State-of-the-art percutaneous coronary interventions applied to the treatment of bifurcation lesions: Are we there yet?

Treatment of bifurcation lesions has advanced with the development of second-generation drug-eluting stents and state-of-the-art percutaneous coronary interventions techniques. This subanalysis of SYNTAX II demonstrates similar major adverse cardiac or cerebrovascular events in patients with bifurcation and nonbifurcation lesions, with a trend toward higher target lesion failure in the bifurcation cohort. The results, while compelling, require larger studies with longer follow-up, stratified by bifurcation strategy.

Robotic PCI: Evolving from novel toward non-inferior.

Robotic-assisted PCI appears to be safe and feasible in both simple and complex lesions. In this small cohort study, analysis of manual versus robotic PCI suggests comparable clinical outcomes. Further adequately powered, randomized, multicenter studies are needed to definitively evaluate outcomes in manual versus robotic-assisted PCI.

Sex-Based Differences in Chronic Total Occlusion Management.

ᅟ: Chronic total occlusions (CTOs) are an important and increasingly recognized subgroup of coronary lesions, documented in at least 30%, but up to 52% of patients with coronary artery disease (CAD) undergoing coronary angiography. Percutaneous coronary intervention (PCI) of these lesions is increasingly pursued, with excellent success rates. PURPOSE OF REVIEW: It is known that gender differences exist in the presentation of CAD, as well as in clinical outcomes after routine PCI; however, it is not well described how these differences pertain to management of CTOs. This review summarizes the available data regarding sex-based differences in CTO management and outcomes. RECENT FINDINGS: Women comprise approximately 20% of CTO registry and trial participants. As has been demonstrated in PCI studies, women comprise a minority of patients in CTO PCI registries and trials. Sex-based differences exist in complication rates, collateral formation, and outcomes and need further evaluation in future studies.

Toolbox for Coronary Chronic Total Occlusion Percutaneous Coronary Intervention.

Since the publication of the hybrid algorithm there has been rapid development of new specialty wires, microcatheters, guide extensions, and low-profile balloons to facilitate successful coronary chronic total occlusion percutaneous coronary intervention. With development of new devices, it is best to categorize them by design and intended task. This enables a safe and systematic approach to coronary chronic total occlusion percutaneous coronary intervention and avoid overlap and waste. This article serves as a guide for tool selection for the interventional cardiologist performing coronary chronic total occlusion percutaneous coronary intervention.

Alternative Access for Mechanical Circulatory Support.

Femoral arterial access is the default strategy for large-bore interventional procedures, including temporary mechanical circulatory support implantation and structural heart therapies, based on superior outcomes and operator ease. In addition to patient size and comorbidities, vessel tortuosity, significant calcification, and diminutive vessel caliber all may make iliofemoral access prohibitively high risk or impossible. Given the increase of large-bore transcatheter procedures, bleeding avoidance strategies are essential and thus novel mechanisms for large-bore access have evolved. This article highlights the advantages, limitations, and practical approaches to the 2 most common percutaneous large-bore alternative access strategies: transaxillary and transcaval access.

Pregnancy in the Cardiac Catheterization Laboratory: A Safe and Feasible Endeavor.

Concerns over radiation exposure are ubiquitous to all interventional cardiologists; however, fear of exposure during childbearing years disproportionately deters women from entering the field. This review summarizes the available data on occupational radiation exposure during pregnancy with an emphasis on radiation quantification, the impact of exposure at various stages of fetal development, societal recommendations for safe levels of exposure during gestation, threshold levels necessary to induce fetal harm, and safe practices for the pregnant interventionalist. Reconciling the available information, we conclude that pregnancy in the cardiac catheterization laboratory is both safe and feasible. This review also highlights new technologies that may augment standard radiation safety techniques and are of particular interest to the pregnant interventional cardiologist. Finally, we propose steps to improve female representation in this field, underscoring the importance of a sex-balanced workforce.

A Novel Hybrid Approach to the Treatment of a Left Main Coronary Artery Aneurysm.

A 66-year-old man with a ramus chronic total occlusion had escalating angina and a high-risk stress test. Coronary angiography the day of his planned ramus chronic total occlusion percutaneous coronary intervention demonstrated a large left main aneurysm. He underwent bypass with left internal mammary artery left anterior descending and failed saphenous vein graft ramus, followed by successful covered stent placement from left main into left circumflex and ramus chronic total occlusion percutaneous coronary intervention. (Level of Difficulty: Advanced.).

Alternative Percutaneous Access for Large Bore Devices.

Common femoral artery access is the default strategy for large-bore interventional procedures, including temporary mechanical circulatory support implantation and structural heart therapies, based on superior outcomes and operator ease. However, the size and caliber of the iliofemoral arterial system are influenced by patient size, sex, and comorbidities. Small vessel caliber, significant calcification or atheroma, and severe tortuosity may place patients at prohibitively high risk or render common femoral access impossible. Given the rapid growth of large-bore transcatheter procedures, bleeding avoidance strategies are essential, and thus, novel mechanisms for large-bore access have evolved. This article will discuss the advantages, limitations, and methods of the 2 most common percutaneous large-bore alternative access strategies: transaxillary and transcaval access.