Intermediate procedural and health status outcomes and the clinical care pathways after chronic total occlusion angioplasty: A report from the OPEN-CTO (outcomes, patient health status, and efficiency in chronic total occlusion hybrid procedures) study.

BACKGROUND: No previous reports have described the comprehensive care pathways involved in chronic total occlusion percutaneous coronary intervention (CTO PCI). METHODS: In a study of 1,000 consecutive patients undergoing CTO PCI using hybrid approach, a systematic algorithm of selecting CTO PCI strategies, the procedural characteristics, complication rates, and patient reported health status outcomes through 12 months were assessed. RESULTS: Technical success of the index CTO PCI was 86%, with 89% of patients having at least one successful CTO PCI within 12 months. A total of 13.8% underwent CTO PCI of another vessel or reattempt of index CTO PCI within 1 year. At 1 year, the unadjusted major adverse cardiac and cerebral event (MACCE) rate was lower in patients with successful index CTO PCI compared to patients with unsuccessful index CTO PCI (9.4% vs. 14.6%, p = .04). The adjusted hazard ratios of myocardial infarction and death at 12 months were numerically lower in patients with successful index CTO PCI, compared to patients with unsuccessful index CTO PCI. Patients with successful index CTO PCI reported significantly greater improvement in health status throughout 12-months compared to patients with unsuccessful index CTO PCI. CONCLUSION: CTO-PCI in the real-world often require treatment of second CTO, non-CTO PCI or repeat procedures to treat initially unsuccessful lesions. Successful CTO PCI is associated with numerically lower MACCE at 1 year and persistent symptomatic improvement compared to unsuccessful CTO PCI. Understanding the relationship between the care pathways following CTO PCI and health status benefit requires further study.

Comparison of device-specific adverse event profiles between Impella platforms.

BACKGROUND: The Impella (Abiomed) ventricular support system is a family of temporary mechanical circulatory support (MCS) devices used to treat patients with cardiogenic shock, acute cardiogenic decompensation, and for high-risk percutaneous or surgical revascularization. These devices include the percutaneously implanted 2.5/cardiac power (CP) and the surgically implanted 5.0/left direct (LD). Despite the beneficial effects and increased usage of these devices, data to assess adverse outcomes and guide clinician decision-making between the Impella CP and 5.0/LD are limited. METHODS: This is a retrospective analysis of 91 consecutive patients who required at least 24 h of Impella support, from January 1, 2015 to December 31, 2019. Groups were stratified based on either initial Impella CP or 5.0/LD placement. Clinical outcomes and in-hospital complications were compared. RESULTS: Impella CP was implanted in 66 patients (mean age: 61 ± 15 years, male 71.2%) and Impella 5.0/LD was implanted in 25 patients (mean age: 62 ± 9 years, male 84.0%). There was greater stability of device position (p = .033), less incidence of hemolysis (p < .001), and less frequent need for additional MCS (p = .001) in patients implanted with the Impella 5.0/LD compared with Impella CP in this study cohort. Patients with Impella 5.0/LD were more likely to survive from Impella and survive to discharge. CONCLUSIONS: This study suggests that for patients who require temporary MCS for more than 24 h, the Impella 5.0/LD may have a more favorable device-specific adverse profile compared with the Impella CP.

Ultrasonographic features of colonic B-cell lymphoma with mesenteric lymphomatosis in a cat.

A 10-year-old male neutered Domestic Shorthair cat was referred for chronic inappetence, weight loss, and hematochezia and an abdominal mass. Abdominal ultrasonography revealed a heterogeneously hypoechoic transmural colonic mass, which extended beyond the serosa and into the adjacent mesentery. Cytology and clonality assays of fine needle aspirates of the mass and mesenteric nodules yielded a diagnosis of B-cell lymphoma. Colonic lymphoma with mesenteric involvement can have a similar appearance to carcinomatosis, therefore a definitive diagnosis requires sampling and further testing of the mesenteric lesions.

Airway Diagnostics: Bronchoalveolar Lavage, Tracheal Wash, and Pleural Fluid.

Indications for bronchoalveolar lavage, tracheal wash, and thoracocentesis for the diagnosis of respiratory diseases are discussed. Each technique is described in detail and illustrated by videos. Sample handling, preparation and evaluation are reviewed. The advantages and limitations of bronchoalveolar lavage and tracheal wash procedures as well as a critical comparison between the 2 techniques for equine asthma diagnosis are presented. Finally, validated cut-off values for equine asthma diagnosis are reviewed.

