Safety and outcomes of combined carbon dioxide angiography and OCT-guided femoro-popliteal chronic total occlusion crossing and directional atherectomy in patients with chronic kidney disease.

BACKGROUND: Carbon dioxide angiography with addition of optical coherence tomography imaging may improve procedural success and clinical outcomes in patients with peripheral artery disease and chronic kidney disease. METHODS: Single-center, retrospective analysis of patients with chronic kidney disease who underwent carbon dioxide angiography and optical coherence tomography-guided chronic total occlusion crossing and/or optical coherence tomography-guided directional atherectomy was performed. Patient and procedure-related characteristics, along with peri- and one-year post-procedural major adverse events, were analyzed. RESULTS: A total of 18 vessels in 11 patients, with mean age 70 years were treated. All had co-morbidities such as hypertension, hyperlipidemia, had history or were current smokers with baseline peripheral artery disease. Majority were diabetic with coronary disease (82%); 55% baseline chronic kidney disease IV, 55% Rutherford class III and 45% class IV. Contrast was used in only two patients. Mean total fluoroscopy time and radiation dose was 24.1 min and 249.2 mGY, respectively. Half of the lesions were femoro-popliteal chronic total occlusions, and Ocelot catheter was used to cross seven of nine chronic total occlusions and was successful in six. Adjunctive optical coherence tomography-guided directional atherectomy was performed in 8 of 11 patients. Only two adverse events occurred: one clinically significant event of slow-flow intra-procedurally and one target limb revascularization within one year of index procedure in a vessel different than prior treated. Optical coherence tomography imaging in both chronic total occlusion-crossing and atherectomy resulted in 10-min mean fluoroscopy reduction time and 32 mGY reduction in radiation dose. CONCLUSION: Carbon dioxide angiography with the addition of optical coherence tomography imaging for chronic total occlusion crossing and/or optical coherence tomography-guided directional atherectomy reduced the need for contrast agents, total fluoroscopy time, and radiation exposure in patients with peripheral artery disease and baseline chronic kidney disease.

Robotic-assisted percutaneous coronary intervention in a COVID-19 patient.

Coronavirus disease-2019 (COVID-19) pandemic is the biggest global health threat in the 21st century. We describe a case of a patient with suspected COVID-19 who needed urgent coronary artery interrogation, in which we utilized robotic assistance to minimize the risk of exposure to COVID-19 and reduced personal protective equipment needed by the procedural team.

Antegrade and retrograde in-stent tibial artery chronic total occlusion recanalization with double kiss crush (DK crush) stenting of previous stent.

Below the knee (BTK) peripheral arterial disease often presents with critical limb ischemia (CLI) clinically with involvement of more than one tibial vessels. Drug eluting stent (DES) technology for treatment of BTK disease has shown promising long-term durable results; however, currently only coronary DESs are available for application in the United States. Although coronary bifurcation stenting techniques are backed by extensive data in literature, there is a scarcity of data for the treatment of tibial bifurcation disease. Bifurcation angles in the tibials are similar to those in the coronaries and therefore the same two stent bifurcation technique can be applied in BTK disease. Double Kiss crush (DK crush) stenting has superior outcomes when compared to provisional or culotte stenting in randomized coronary trials (based on Medina classification). We present a case of BTK CLI with tibial bifurcation chronic total occlusion treated with two stent DK crush technique using coronary DES.

Robotic-assisted balloon angioplasty and stent placement with distal embolic protection device for severe carotid artery stenosis in a high-risk surgical patient.

The use of robotic assistance in endovascular interventions may facilitate smoother procedures with fewer device manipulations, improve precision and accuracy of device deployment, and reduce exposure to fluoroscopic radiation. We used the CorPath GRX Robotic System for carotid balloon angioplasty and stent placement in a patient with limited surgical options.

Stent crush: A novel endovascular approach for treatment of complex in-stent femoropopliteal chronic total occlusion.

