An analysis of long-term clinical outcome following the use of excimer laser coronary atherectomy in a large UK PCI center.

BACKGROUND: Excimer laser atherectomy (ELCA) is an established adjunctive technique to facilitate acute success in percutaneous coronary intervention (PCI). Despite this there are a lack of contemporary outcome data, particulary longer-term, forpatients treated with ELCA PCI. AIMS: To evaluate the contemporary use ofELCA in PCI, the frequency of periprocedural complications and the longer-term outcomes associated with ELCA PCI. METHODS: This was a retrospective study that included all patients undergoing PCI (with or without ELCA) between April 2005 and May 2021. Relevant features from all cases were downloaded from the patient record and matched to hospital data on mortality on November 22, 2022. Kaplan Meier curves were used to compare mortality between the ELCA PCI and non-ELCA PCI cohorts with a landmark at 1 year. Multivariable Cox regression was performed to assess whether ELCA PCI was independently associated with long-term mortality. RESULT: There were 21,256 patients in this analysis, of which 448 (2.1%) were treated with ELCA PCI. ELCA PCI was associated with a higher frequency of any periprocedural complication. Median follow-up was 2812 days (IQR, 1577-4245 days) with higher mortality in ELCA PCI (38.2% vs. 29.0%, p < 0.001). However, on multivariable analysis, ELCA PCI was not independently associated with long-term mortality. The TVR frequency in ELCA PCI was 16.7% but TVR was significantly higher for cases of in-stent restenosis (ISR) (29.5%). CONCLUSION: Despite ELCA PCI being used in higher risk populations with complex coronary artery disease there was no long-term increased mortality associated with the use of this device. ELCA PCI for ISR is highly effective and safe although TVR in this cohort remains high in long-term follow-up.

Novel application of intravascular lithotripsy in stent under-expansion: A single-center experience.

INTRODUCTION: Stent under-expansion due to calcification is associated with a less durable result. The development of intravascular lithotripsy (IVL) has provided clinicians with a readily available, simple-to-use treatment option for coronary calcification, but the use of IVL within a previously stented segment is currently off-license. There are, however, developing data suggesting that the use of IVL can be an effective treatment option for patients with calcific stent under-expansion. METHOD: This was a single-center study of all patients treated with IVL for calcific stent under-expansion between January 2019 and June 2021. The impact of IVL on quantitative coronary angiography (QCA) stenosis and on the minimal stent area (MSA) derived from intracoronary imaging were recorded. The presence of periprocedural complications and adverse cardiovascular events was obtained from the clinical record during the study timeframe. RESULTS: Thirty-nine patients underwent IVL for calcific stent under-expansion during the study time frame with one patient treated with more than one lesion in the same session. In all lesions, there was an improvement in the QCA stenosis with 37 (92.5%) having a residual stenosis of ≤30%. The mean QCA stenosis pre-IVL was 68 ± 21% and following IVL the mean QCA was 18 ± 9% (p < 0.001). In all lesions, there was an improvement in the MSA, with 26 (92.9%) achieving an MSA of more than 4.5 mm2 . The mean MSA pre-IVL was 3.88 ± 1.51 mm2 and following IVL the mean MSA was 7.41 ± 2.34 mm2 (p < 0.001). There were no major procedural complications. Over a mean follow-up of 506 ± 277 days, one patient died from ventricular arrhythmia but there were no other major adverse cardiovascular events. CONCLUSION: This single-center study demonstrates that IVL is a safe and effective treatment for calcific stent under-expansion with good medium-term results.

Feasibility and Efficacy of Herculink Elite ((TM)) Biliary Stent Implantation in Large Coronary Arteries (≥ 5 mm) and Venous Conduits: An Observational Study.

BACKGROUND AND OBJECTIVES: Percutaneous coronary intervention (PCI) in patients with lesions of large calibre coronary arteries (≥ 5 mm) and saphenous venous grafts (≥ 5 mm) can be challenging. There are no separate guidelines available to treat these vessels with PCI. Standard coronary stents of 4 mm diameter are used to treat these lesions conventionally but carry the risk of under deployment, distortion of stent architecture and future stent thrombosis even if they are subsequently expanded beyond 5 mm. METHODS AND RESULTS: Biliary stents (Herculink Elite™) provide a better alternative to standard coronary stents in these patients. These stents are of larger diameter (5-7 mm) and can be safely delivered over a 6 French sheath. In our case series, we demonstrate the use of intravascular ultrasound examination to confirm that biliary stents provide improved stent strut apposition within the coronary artery associated with extremely low repeat revascularisation rates. CONCLUSION: Our paper highlights that PCI of lesions in patients with large calibre coronary arteries can successfully be achieved using biliary stents.

