RAPSTROM™ first-in-man study long-term results of a biodegradable polymer sustained-release sirolimus-eluting stent in de novo coronary stenoses.

BACKGROUND: Durable polymers used for first-generation drug-eluting stents (DES) potentially contribute to persistent inflammation and late DES thrombosis. We report the first real-life human experience with the rapamycin-eluting biodegradable polymer-coated Rapstrom stent. METHODS: All consecutive patients with single de novo native coronary stenosis (<30 mm and between 2.5 and 4.0 mm) were enrolled. Major adverse cardiac events (MACE) at 1 year (cardiac death, myocardial infarction [Q and non-Q], or ischemia-driven target lesion revascularization) were the primary end-point. RESULTS: A total of 123 patients were enrolled. The stent was implanted without complications in all patients, and no MACE were recorded at 30 days. At 12-month follow-up 9 patients (7.3%) experienced a MACE and 4 (3.2%) required a target lesion revascularization, while 1 (1%) stent thrombosis was recorded. A planned angiographic follow-up (FU) was performed in 73 patients (59%) at 9.4 ± 2.6 months following the index procedure. In-stent late loss was 0.16 ± 0.09 mm, and in-segment late loss was 0.18 ± 0.8 mm. CONCLUSION: The Rapstrom biodegradable polymer rapamycin-eluting stent appeared safe and efficacious in this first real-life human experience, due to a low late lumen loss. Larger randomized studies are required to confirm these preliminary results.

Retrograde Percutaneous Coronary Intervention in a Case of Takayasu Arteritis with Left Main Coronary Artery Chronic Total Occlusion.

Background: Takayasu arteritis (TA) frequently involves the coronary arteries, and restenosis is common after initial percutaneous coronary intervention (PCI). However, PCI remains a good option for patients who develop graft failure after coronary artery bypass graft surgery (CABG). Drug-coated balloons help in repeat revascularization after stent failure in TA. Case Presentation. A 31-year-old female with previous history of Takayasu arteritis (TA) and CABG with left internal mammary artery (LIMA) to left anterior descending artery (LAD) grafting in 2012, presented to us with exertional angina of 6-month duration. Her coronary angiogram showed total occlusion of the left main coronary artery (LMCA) ostium and atretic LIMA graft. Since the guiding catheter could not engage the LMCA, a retrograde approach was planned. After lesion crossing, the retrograde guidewire could not be externalized even after multiple attempts. Hence, a repeat antegrade approach was tried, and antegrade wire crossed through the channel created by the retrograde microcatheter. Then, intravascular ultrasound (IVUS) guided LMCA-LAD stenting was done. The patient was started on dual antiplatelets and prednisolone and was on regular follow-up. Three months later, the patient presented to us with non-ST elevation MI. Coronary angiogram showed critical in-stent restenosis of the LMCA stent, and optical coherence tomography (OCT) showed diffuse neointimal hyperplasia. OCT-guided PCI using sirolimus-coated balloon was done. On 8 months of follow-up, the patient remains symptom free. Conclusion: Coronary artery disease in TA may require repeated interventions due to stent/graft failure. Drug-coated balloons play a crucial role in repeat revascularization for stent failure in TA. Retrograde approach increases the technical success rate of PCI in LMCA-CTO.

Absolute zero-contrast percutaneous coronary intervention under intravascular ultrasound guidance in chronic kidney disease patients - From despair to hope?