Femoropopliteal in-stent chronic total occlusions (CTOs) remain one of the most challenging subsets of peripheral arterial disease to treat percutaneously. Advances in available CTO crossing technology and operator experience have increased percutaneous intervention success rates. We report a case of critical limb ischemia in a patient with chronically occluded femoropopliteal nonoverlapping stents treated with a novel percutaneous approach of subintimal retrograde angioplasty using high compression resistant nitinol stents to crush the occluded previous stents to create a neo-lumen.

Recanalization of superior mesenteric artery chronic total occlusion using hybrid algorithm and dissection reentry device.

Chronic total occlusion (CTO) of mesenteric arteries with associated chronic mesenteric ischemia (CMI) is associated with high morbidity and mortality. Endovascular intervention has been associated with high technical success with high rates of freedom from symptoms and long-term patency. However, to achieve high procedural success, use of optimal vascular access and expertise in CTO hybrid algorithm including advanced dissection reentry strategies are essential. We present a case of CMI from severe celiac artery (CA) stenosis and CTO of superior mesenteric artery (SMA) and inferior mesenteric artery (IMA). After treatment of CA stenosis, we were unsuccessful in our first attempt at recanalization of SMA CTO. On second attempt, left brachial artery (BA) access was obtained and the hybrid algorithm along with use of Stingray Reentry balloon (Boston Scientific) for dissection reentry into true lumen was successful in recanalizing the SMA CTO with placement of balloon expandable covered stents (CS). To the best of our knowledge, this is the first case report utilizing Sting-ray Reentry balloon in the mesenteric arteries.

One-Year Outcomes Following Directional Atherectomy of Popliteal Artery Lesions: Subgroup Analysis of the Prospective, Multicenter DEFINITIVE LE Trial.

PURPOSE: To report the effectiveness of directional atherectomy for the treatment of popliteal artery occlusive disease. METHODS: This subset of the prospective, multicenter, single-arm DEFINITIVE LE trial included 158 patients (mean age 72.0±10.9 years; 82 men) who underwent directional atherectomy in 162 popliteal artery lesions between 2009 and 2011. Forty-eight (30.4%) patients were suffering from critical limb ischemia (CLI). The mean lesion length was 5.8±3.9 cm; 38 (23.5%) arteries were occluded. The primary outcome measure for patients with intermittent claudication (IC) was duplex ultrasound-defined primary patency at 1 year; the outcome for subjects with CLI was freedom from major amputation of the target limb at 1 year. Outcomes and adverse events were independently assessed. RESULTS: Procedure success (≤30% residual stenosis) was achieved in 84.4% of treated lesions; adjunctive stenting was required in 6 (3.7%) of the 162 lesions. The 1-year primary patency rate was 75.0% (IC patients 78.2% and CLI patients 67.5%, p=0.118). The freedom from major amputation in both cohorts was 100%. In both IC and CLI patients, significant improvements were demonstrated at 1 year in the Rutherford category, walking distance, and quality of life in comparison to baseline. CONCLUSION: This study indicates that directional atherectomy in popliteal arteries leads to favorable technical and clinical results at 1 year for claudicant as well as CLI patients.

Lower Extremity Revascularization Using Optical Coherence Tomography-Guided Directional Atherectomy: Final Results of the EValuatIon of the PantheriS OptIcal COherence Tomography ImagiNg Atherectomy System for Use in the Peripheral Vasculature (VISION) Study.