Extensive aortic thrombosis and testicular infarction - a rare complication of biventricular cardiac thrombi.

Heart failure is a heterogenous syndrome which is increasing in prevalence, with a prognosis worse than many malignancies. Morbidity and mortality most commonly occur secondary to pump failure or ventricular arrhythmias; however, a more infrequently seen complication is the formation of mural thrombi. More commonly seen within the left ventricle, thrombi can embolize leading to stroke or end organ infarction. We present the case of a male who presented with decompensated heart failure. The presence of biventricular thrombi was found on echocardiography and subsequent cross-sectional imaging revealed these had embolized resulting in the rare complication of extensive abdominal aortic thrombosis with renal and testicular infarction. Biventricular thrombi are rare but high risk due to the potential for embolization as demonstrated in this case. Prompt recognition and management with anti-coagulation are essential, followed by treatment of the underlying pathology, which resulted in the formation of thrombi to prevent recurrence.

Delayed bubble, coil and trouble: young stroke as a presentation of paradoxical embolism from previously unrecognised pulmonary arterio-venous malformation (PAVM).

Young stroke patients should be investigated thoroughly to look for cardiac and extra-cardiac sources of emboli. We present a patient who was investigated for a cardiac source of emboli following an ischemic stroke. She was found to have a small patent foramen ovale (PFO), but due to the late appearances of bubbles on the bubble study it was thought that this was an incidental finding. Further investigation confirmed a PAVM was the source of emboli causing her stroke.

Detection of myocardial ischaemia caused by coronary artery-left ventricular fistulae using myocardial contrast echocardiography.

A coronary artery-left ventricular fistula (CAF) is an extremely rare anatomical abnormality in which blood drains directly from a coronary artery into the left ventricle. CAF may cause myocardial ischaemia and angina. Myocardial contrast echocardiography (MCE) is a non-invasive technique which assesses myocardial perfusion. We describe a patient with CAF in whom transmural myocardial ischaemia was demonstrated using MCE.

The impact of routine and intravascular ultrasound-guided high-pressure postdilatation after drug-eluting stent deployment: the STent OPtimization (STOP) study.

OBJECTIVES: Drug-eluting stent (DES) implantations with low final cross-sectional area (CSA) are associated with adverse clinical outcomes. However, there is no guidance to facilitate optimal stent deployment (SD). The stent optimization (STOP) study was performed to assess DES routine postdilatation (PD) following implantation with intravascular ultrasound (IVUS) guidance. METHODS: Forty-eight patients were included in this single-center prospective study. All DESs were deployed at 16 atm for 20 seconds and underwent routine non-compliant balloon PD (minimum 20 atm for 10 seconds). IVUS performed after SD (blinded) and PD (unblinded) measured CSA at 4 stent reference points. Optimal deployment was defined as distal and proximal stent CSA ≥60% distal and proximal reference CSA; mid and minimum stent CSA ≥70% of distal reference CSA. All per-protocol criteria were required to define optimal SD. Suboptimally deployed DESs underwent further PD with IVUS guidance (IVPD). RESULTS: Fifty-two lesions were treated in 48 patients. CSA increased by 20% following PD. STOP criteria were only achieved in 21% of DESs after SD compared to 54% after PD. IVPD was performed in 20 DESs, which increased CSA by a further 21%. STOP criteria were eventually attained in 81% cases (P<.001 for all comparisons). CONCLUSION: DES deployment leads to suboptimal deployment, which can be optimized by routine PD. IVUS identifies DES implantations that benefit from further PD. Optimizing final DES-CSA may have longterm clinical benefits, although a randomized study is required.

Beyond the balloon: excimer coronary laser atherectomy used alone or in combination with rotational atherectomy in the treatment of chronic total occlusions, non-crossable and non-expansible coronary lesions.

