs. 69.8%). In addition, premature CAD patients presented more often with ST-segment elevation MI and underwent less often treatment of multiple vessels, and calcified or bifurcated lesions. Furthermore, premature CAD patients had a lower all-cause mortality risk (adj.HR: 0.23, 95%-CI: 0.10-0.52; p  < 0.001), but target vessel revascularization (adj.HR: 1.63, 95%-CI: 1.18-2.26; p  = 0.003) and definite stent thrombosis risks (adj.HR: 2.24, 95%-CI: 1.06-4.72; p  = 0.034) were higher. MACE rates showed no statistically significant difference (6.6% vs. 9.4%; adj.HR: 0.86, 95%-CI: 0.65-1.16; p  = 0.33)., Conclusions: About one out of seven PCI patients was treated for premature CAD. These patients had less complex risk profiles than patients with non-premature CAD; yet, their risk of repeated revascularization and stent thrombosis was higher. As lifetime event risk of patients with premature CAD is known to be particularly high, further efforts should be made to improve modifiable risk factors such as smoking and overweight., Twente Trials: (TWENTE I, clinicaltrials.gov: NCT01066650 ), DUTCH PEERS (TWENTE II, NCT01331707 ), BIO-RESORT (TWENTE III, NCT01674803 ), and BIONYX (TWENTE IV, NCT02508714 )., Competing Interests: CvB reports that the research department of Thoraxcentrum Twente has received research grants provided by Abbott Vascular, Biotronik, Boston Scientific, and Medtronic. RLA reports a teaching grant from Biotronik, a license from Sanofi, a speaking fee from Abiomed and support from Amgen for attending a meeting, all outside the submitted work. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Pinxterhuis, Ploumen, Zocca, Doggen, Schotborgh, Anthonio, Roguin, Danse, Benit, Aminian, Hartmann, Linssen and von Birgelen.)

Background: Percutaneous coronary intervention (PCI) for bifurcation lesions can be technically challenging and is associated with higher risk. There is little data on sex-based differences in strategy and outcomes in bifurcation PCI., Aims: We sought to assess whether differences exist between women and men in the treatment and outcomes of bifurcation PCI., Methods: We collected data on 4006 patients undergoing bifurcation PCI, from the e-ULTIMASTER study, a prospective, multicentre study enrolling patients from 2014 to 2018. We divided the bifurcation cohort according to sex, with 1-year follow-up of outcomes (target lesion failure [TLF], target vessel failure [TVF], and patient-oriented composite endpoint [POCE])., Findings: Women were older (69.2 ± 10.9 years vs. 64.4 ± 11.0 years), with a greater burden of cardiovascular comorbidities. For true and non-true bifurcation lesions, women and men were equally likely to undergo a single stent approach (true: 63.2% vs. 63.6%, p = 0.79, non-true: 95.4% vs. 94.3%, p = 0.32), with similar rates of final kissing balloon (FKB) (37.2% vs. 35.5%, p = 0.36) and proximal optimization (POT) (34.4% vs. 34.2%, p = 0.93) in cases where two stents were used. Lastly, after propensity score matching, there was no difference between women and men in the incidence of the composite endpoints of TLF (5.5% vs. 5.2%, RR 1.05 [95% CI 0.77-1.44], p = 0.75), TVF (6.2% vs. 6.3%, RR 0.99 [95% CI 0.74-1.32], p = 0.96), and POCE (9.9% vs. 9.5%, RR 1.05 [95% CI 0.83-1.31], p = 0.70)., Conclusion: In this contemporary, real-world study of bifurcation PCI, we report no difference in stent strategy between women and men, with similar outcomes at 1-year., (© 2023 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Background: In patients with peripheral arterial disease (PADs), who underwent percutaneous coronary intervention (PCI), little is known about the potential impact of using different new-generation drug-eluting