Guidewire and microcatheter utilization patterns during antegrade wire escalation in chronic total occlusion percutaneous coronary intervention: Insights from a contemporary multicenter registry.

OBJECTIVES: We sought to describe contemporary guidewire and microcatheter utilization for antegrade wire escalation (AWE) during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BACKGROUND: Equipment utilization for AWE has been variable and evolving over time. METHODS: We examined device utilization during 694 AWE attempts in 679 patients performed at 15 experienced US centers between May 2012 and April 2015. RESULTS: Mean age was 65.6 ± 9.7 years, and 85% of the patients were men. Successful wiring occurred in 436 AWE attempts (63%). Final technical and procedural success was 91% and 89%, respectively. The mean number of guidewire types used for AWE was 2.2 ± 1.4. The most frequently used guidewire types were the Pilot 200 (Abbott Vascular, 56% of AWE procedures), Fielder XT (Asahi Intecc, 45%), and the Confianza Pro 12 (Asahi Intecc, 28%). The same guidewires were the ones that most commonly crossed the occlusion: Pilot 200 (36% of successful AWE crossings), Fielder XT (20%), and Confianza Pro 12 (11%). A microcatheter or over-the-wire balloon was used for 81% of AWE attempts; the Corsair microcatheter (Asahi Intecc) was the most commonly used (44%). No significant association was found between guidewire type and incidence of major adverse cardiac events (MACE). CONCLUSIONS: Our contemporary, multicenter CTO PCI registry demonstrates that the most commonly used wires for AWE are polymer-jacketed guidewires. "Stiff" and polymer-jacketed guidewires appear to provide high crossing rates without an increase in MACE or perforation, and may thus be considered for upfront use. © 2016 Wiley Periodicals, Inc.

Treatment of the chronic total occlusion: a call to action for the interventional community.

There is substantial evidence that recanalization of a chronic total occlusion is beneficial; nonetheless, it is generally underutilized in clinical practice. We consider the Aesop's fable of the "Fox and the Grapes" as analogous to the current situation in interventional cardiology. The technical challenges in achieving CTO recanalization has led interventionalists, clinical cardiologists, and sometimes even patients to believe that CTO recanalization is not effective, and, therefore, not needed. This perspective reviews available data regarding efficacy and safety of CTO percutaneous coronary intervention (PCI) in the current drug-eluting stent era, discusses areas where more studies are required, and encourages the interventional community to utilize CTO PCI where appropriate based on current evidence.

Procedural failure of chronic total occlusion percutaneous coronary intervention: Insights from a multicenter US registry.

BACKGROUND: The hybrid approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has significantly increased procedural success rates, yet some cases still fail. We sought to evaluate the causes of failure in a contemporary CTO PCI registry. METHODS: We examined 380 consecutive patients who underwent CTO-PCI at 4 high volume CTO PCI centers in the United States using the "hybrid" approach. Clinical, angiographic, complication, and efficiency outcomes were compared between successful and failed cases. Failed cases were individually reviewed by an independent reviewer to determine the cause of failure. RESULTS: Procedural success was 91.3%. Compared with patients in whom CTO PCI was successful, those in whom CTO PCI failed had similar baseline clinical characteristics, but were more likely to have longer occlusion length, more tortuosity, more proximal cap ambiguity and blunt stump, and higher mean J-CTO scores (2.8 ± 1.1 vs. 3.5 ± 1.0, P < 0.001), and less likely to have collaterals suitable for the retrograde approach (66% vs. 45%, P = 0.021). Failure was due to a complication in 10 cases (30%). In the remaining 23 cases (70%) failure was due to inability to wire the lesion (n = 21, 4 of which were CTOs due to in-stent restenosis), or poor antegrade flow after PCI (n = 5). CONCLUSIONS: Compared with successful cases, failed CTO-PCI cases are more likely to have higher J-CTO scores, longer occlusion length, ambiguous proximal cap and no appropriate collaterals for retrograde crossing. Development of novel CTO crossing techniques is needed to further increase CTO PCI success rates.

Transradial approach for coronary chronic total occlusion interventions: Insights from a contemporary multicenter registry.