Background: Zero contrast percutaneous coronary intervention (PCI) reduces contrast induced acute kidney injury (CI-AKI), and it improves the outcome of chronic kidney disease (CKD) patients undergoing PCI. Objectives: We sought to assess the safety and short-term outcomes of 'absolute' zero-contrast PCI under intravascular ultrasound (IVUS) guidance in CKD patients. Methods: Data from all consecutive CKD patients who were included for absolute zero contrast PCI during the period of June 2020 to March 2021 were included in this analysis. Clinical characteristics, angiographic, IVUS and procedural data, and follow-up data were analyzed. Results: Totally 42 patients (66 vessels) with the mean age of 69.04 ± 11.9 years, were included for absolute zero-contrast PCI. The mean serum creatinine and estimated glomerular filtration rate (eGFR) were 2.67 ± 1.46 mgs% and 30.67 ± 12.26 ml/min/1.73 m2 respectively. The most common presentation was acute coronary syndrome (ACS) and the mean left ventricular ejection fraction (LVEF) and SYNTAX score were 43.7 ± 11.9% and 27.7 ± 14.1 respectively. Complex PCI including 14 (21.2%) left main coronary artery (LMCA) PCI (seven LMCA bifurcation PCI) and three chronic total occlusion (CTO) PCI were also done. Technical success was 92.4% without any major complications. Two patients died of non cardiac causes on follow up (3-12 months), and all the remaining were symptom free. Conclusion: IVUS guided 'absolute' zero-contrast PCI is feasible and safe CKD patients. Even in complex lesion morphologies, the procedure can be completed without any contrast and complications.

Retrograde percutaneous coronary intervention in a calcified and dissected left anterior descending artery using single catheter - To lose the patience is to lose the battle.

Percutaneous coronary intervention (PCI) after iatrogenic coronary dissection in a heavily calcified vessel is technically challenging and a retrograde approach helps in that scenario. "Reverse rota wiring" shortens the procedure time in retrograde PCI whenever rotational atherectomy is planned. A 70-year-old male patient with previous PCI to diagonal and left circumflex arteries and attempted PCI to left anterior descending (LAD) and right coronary arteries, presented with exertional angina. After documenting ischemia, PCI to LAD was scheduled. After failed initial antegrade attempts, retrograde wiring through the diagonal was done. Then reverse rota wiring and rotational atherectomy (RA) to LAD using 1.25 mm burr was done. Since the 1.25 mm rota burr was entrapped, the entire system was manually pulled back. Repeat retrograde wiring and RA using 1.5 burr was done since the intravascular ultrasound showed >270° calcium. After multiple balloon dilatations, stenting was done using two drug-eluting stents. Coronary perforation with cardiac tamponade occurred after stenting. After pericardiocentesis, perforation was sealed with a guidezilla-II assisted covered stent implantation and final thrombolysis in myocardial infarction (TIMI) 3 flow was achieved. The patient remained symptom-free at one-year follow-up. Operator skills and perseverance are essential for good outcome in complex PCIs. Learning objectives: 1.Retrograde percutaneous coronary intervention is useful in iatrogenic coronary dissection, when antegrade attempts to enter the true lumen fail.2.'Reverse rota wiring' is an alternative method to do rotational atherectomy after retrograde wire crossing. It shortens the procedure time and it is useful in heavily calcified lesions where balloon uncrossability is anticipated.

Clinical expert consensus document on the use of percutaneous left ventricular assist devices during complex high-risk PCI in India using a standardised algorithm.

Over the past decade, percutaneous left ventricular assist devices (pLVAD), such as the Impella microaxial flow pump (Abiomed), have been increasingly used to provide haemodynamic support during complex and high-risk revascularisation procedures to reduce the risk of intraprocedural haemodynamic compromise and to facilitate complete and optimal revascularisation. A global consensus on patient selection for the use of pLVADs, however, is currently lacking. Access to these devices is different across the world, thus, individual health care environments need to create and refine patient selection paradigms to optimise the use of these devices. The Impella pLVAD has recently been introduced in India and is being used in several centres in the management of high-risk percutaneous coronary intervention (PCI) and cardiogenic shock. With this increasing utilisation, there is a need for a standardised evaluation protocol to guide Impella use that factors in the unique economic and infrastructural characteristics of India's health care system to ensure that the needs of patients are optimally managed. In this consensus document, we present an algorithm to guide Impella use in Indian patients: to establish a standardised patient selection and usage paradigm that will allow both optimal patient outcomes and ongoing data collection.

Zero-Contrast Left Main Bifurcation PCI in an Elderly Patient with Chronic Kidney Disease.