PURPOSE: To evaluate the safety and efficacy of a novel optical coherence tomography (OCT)-guided atherectomy catheter in treating patients with symptomatic femoropopliteal disease. METHODS: The VISION trial ( ClinicalTrials.gov identifier NCT01937351) was a single-arm, multicenter, global investigational device exemption study enrolling 158 subjects (mean age 67.2±10.5 years; 87 men) across 20 participating sites. In this cohort, 198 lesions were treated with an average length of 53±40 mm using the Pantheris catheter alone or Pantheris + adjunctive therapy. The primary safety endpoint was the composite of major adverse events (MAEs) through 6 months (objective performance goal 43.2%). Technical success (primary efficacy outcome) was defined as the percent of target lesions with a residual diameter stenosis ≤50% after treatment with the Pantheris device alone (objective performance goal 87.0%). Procedural success was defined as reduction in stenosis to ≤30% after Pantheris ± adjunctive therapy. Tissue specimens retrieved from each treated lesion were histologically analyzed to evaluate the accuracy and precision of OCT image guidance. RESULTS: The primary efficacy outcome was achieved in 192 (97.0%) of the 198 lesions treated with the Pantheris catheter. Across all lesions, mean diameter stenosis was reduced from 78.7%±15.1% at baseline to 30.3%±11.8% after Pantheris alone (p<0.001) and to 22.4%±9.9% after Pantheris ± adjunctive therapy (p<0.001). Of the 198 target lesions, 104 (52.5%) were treated with the Pantheris alone, 84 (42.4%) were treated with Pantheris + adjunctive angioplasty, and 10 (5.1%) with Pantheris + angioplasty + stenting. The composite MAE outcome through 6 months occurred in 25 (16.6%) of 151 subjects. There were no clinically significant perforations, 1 (0.5%) catheter-related dissection, 4 (2%) embolic events, and a 6.4% clinically driven target lesion revascularization rate at 6 months. The 40-lesion chronic total occlusion (CTO) subset (mean lesion length 82±38 mm) achieved a similar significant reduction in stenosis to 35.5%±13.6% after Pantheris alone (p<0.001). Histological analysis of atherectomy specimens confirmed <1% adventitia in 82.1% of the samples, highlighting the precision of OCT guidance. Characterization of the OCT-guided lesions revealed evidence of an underestimation of disease burden when using fluoroscopy. CONCLUSION: OCT-guided atherectomy for femoropopliteal disease is safe and effective. Additionally, the precision afforded by OCT guidance leads to greater removal of plaque during atherectomy while sparing the adventitia.

Final results of the Chronic Total Occlusion Crossing With the Ocelot System II (CONNECT II) study.

PURPOSE: To evaluate the safety and effectiveness of the optical coherence tomography-guided Ocelot catheter to cross femoropopliteal chronic total occlusions (CTOs). METHODS: The CONNECT II study was a prospective, multicenter, non-randomized single-arm study of the safety and effectiveness of the Ocelot catheter in CTO crossing. Key inclusion criteria were a 99% to 100% stenosed femoropopliteal segment, lesion length between 1 and 30 cm, and resistance to guidewire crossing. The main exclusion criterion was a severely calcified target vessel. The primary safety endpoint was 30-day major adverse events (MAE), while the primary effectiveness endpoint was successful CTO crossing (i.e., guidewire placement in the distal true lumen) with the Ocelot catheter. Endpoint analysis was based on pre-specified objective performance criteria. Between February and June 2012, 100 patients (55 men; mean age 69 years) were enrolled. Most of the CTOs (94%) were in the superficial femoral artery (SFA); mean lesion length was 16.6±9.3 cm. RESULTS: Through 30 days, 2 patients experienced MAE (significant perforations) related to the Ocelot catheter. The Ocelot catheter successfully crossed 97% of target CTOs either alone (72%), in conjunction with an assist device (18%), or in conjunction with a re-entry device (7%). Both primary safety and effectiveness endpoints were met. CONCLUSION: The Ocelot catheter with optical coherence tomography guidance offers physicians a reliable option for crossing femoral and popliteal chronic total occlusions with low MAE rates.

3D Printing for Mesenteric Artery Endovascular Interventions: Feasibility and Utility for Preprocedural Planning and Angiographic Correlation.

BACKGROUND: Three-dimensional (3D) printing of mesenteric artery (MA) anatomy preprocedurally for endovascular interventions can allow strategic preprocedure planning and improve procedure-related clinical outcomes. METHODS: Three patients with computed tomography angiography (CTA) of the abdomen and pelvis who subsequently underwent MA interventions were 3D printed retrospectively, and 2 patients with symptoms and severe MA stenosis on CTA, who had not undergone intervention, were 3D printed for procedure-related planning and anatomy-specific implications. The 3D-printed models (3D-PMs) were painted with acrylic paint to highlight anatomy. Reference vessel size, lesion length (LL), and renal artery (RA) to MA distance were determined using a digital millimeter caliper. RESULTS: Each of the 5 patients with variable anatomy, including an MA chronic total occlusion (CTO), were successfully 3D printed. A digital caliper allowed determination of vessel size, LL, and RA to MA distance, which were then compared with intraprocedural MA angiograms and intravascular imaging when available. Further complex anatomies, such as intraprocedural navigation in the setting of prior abdominal aortic endograft and CTO assessment with relevance to cap morphology, small branch arteries, and collateral flow, were also successfully 3D printed. CONCLUSION: Preprocedural 3D printing of MA anatomy for interventions can theoretically lead to decreases in contrast use, radiation dose, and fluoroscopic and procedural times, as well as enhance comprehension of complex patient-specific anatomy.