OBJECTIVES: To examine the impact of transradial access on the procedural outcomes of chronic total occlusion (CTO) percutaneous coronary interventions (PCI). BACKGROUND: The efficacy and safety of transradial access in CTO PCI has received limited study. METHODS: We compared the technique and outcomes of transradial vs. transfemoral access among 650 CTO PCI cases performed between January 2012 and March 2014 at 6 US centers. RESULTS: Most patients were men (87%) with high frequency of diabetes mellitus (42%) and prior coronary artery bypass graft surgery (36%). The CTO target vessel was the right coronary (59%), left anterior descending (20%), or circumflex (17%) artery. TR access was used in 110 (17%) of the 650 cases, as follows: bilateral radial access (63%); bilateral radial access plus unilateral or bilateral femoral access (7%); unilateral radial access plus unilateral or bilateral femoral access (26%); and unilateral radial access (4%). Six and eight French guide catheters were used through the radial and femoral artery, respectively. Compared to transfemoral, transradial cases had similar technical (92.6% vs. 93.0%, P = 0.87) and procedural (91.1% vs. 90.0%, P = 0.95) success and major complication rates (1.7% vs 1.8%, P = 0.99). However, transradial access was associated with higher mean procedure (142 ± 83 vs. 120 ± 60 min, P = 0.008) and fluoroscopy (58 ± 40 vs. 49 ± 31 min, P <0.026) time, and number of crossing approach changes (0.7 ± 1.0 vs. 0.5 ± 0.7, P = 0.008). CONCLUSION: Transradial CTO PCI can be performed with similar success and complication rates with transfemoral CTO PCI, but is associated with longer procedural and fluoroscopy times. © 2015 Wiley Periodicals, Inc.

Characteristic lipid profiles of canine non-Hodgkin's lymphoma from surgical biopsy tissue sections and fine needle aspirate smears by desorption electrospray ionization--mass spectrometry.

Canine non-Hodgkin's lymphoma (NHL) is a heterogeneous group of cancers representing approximately 15% of all canine cancers. Further, canine NHL mimics human disease in regards to histopathology and clinical behavior and could function as a comparative model. Diagnosis is currently performed by histopathological evaluation of surgical biopsy specimens and fine needle aspirate (FNA) cytology, an alternative and less invasive method for diagnosis. Desorption electrospray ionization - mass spectrometry (DESI-MS) imaging was performed on tissue sections of surgical biopsies and FNA smears. Mass spectra acquired from normal lymph nodes and NHL tumors were explored using multivariate statistics (e.g. principal component analysis). Tissue sections yielded a predicted sensitivity of 100% for normal and 93.1% for tumor. Further, preliminary results suggest B-cell and T-cell lymphoma can be discriminated (CV sensitivity of 95.5% and 85.7%, respectively). Normal and B-cell NHL FNA samples analyzed by DESI produced spectra that were similar to spectra obtained from surgical biopsies. FNA samples were evaluated using a PCA-LDA classification system built using tissue section data, exploring if the chemical information obtained from the different sample types is similar and whether DESI-MS performed on FNA samples is of diagnostic value. FNA prediction rate for normal (85.7%) and B-cell NHL (89.3%) indicated that DESI-MS analysis of FNA, not previously explored, could provide rapid preliminary diagnosis. Certainly, MS provides complementary molecular information to be used in conjunction with histopathology/cytology, potentially improving diagnostic confidence. The methodology outlined here is applicable to canine NHL, further supports canine models of human NHL, and translation to humans is envisioned.

Ultrasonographic features of uterus masculinus in six dogs.

Uterus masculinus (persistent Mullerian duct) is a vestigial embryological remnant of the paramesonephric duct system in males and has been associated with clinical signs such as dysuria, incontinence, tenesmus and urethral obstruction in dogs. The radiological appearance of cystic uterus masculinus in dogs has been described previously with the aid of retrograde positive or negative contrast cystography. The purpose of this retrospective study was to describe ultrasonographic features of confirmed or presumed uterus masculinus in a group of dogs with confirmed or presumed disease. Ultrasonographic findings were recorded based on a consensus opinion of two readers. A uterus masculinus was defined as cylindrical when no lumen was observed and tubular when it had lumen that was filled with anechoic fluid. Six dogs met the inclusion criterion with a mean age of 8 years and 9 months. Uterus masculinus appeared as single (four dogs) or two (two dogs) horn-like, tubular (four dogs) or cylindrical (two dogs) structures, originating from the craniodorsal aspect of the prostate gland and extending cranially. The walls of the uterus masculinus were isoechoic to the urinary bladder wall. The diameter of the observed uterus masculinus varied from 0.3 cm to 1 cm. The length of the uterus masculinus varied from 2 cm to 6.5 cm but the cranial terminal end was not identified in two dogs. Concomitant prostatomegaly was seen in five dogs (83.3%) and urinary tract infection was noted in three dogs (50%). Findings indicated that uterus masculinus should be included as a differential diagnosis for male dogs with these ultrasonographic characteristics.