Patients with chronic kidney disease develop acute kidney injury (AKI) following percutaneous coronary intervention (PCI). We report a case highlighting the benefits of zero-contrast left main bifurcation PCI in an 82-year-old male with non-ST elevation myocardial infarction and contrast-induced AKI following coronary angiography. The patient was on routine follow-up, and he was stable and asymptomatic at nine months follow-up.

Two-year safety and efficacy of Indigenous Abluminus Sirolimus Eluting Stent. Does it differ amongst diabetics? - Data from en-ABLe- REGISTRY.

Introduction: To evaluate the efficacy/safety profile of the Abluminus DES+ over 2-years follow-up in the "real-world" scenario in diabetics as compared to non-diabetics. Methods: In prospective, all-comers, open-label registry conducted at 31 sites, patients were analyzed for 1 & 2-year outcomes with the primary endpoint defined as 3P-MACE of CV death, target vessel related myocardial infarction (TV-MI), ischemia-driven target lesion revascularization (TLR)/target vessel revascularization (TVR) apart from Stent thrombosis (ST). Results: Of 2500 patients of PCI with 3286 Abluminus-DES+, 1641 (65.64%) were non-diabetics while859 (34.36%) were diabetics. The 3-P MACE for the cohort at 1 & 2 years were 2.9%, and 3.16%; TLR/TVR - 1.4% at both the intervals for 2493 patients at 2 yrs. follow-up. TV-MI & ST were 0.36% and0.56% at 1st and 2nd year respectively. The 3P-MACE was lower in non-diabetics at 1 & 2 years (2.3%vs 4.2%; 2.4% vs 4.7% respectively). For components of MACE, CV mortality (0.9 vs 1.9% at 1 yr ; 1.0vs 2.1% at 2 years) was significant (P < 0.05) while TLR (1.1 vs 1.9% at 1 yr. & 1.1 vs 2.1% at 2 yrs.) and TV-MI (0.9 vs 1.9% at 1 yr. & 1 vs 2.1% at 2 years) were similar for diabetics and non-diabetics so was ST (P > 0.05). Conclusion: Abluminus-DES+ showed excellent 2-year safety and efficacy with low 3-P MACE which was higher in diabetics driven by higher CV death but similar TLR, TV-MI and ST.

Retrograde chronic total occlusion percutaneous coronary intervention using single catheter: A single centre registry.

OBJECTIVES: To analyse the feasibility, safety and procedural outcomes of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) through retrograde approach using single catheter. METHODS: Our study was a retrospective observational study that enrolled patients who underwent retrograde CTO PCI using a single catheter between June 2016 and February 2020. Clinical success was defined as successful completion of CTO PCI without associated in-hospital major clinical complications like death, myocardial infarction, stroke or urgent revascularisation. Technical success was defined as successful completion of CTO PCI using single catheter and minimum diameter stenosis of <30% with thrombolysis in myocardial infarction (TIMI) flow grade 3, without significant side branch occlusion, flow-limiting dissection, distal embolization, or angiographic thrombus. RESULTS: Totally 102 patients underwent retrograde CTO PCI during the study period. Out of which, 15 cases were attempted using single catheter. Mean age of the population was 59.1 ± 8.9 years (males: 86.7%) and the left ventricular ejection fraction (LVEF) was (61% ± 9.1%). Mean number of diseased arteries was 2.1 ± 0.7, length of the CTO was 25.5 ± 7.4 mm and J-CTO score was 2.3 ± 0.7. We achieved a technical success rate of 73.3% using single catheter, and the overall clinical success (Including single catheter and ping pong) was obtained in 86.7% cases. One patient (6.7%) developed cardiac tamponade and none of study population required dialysis for contrast induced acute kidney injury (CI-AKI) CONCLUSIONS: Retrograde CTO PCI using single catheter is a technically challenging procedure when compared with other CTO PCI. Our study demonstrated acceptable outcomes which is comparable to other antegrade and retrograde CTO PCI registries.

Dual Antiplatelet Therapy in Coronary Artery Disease.