stents (DES) on outcome. In PCI all-comers, the results of most between-stent comparisons-stratified by strut thickness-suggested some advantage of coronary stents with ultrathin-struts. The current post-hoc analysis aimed to assess outcomes of PCI with ultrathin-strut biodegradable polymer sirolimus-eluting stents (BP-SES) vs. thin-strut durable polymer zotarolimus-eluting stents (DP-ZES) in patients with PADs., Methods: We pooled 3-year patient-level data from two large-scale randomized all-comer trials to compare Orsiro ultrathin-strut BP-SES vs. Resolute-type thin-strut DP-ZES in trial participants with concomitant PADs. BIO-RESORT (December 2012 to August 2015) and BIONYX (October 2015 to December 2016) included all-comer patients who were aged 18 years or older, capable of providing informed consent, and required a PCI. The trials had web-based randomization, with block sizes of 4 and 8, performed in a 1:1:1 or 1:1 fashion. Assessors, research staff, and patients were blinded to the type of stent used. We assessed the composite main clinical endpoint target vessel failure [TVF: cardiac death, target vessel related myocardial infarction (MI), or clinically indicated target vessel revascularization (TVR)], its components, and stent thrombosis., Results: Of 4,830 trial participants, 360 had PADs: 177 (49.2%) were treated with BP-SES and 183 (50.8%) with DP-ZES. Baseline characteristics were similar. For BP-SES, the 3-year TVF rate was 11.0% and for DP-ZES 17.9% [hazard ratio (HR): 0.59, 95% CI: 0.33-1.04; P=0.07]. For BP-SES, the TVR rate was lower than for DP-ZES (4.1% vs. 11.0%; HR: 0.36, 95% CI: 0.15-0.86; P=0.016), but this did not translate into between-group differences in cardiac death or MI. In small vessels (<2.75 mm), the TVR rate was also lower in BP-SES (5.6% vs. 13.9%; HR: 0.32, 95% CI: 0.11-0.91; P=0.024). Definite-or-probable stent thrombosis rates were 1.2% and 2.3% (P=0.43)., Conclusions: In PCI patients with PADs, the 3-year TVF incidence was numerically lower in the ultrathin-strut BP-SES vs. the thin-strut DP-ZES group. Furthermore, TVR risk was significantly lower in ultrathin-strut BP-SES, mainly driven by a lower TVR rate in small vessels., Trial Registration: BIO-RESORT trial: clinicaltrials.gov ( NCT01674803 ); BIONYX trial: clinicaltrials.gov ( NCT02508714 )., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://cdt.amegroups.com/article/view/10.21037/cdt-22-584/coif). EHP reports that the Research Department of Thoraxcentrum Twente has received institutional research grants from these companies (Biotronik, Boston Scientific, and Medtronic) for performing the 2 RCTs on which the analyses of this manuscript are based. In addition, the Research Department of Thoraxcentrum Twente has received an institutional research grant for performing a stent study, not directly related with the content of the present manuscript. RLA reports a teaching grant from Biotronik, a license from Sanovi, a speaking fee from Abiomed and support from Amgen for attending a meeting, all outside the submitted work. CvB reports that the Research Department of Thoraxcentrum Twente has received institutional research grants from these companies (Biotronik, Boston Scientific, and Medtronic) for performing the 2 RCTs on which the analyses of this manuscript are based. In addition, the Research Department of Thoraxcentrum Twente has received an institutional research grant for performing a stent study, not directly related with the content of the present manuscript. The author is a DSMB member in a TAVI trial and a vascular surgical trial. The other authors have no conflicts of interest to declare., (2023 Cardiovascular Diagnosis and Therapy. All rights reserved.)