The efficacy of "hybrid" percutaneous coronary intervention in chronic total occlusions caused by in-stent restenosis: insights from a US multicenter registry.

OBJECTIVES: To examine the success and complication rates in percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) caused by in-stent restenosis (ISR). BACKGROUND: PCI for in-stent total occlusive disease has traditionally been associated with low success rates. We sought to examine angiographic and procedural outcomes of patients who underwent CTO PCI due to ISR using the novel "hybrid" algorithm, and compare them with patients with de novo CTOs. METHODS: We examined 521 consecutive patients who underwent CTO PCI at five high-volume PCI centers in the United States using the "hybrid" approach. Clinical, angiographic, and procedural outcomes were compared between CTOs due to ISR and de novo CTOs. RESULTS: The target CTO was due to ISR in 57 of 521 patients (10.9%). Compared to patients with de novo CTOs, those with CTO due to ISR had higher frequency of diabetes (56.1% vs. 39.6%, P = 0.02) and less calcification (5.3% vs. 16.2%, P <0.001), but longer occlusion length [38 (29-55) vs. 30 (20-51), P = 0.04]. Technical success in the ISR and de novo group was 89.4% and 92.5% (P = 0.43), respectively; procedural success was 86.0% and 90.3% (P = 0.31), respectively; and the incidence of major adverse cardiac events was 3.5% and 2.2% (P = 0.63), respectively. CONCLUSIONS: Use of the "hybrid" approach to CTO PCI was associated with similarly high procedural success and similarly low major complication rates in patients with de novo and ISR CTOs.

Clinical Findings and Outcome in 30 Dogs with Presumptive or Confirmed Nerve Sheath Tumors.

Nerve sheath tumors (NSTs) are well-recognized primary nervous system tumors, but there is relatively limited information in dogs including comparison of NSTs in different anatomical locations. This retrospective study describes the clinical features and outcomes in a group of dogs with NSTs affecting the cranial nerves or spinal nerves. Thirty dogs were included, 25 with a presumptive diagnosis and five confirmed by histopathologic analysis. Seven dogs also had cytology of tumor samples, which were supportive of the NST diagnosis in four. Eight dogs had cranial nerve-associated NSTs, with six involving the trigeminal nerve. Twenty-two dogs had spinal nerve-associated NSTs including 13 invading the spinal canal and nine peripheral to the spinal canal, with the majority affecting nerves or nerve roots of the brachial plexus. The prognosis was poor, with dogs being euthanized eventually because of disease progression. Among dogs alive 1 week after diagnosis, the median survival time was 4 months but ranged from 2 weeks to >2 years. While there was a broad overlap between NST locations, survival was generally longer for dogs without spinal canal or intracranial involvement. The results expand available information on NSTs in dogs but should be interpreted with caution given the small number of dogs with a definitive diagnosis. Further investigation is warranted to determine how tumor location, invasiveness, and treatments pursued impact outcome.

The retrograde approach to coronary artery chronic total occlusions: a practical approach.

The retrograde approach has revolutionized the treatment of chronic total occlusions. Several retrograde techniques have recently been described. In this article, we present a practical review with step-by-step instructions on the indications for retrograde interventions, equipment and retrograde channel selection, and techniques for retrograde crossing and treatment of chronic total occlusions.

Initial experience with a dedicated coronary re-entry device for revascularization of chronic total occlusions.