AIMS: To establish success and complication rates of excimer laser coronary atherectomy (ELCA) in a contemporary series of patients with balloon failure during percutaneous coronary intervention (PCI) of both chronic total occlusions (CTO) and lesions with distal TIMI 3 flow. METHODS AND RESULTS: We identified 58 cases of balloon failure treated with ELCA±rotational atherectomy (RA) over four years, representing 0.84% of all PCI performed in our centre during this period. Balloon failures were classified according to: (i) mechanism of balloon failure; and (ii) whether this occurred in the context of treating a CTO. ELCA was performed following balloon failure using the CVX-300 Excimer Laser System and a 0.9 mm catheter with saline flush. For the entire cohort, procedure success was achieved in 91% (with ELCA successful: alone in 76.1%, after RA failure in 6.8% and in combination with RA for 8.6%). Only in one case did RA succeed where ELCA had failed. There were four procedure-related complications, including transient no-reflow, side branch occlusion and two coronary perforations, of which one was directly attributable to ELCA and led to subsequent mortality. CONCLUSIONS: ELCA provides safe and effective adjunctive therapy in contemporary PCI to treat lesions associated with balloon failure due to an inability either to cross the lesion or to expand a balloon sufficiently to permit stenting. ELCA was successful in the majority of these selected cases when used independently with further effectiveness achieved when combined with RA or after RA failure.

Saphenous vein graft aneurysm: an incidental finding.

Saphenous vein graft aneurysm (SVGA) is an uncommon complication of coronary artery bypass graft surgery (CABG). An 82-year-old man underwent contrast-enhanced computed tomography to investigate aorto-iliac disease. He was coincidentally noted to have an aneurysm of the saphenous vein graft to his right coronary artery. This was visualised on transthoracic echocardiography, computed tomography and coronary angiography. In the absence of symptoms and in view of high surgical risk, conservative management with anticoagulation was chosen. The patient was commenced on warfarin and remains asymptomatic.

A novel strategy for managing clopidogrel-induced adverse skin reactions.

AIMS: We conducted a prospective observational study using a course of steroids and antihistamines to treat a cohort of patients who developed skin reactions to clopidogrel, to assess whether dual antiplatelet therapy could be continued in an outpatient setting. METHODS AND RESULTS: This study included 2,701 patients who underwent percutaneous coronary intervention (PCI) at our centre over a 23 month period. Patients with skin reactions to clopidogrel were identified and then commenced on five days oral prednisolone (30 mg/od) and chlorpheniramine (4 mg/tds) for seven days. A subsequent telephone survey was performed to evaluate a number of variables. The probability of the adverse reaction being secondary to clopidogrel was assessed using the Naranjo adverse drug reaction probability scale. Twenty (0.7%) patients were identified who developed adverse skin reactions to clopidogrel. There was complete resolution seen in the majority (89%) of patients within an average of 3.2 days following treatment. One patient had partial resolution, and one had no response to treatment, but both were able to continue clopidogrel. CONCLUSIONS: We propose a novel, safe and effective way of managing clopidogrel-induced skin reactions using a short course of prednisolone and chlorpheniramine, without stopping or substituting clopidogrel.

Drug-eluting stents for the treatment of in-stent restenosis--'real world' double centre experience in consecutive patients.

OBJECTIVES: We evaluated clinical outcome of consecutive patients with in stent restenosis (ISR) treated with drug-eluting stents (DES) at two intervention centres from April 2002 to April 2004, reflecting 'real world' practice. BACKGROUND: ISR is the major limitation to successful long-term outcome after implantation of bare metal stents during percutaneous coronary intervention (PCI). The optimal strategy for the treatment of ISR has yet to be determined. METHODS: 121 consecutive patients with significant ISR were treated with DES. Sirolimus DES were used in 60 patients and paclitaxel DES in the remainder. All patients were followed up to evaluate the incidence of major adverse cardiac events (MACE), angina class and clinically driven angiography. Data were collected between 7 and 27 months after the procedure (mean follow up of 16.5 months). RESULTS: Overall MACE rate at 16.5 months was 13.2% (16 patients) including 4 deaths (3%). Fifteen (12.3%) patients underwent clinically driven angiography. Eight patients (6.6%) developed ISR within the treated segment, of whom, four underwent further PCI and 4 CABG. Mean Canadian angina class decreased from 2.46+/-0.7 pre-procedure to 0.69+/-0.6 at follow up. All patients achieved an improvement in angina, with 59% being rendered angina free and 87% free of MACE. There were no differences in clinical outcome in those who received a paclitaxel and sirolimus DES. CONCLUSIONS: The use of DES implantation for the treatment of ISR is safe, effective and associated with low recurrence rates in a 'real world' large cohort of patients with a complex mix of anatomical and clinical factors.