Background: Left atrial appendage occlusion (LAAO) procedures are widely guided by standard transesophageal echocardiography (TEE) probes, requiring general anesthesia in most patients. The use of miniaturized TEE probes allows for LAAO guidance under local anesthesia and offers an attractive imaging alternative to standard TEE probes., Objectives: The aim of this study was to assess the safety and efficacy of miniaturized TEE probes for procedural guidance of LAAO., Methods: Multicenter retrospective observational study of LAAO procedures performed under miniaturized TEE guidance and conscious sedation. The primary efficacy endpoint was technical success. The secondary efficacy endpoint was procedural success (technical success without major periprocedural complications). The safety outcome was a composite of major periprocedural complications., Results: A total of 546 consecutive LAAO procedures were performed in 5 European centers. Technical success was achieved in 534 (98.0%) patients. Sixteen major periprocedural complications occurred in 15 (2.9%) patients, yielding a procedural success rate of 97.0%. Conversion to general anesthesia was required in 4 (0.7%) patients. Short-term imaging follow-up was available in 422 patients with an incidence of major (>5 mm) TEE-detected residual leaks of 0.7%, complete LAA occlusion of 82.2% on cardiac computed tomography, and device-related thrombus of 5%. As compared with procedural 2-dimensional imaging for device sizing, preprocedural assessment by 3-dimensional imaging resulted in improved technical success (100% vs 95.0%; P < 0.001)., Conclusions: LAAO under conscious sedation and miniaturized TEE guidance is safe and feasible with a high rate of technical success and a low rate of periprocedural complications., Competing Interests: Funding Support and Author Disclosures Dr Aminian has served as a proctor and consultant for Abbott and Boston Scientific. Dr Freixa has served as a proctor and consultant for Abbott and Lifetech. Dr Swaans has served as a lecturer/proctor for Abbott Vascular, Boston Scientific, Edwards Lifesciences, Bioventrix, GE Healthcare, and Philips Healthcare. Dr Sanchis has served as proctor for Abbott; and received speaker honoraria from Abbott and GE Healthcare. Dr Cruz-González has served as proctor and consultant for Abbott, Boston Scientific, and Lifetech. Dr Boersma has received consultation funds from Boston Scientific, Abbott Medical, and Philips Healthcare. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

The outcomes of chronic total occlusion percutaneous coronary intervention have considerably improved during the last decade with continued emphasis on improving procedural safety. Vascular access site bleeding remains one of the most frequent complications. Several procedural strategies have been implemented to reduce the rate of vascular access site complications. This state-of-the-art review summarizes and describes the current evidence on optimal vascular access strategies for chronic total occlusion percutaneous coronary intervention., Competing Interests: Disclosures Drs Aminian and Dens are consultants for Terumo Corporation. Dr Iglesias is a consultant for Biotronik, Cordis, Medtronic, and Terumo Corporation; has received unrestricted research grants to the institution from Abbott Vascular, AstraZeneca, Biotronik, Biosensors, Concept Medical, Philips Volcano, and Terumo Corporation; and has received honoraria/speaker fees for AstraZeneca, Biosensors, Biotronik, Bristol Myers Squibb/Pfizer, Cordis, Concept Medical, Medalliance, Medtronic, Novartis, Terumo Corporation, and Philips Volcano. Dr Brilakis has received consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), Cardiovascular Systems, Inc, Elsevier, GE Healthcare, Interventional Medical Device Solutions (IMDS), Medicure, Medtronic, Siemens, Teleflex, and Terumo Corporation; has received research support from Boston Scientific and GE Healthcare; is the owner at Hippocrates LLC; and is a shareholder at MHI Ventures, Cleerly Health, and Stallion Medical. Dr Gasparini reports consulting/speaker honoraria from Abbott Vascular, Cordis, Terumo Corporation, Asahi Intecc, IMDS, Boston Scientific, and Medtronic. Dr Valgimigli reports personal fees from AstraZeneca, grants and personal fees from Terumo Corporation, personal fees from Alvimedica/Carbostent and Implantable Devices, personal fees from Abbott Vascular, personal fees from Daiichi Sankyo, personal fees from Bayer, personal fees from Abiomed, personal fees from CoreFLOW, personal fees from Idorsia Pharmaceuticals, Ltd, personal fees from Universität Basel, Deptartment Klinische Forschung, personal fees from Bristol Myers Squib SA, personal fees from Medscape, personal fees from Biotronik, and personal fees from Novartis, outside the submitted work. Dr van Royen received research grants from Philips, Abbott, Biotronik, and Medtronic and personal fees from Abbott, Microport, and Rainmed. Dr van Leeuwen received speaker/consulting services honoraria from Terumo Corporation, Daiichi Sankyo, and Abbott and research grants from AstraZeneca, Top Sector Life Sciences & Health, Terumo Corporation, Top Medical B.V., and Abbott. The other authors report no conflicts.