Acute coronary syndrome (ACS) is principally driven by platelet aggregation. Dual antiplatelet therapy (DAPT) has demonstrated a reduction in recurrent ischemic events. The newer antiplatelets ticagrelor and prasugrel have demonstrated superiority over clopidogrel. While prasugrel demonstrated benefit in patients scheduled for percutaneous intervention (PCI), benefits of ticagrelor were seen irrespective of the treatment strategy. Current guidelines recommend the use of DAPT for 1 year in all patients with ACS. Ticagrelor 60 mg is recommended for up to 3 years in high-risk patients. DAPT and Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy (PRECISE DAPT) scores are tools to support decision-making in deciding duration of dual antiplatelet therapy.

Immediate and medium-term outcomes following the treatment of very long (> or =50 mm) chronic total coronary artery occlusions.

OBJECTIVE: The follow-up patency rates and associated clinical and angiographic variables following stenting of very long (> or =50 mm) and chronic (>6 months) total coronary artery occlusive lesions are not well documented. The aim of the present study was to evaluate the early results and mid-term outcomes following angioplasty of such lesions. METHODS: Between January 2000 and June 2002, we treated 278 chronic coronary occlusions. Of these, eighty-nine occlusions (89 patients) were with lesions > or =50 mm long; these patients constituted the study population. RESULTS: Mean duration of occlusion was 7 +/- 2 months (range, 6-13 months). Procedural success was obtained in 81 patients. A total of 211 coronary stents (2.6 +/- 1.1 stents/patient) were implanted, and mean stent length was 59 +/- 9 mm. In 3 patients, TIMI flow 1-2 was observed after stent implantation. Thus, the angiographic success was considered to be 78/89 patients (87.6%). Periprocedural major adverse cardiac events occurred in 6 patients (6.7%). Clinical success was obtained in 74 patients (83%). During a 9.6 +/- 2 month follow-up, forty-three patients (55.1%) remained angina free, thirty-two (41%) had recurrence of angina, three patients (3.9%) had a new myocardial infarction and no deaths were reported. Target vessel revascularization was required in 34 patients (43.6%). Angiographic follow-up was obtained in 70 patients (90%) at a mean of 7.4 +/- 2 months. Restenosis was observed in 36 patients (51%), six of whom had reocclusion. A significant correlation was observed between the need for reintervention and stent length (R 0.52), residual stenosis (R 0.73) and diabetes mellitus (0.68). CONCLUSION: Although coronary artery stenting for very long (> or =50 mm) chronically occlusive lesions is feasible, safe and associated with a low incidence of periprocedural adverse clinical events, these complex and expensive procedures still have a high 6-month restenosis rate. These results might be significantly improved with the advent of drug-eluting stents.

Nonscaphoid carpal injuries - Incidence and associated injuries.

AIMS: Nonscaphoid fractures comprise approximately 40% of all carpal fractures. But the exact incidence of these rare injuries is still not clear. Missed or late diagnosis can lead to serious ligamentous disruption and permanent wrist dysfunction. METHODS: A retrospective analysis of wrist X-rays and CT scans were carried out for a period of 3 years. Incidence and associated injuries from this study was compared with literature. A total of 33 patients were included in our study. Both wrist X-rays and CT scans were reviewed individually by two authors. DASH scores were recorded for each patient. RESULTS: There were 26 male and 7 female patients. Out of 33 patients 13 (35%) were Triquetral fractures, 10 (27%) were Hamate fractures, 5 (14%) were Capitate fractures, 4 (11%) were Lunate fractures, 3 (8%) were Trapezium fractures and 2 (5%) were Pisiform fractures. There were no Trapezoid fractures in our study. CONCLUSION: Incidence of nonscaphoid carpal fractures in our study is considerably higher when compared to literature. We propose that high index of suspicion should always be borne in mind when dealing with carpal fractures and detailed examination of wrist should be conducted even when X-rays does not show any obvious bony injuries. CT scans and other specialized images should be judiciously used in areas of suspicion for early diagnosis, to initiate immediate treatment, for early mobilisation and good functional recovery.