OBJECTIVE: The aim of this registry was to evaluate a new device designed to facilitate antegrade guidewire re-entry into the true lumen of a chronic total coronary occlusion (CTO) from the adjacent subintimal space. BACKGROUND: Successful recanalization of CTOs results in clinical improvement in appropriately selected patients. CTO intervention is time- and resource-consuming, and a simplified approach enabling antegrade guidewire re-entry into the distal true lumen might improve success. METHODS: Patients with CTO and ischemia were entered into a prospective registry regardless of lesion characteristics. If wire manipulation resulted in subintimal wire entrapment, a new re-entry tool (a 2.5-mm flat subintimal balloon with two exit ports offset by 180°) was used as a platform to attempt guidewire penetration into the distal true lumen. The primary endpoint assessed was successful device-guided re-entry. Standard techniques were then utilized to open the CTO. RESULTS: In 40 consecutive CTO lesions attempted, 19 resulted in subintimal wire entrapment (mean occlusion length 44 mm). Sixteen of these 19 were successfully crossed with an antegrade guidewire into the distal true lumen using the new device (84%). One patient with unsuccessful re-entry was subsequently recanalized with a retrograde technique. All crossed lesions were stented (17/17), resulting in TIMI 3 flow without major complications. Two cases were unsuccessful. One patient had a grade I coronary perforation requiring no treatment. CONCLUSIONS: A new device to recanalize CTOs complicated by subintimal wire entrapment can be used successfully by experienced operators. Further study of this coronary re-entry device is ongoing.

Pathology in Practice.

In collaboration with the American College of Veterinary Pathologists.

Pathology in Practice.

In collaboration with the American College of Veterinary Pathologists.

Application of magnetically actuated self-clearing catheter for rapid in situ blood clot clearance in hemorrhagic stroke treatment.

Maintaining the patency of indwelling drainage devices is critical in preventing further complications following an intraventricular hemorrhage (IVH) and other chronic disease management. Surgeons often use drainage devices to remove blood and cerebrospinal fluid but these catheters frequently become occluded with hematoma. Using an implantable magnetic microactuator, we created a self-clearing catheter that can generate large enough forces to break down obstructive blood clots by applying time-varying magnetic fields. In a blood-circulating model, our self-clearing catheters demonstrated a > 7x longer functionality than traditional catheters (211 vs. 27 min) and maintained a low pressure for longer periods (239 vs. 79 min). Using a porcine IVH model, the self-clearing catheters showed a greater survival rate than control catheters (86% vs. 0%) over the course of 6 weeks. The treated animals also had significantly smaller ventricle sizes 1 week after implantation compared to the control animals with traditional catheters. Our results suggest that these magnetic microactuator-embedded smart catheters can expedite the removal of blood from the ventricles and potentially improve the outcomes of critical patients suffering from often deadly IVH.

The Hybrid Approach and Its Variations for Chronic Total Occlusion Percutaneous Coronary Intervention.

Selected patients with coronary chronic total occlusion (CTO) benefit with respect to symptoms, quality of life, ischemia reduction, and potentially longevity among other benefits. CTO lesions tend to be the most technically challenging for practicing interventional cardiologists to deliver a successful and safe result and clinical experience for a given patient. The Hybrid algorithm for CTO percutaneous coronary intervention and the subsequent subalgorithms for focused technical challenges have a standardized process and provide a consistent platform for optimized patient care, medical education, and clinical investigation in patients challenged with total occlusion and complex coronary disease.

Case Report: Suspected Solitary Osseous Plasmacytoma in a Cat: Use of Magnetic Resonance Imaging to Diagnose and Confirm Resolution of Disease Following Chemotherapy.

A 9-year-old female spayed Domestic Shorthair cat presented for pain, reluctance to jump, and hyporexia of 14 days duration. Neurologic examination was consistent with C6-T2 myelopathy. Magnetic resonance imaging (MRI) revealed a solitary, contrast-enhancing lesion within the T2 vertebral body. Solitary osseous plasmacytoma was diagnosed based on neurologic examination, advanced imaging, and clinicopathologic findings. Melphalan and prednisolone therapy were initiated. Complete resolution of clinical signs and the vertebral lesion were documented at a 2-year follow up examination with neurologic examination and repeat spinal MRI, respectively. Solitary osseous plasmacytoma are rare neoplasms in humans and domestic animals. As such, there is a paucity of published information regarding diagnostic criteria, MRI findings, treatment modalities, progression, and remission of disease in the feline patient. Most data are extrapolated from human medicine. The purpose of this report is to document neurologic exam and MR findings at the time of diagnosis and complete resolution of a solitary osseous vertebral plasmacytoma following melphalan and prednisolone therapy.