3D Printing of Subclavian Artery: Utility for Preprocedural Planning and Correlation With Subclavian Artery Percutaneous Vascular Interventions.

BACKGROUND: Three-dimensional (3D) printing for subclavian artery (SA) percutaneous vascular interventions (PVI) may allow superior understanding of patient specific complex anatomy and aid with preprocedural planning. METHODS: Five patients with computed tomography angiography (CTA) of the neck who underwent SA PVI were queried retrospectively. 3D printing of aortic arch and great vessels was accomplished with 3D slicer software and painted with acrylic paint to highlight anatomic features. The aortic arch type and implications for preprocedural planning for SA interventions including complex chronic total occlusion (CTO) lesions were determined. Comparisons were made with SA angiograms and 3D-CTA. RESULTS: Of the 5 patients, type I (n = 2), type II (n = 1), and type III (n = 2) aortic arches were identified. Proximal and distal reference vessel size and total lesion length were determined using a digital millimeter caliper and correlated with intraprocedural balloons and stents. In 3D-printed models (3D-PMs) of patients with SA-CTO (n = 2), cap morphology (tapered vs blunt) and distal vessel filling were visualized, permitting optimal arterial access site selection for successful cap crossing. The vertebral arteries (VAs) were also 3D printed which further allowed the ability to delineate optimal stent deployment site (proximal or distal to VA), a common dilemma that is faced intraprocedurally. The 3D-PMs also allowed preprocedural precision in stent and balloon size and length, potentially leading to procedural efficiency and cost-effectiveness. CONCLUSION: 3D printing of aortic arch and great vessel anatomy for SA-PVI allows multiple procedure-related factors to be predicted in advance, translating to decrease in contrast volume, radiation time, procedure and fluoroscopic time, thereby improving procedure and cost efficiency.

3D Printing of Renal Arteries for Endovascular Interventions: Feasibility, Utility, and Correlation With Renal Arteriograms.

BACKGROUND: Three-dimensional (3D) printing technology is increasingly being utilized for preprocedural planning of interventional procedures. However, utility of 3D models of obstructive and clinically relevant renal artery disease has not been evaluated and could potentially assist in preprocedural planning of renal artery endovascular interventions. METHODS: Five patients with computed tomography angiography (CTA) of abdomen and pelvis who also subsequently underwent renal artery interventions were 3D printed retrospectively. Standard 3D slicer software was used to segment out descending aorta, renal artery, and renal anatomy to create a computer aided image. The 3D-printed models (3D-PMs) were painted with acrylic paint to highlight anatomic features for comparison with renal arteriograms and 3D-CTA to aid in endovascular interventions. RESULTS: 3D-PMs were successfully produced in diverse renal artery pathology: atherosclerotic disease, fibromuscular dysplasia, in-stent restenosis, and bilateral renal artery stenosis. Renal artery ostium angulation and optimal axial guiding catheter engagement were elucidated. Additionally, reference vessel size and lesion length were measured using digital millimeter calipers. Renal arteriogram along with renal interventional devices utilized during each case were compared for size correlation, reproducibility, and clinical utility. CONCLUSION: Preprocedural 3D printing of renal artery anatomy requiring endovascular intervention could allow for better appreciation of renal anatomy and could serve as an adjunctive tool to minimize use of contrast, fluoroscopy, and procedure time.

Histopathologic Characterization of Chronic Total Occlusions by Directional Atherectomy: The HIPACT Study.

BACKGROUND: Chronic total occlusions (CTOs) and long lesions have been associated with higher reocclusion rates in femoropopliteal arteries and increased need for revascularization. While several studies have analyzed atherectomy samples, no study to date has correlated the tissue characteristics of CTOs with clinical outcomes. This pilot study assessed lesions in order to predict clinical outcomes based on lesion characteristics. METHODS: Patients presenting with femoropopliteal (FP) CTO lesions, including in-stent restenosis and de novo lesions, were enrolled in a prospective, observational study. With patient consent, CTOs were crossed using a crossing catheter guided by optical coherence tomography (OCT) imaging. Atherectomy was performed with a directional atherectomy device and tissue samples were collected and subjected to histopathological analysis for the presence of adventitial tissue and thrombus, and the amounts of hypercellular cells, fibrocellular material, fibrous tissue, and lipid-rich tissue in the excised tissue were measured. The compiled data were correlated with clinical outcomes, as recorded at each patient's clinical follow-up visit. RESULTS: All CTO lesions (n = 19) were successfully crossed, with no dissections or perforations. Adventitial tissue was found in excised tissue from all 19 lesions (up to 57% of total lesion area), and thrombus was found in 15 lesions (up to 34% of total lesion area). The amount of hypercellular cells, fibrocellular material, fibrous tissue, and lipid-rich tissue present in the excised tissue did not correlate with the incidence of target-lesion revascularization (TLR). At 6-month follow-up exam, 79% of the treated lesions had TLR. Risk of TLR was assessed based on weighted risk of each variable; the results determined that occurrence of TLR was associated with elevated levels of adventitia and thrombus in the lesions and with lesions >15 cm in length. There was a significant correlation (P<.05) between TLR and the lesion characterization as set forth in the present study. CONCLUSIONS: Pairing the histological analysis, including content of adventitia and thrombus, with lesion length and binary clinical outcomes enabled the predictive incidence of TLR in this pilot study. Further work needs to be conducted to validate these findings in larger studies.

Intravascular Lithotripsy for Severe Calcium-Mediated Peripheral Vascular Stent Underexpansion.

Severely calcified lesions are the leading cause of stent under-expansion in peripheral vascular interventions. Current approved treatment options are limited to high pressure balloon angioplasty and laser atherectomy, both of which often yield sub-optimal results. Intravascular Lithotripsy offers a promising new treatment option for calcium-mediated peripheral vascular stent under-expansion.

Transulnar Versus Transradial Access for Coronary Angiography and Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Controlled Trials.

OBJECTIVES: To compare the outcomes of transulnar access (TUA) versus transradial access (TRA) for coronary angiography (CA) and percutaneous coronary intervention (PCI). BACKGROUND: TUA has emerged as an alternative access site in patients who fail TRA or not candidates for it. Data comparing both approaches have been limited. METHODS: We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) that compared outcomes of TUA versus TRA for CA and/or PCI. RESULTS: Data from seven RCTs, with 5721 patients (TUA = 2874 and TRA = 2847), were analyzed. TUA, compared with TRA, was associated with a similar risk of major adverse cardiovascular and cerebrovascular events (MACCE) (3.05% vs. 3.32%, OR 0.9, 95% CI [0.65, 1.25]; P = 0.53), access cross-over rate (9.4% vs. 4.1%, OR 1.92, 95% CI [0.91, 4.06]; P = 0.09), access-site complications (12.7% vs. 13%, OR 0.97, 95% CI [0.79, 1.19]; P = 0.75), vasospasm (8.1% vs. 9%, OR 0.83, 95% CI [0.54, 1.27]; P = 0.38), procedural time (MD 1.34 min, 95% CI [-1.31, 3.99]; P = 0.32) and fluoroscopy time (MD 0.29 min, 95% CI [-0.33, 0.91]; P = 0.36). Additional analysis of patients who underwent PCI showed no difference in the incidence of MACCE, access-site complications and large hematoma. The risk of local bleeding was lower in the TUA group compared with TRA (4.9% vs. 8.5%, OR 0.55, 95% CI [0.33, 0.93]; P = 0.02). CONCLUSION: TUA is a safe approach in both CA and PCI with comparable outcomes to TRA. PCI with TUA might be associated with a lower risk of local bleeding compared with TRA.

Patient-Specific Coronary Artery Bypass Graft 3D Printing: Implications for Procedural Planning in Complex Percutaneous Coronary Interventions.

BACKGROUND: Three-dimensional (3D) printing technology has seen tremendous growth in augmenting didactics, research, and preprocedural planning with structural heart procedures. Limited investigative efforts have been made in other areas of the cardiovascular spectrum. 3D-printed models (PMs) of anatomically complex coronary artery bypass graft (CABG) patients from coronary computed tomography angiography (CCTA) have implications for adaptive learning and preprocedural planning. METHODS: Five patients with CCTA who underwent subsequent coronary angiography were 3D printed for retrospective comparisons. Standard slicer software was used to create a computer-aided image of the ascending aorta, native coronary arteries, bypass grafts, aortic arch, and great vessels and 3D printed using polylactic acid filament. The models were painted with acrylic paint to highlight anatomical features and comparison was made with coronary angiography and 3D-CTA images. RESULTS: All occluded vein grafts, left and right internal mammary artery (IMA) grafts, patent saphenous vein grafts, along with distal graft anastomotic sites, were accurately 3D printed. In cases with chronic total occlusions (CTOs), ambiguous ostial caps, mid or distal vessel chronic occlusions, and occlusions seen as CTOs on coronary angiography were 3D printed showing either distal vessel reconstitution via collaterals or complete arterial filling seen in a setting of calcification, microchannels, and collateral flow. Lastly, 3D printing of the aortic root and great vessels allowed for better appreciation of vessel tortuosity to aid in the cannulation of IMA grafts and optimizing engagement with diagnostic and guiding catheters. CONCLUSIONS: 3D printing of anatomically complex CABG patients has the potential to assist with preprocedural planning and operator understanding of complex coronary anatomy.

3D Printing of Carotid Artery and Aortic Arch Anatomy: Implications for Preprocedural Planning and Carotid Stenting.

BACKGROUND: Carotid artery stenting (CAS) has been associated with increased periprocedural stroke in comparison with carotid endarterectomy (CEA). Three-dimensional (3D) printing of aortic arch and carotid artery may aid with preprocedural planning and adaptive learning, possibly reducing procedure-related complications. METHODS: Five CAS cases with available computed tomography angiography (CTA) were retrospectively evaluated and 3D-printed models (3D-PMs) were made. One additional case that was 3D printed preprocedurally provided prospective analysis. Standard 3D printing software was used to create a computer-aided image from CTA series that were 3D printed. The models were painted with acrylic paint to highlight anatomical features. The type of aortic arch, common carotid artery (CCA) to internal carotid artery (ICA) angle, and ICA distal landing zone for embolic protection device (EPD) were analyzed. In addition, stent and EPD sizing was determined preprocedurally for the prospective case. Comparisons of 3D-PM were made with 3D-CTA reconstruction and carotid angiography. RESULTS: Of 6 cases, 2 had type III and 4 had type I aortic arches. One case, a failed endovascular approach from femoral artery access site requiring reattempt via right brachial artery, had a CCA to ICA angle >60° and a tortuous innominate artery and distal ICA for EPD. The remaining 5 cases had straight distal landing zones for EPD and <60° CCA to ICA angles with successful first endovascular attempt. Additionally, vessel-specific stent and EPD sizing was appropriately chosen for the 1 prospective case. CONCLUSIONS: 3D-PM for CAS offers added value compared with CTA by providing improved perceptual and visual understanding of 3D anatomy.

Outcomes of Transpedal Arterial Access Hemostasis Using a Radial Hemostatic Band.

BACKGROUND: There is increasing burden of peripheral arterial disease (PAD) in the United States. Despite advancements in endovascular therapy, there have been significant limitations in invasive interventions aimed at revascularization. The transpedal tibial artery retrograde approach has been described as an alternative access for patients with complex disease requiring dual access or failed revascularization via conventional common femoral artery access. In this study, we examined the safety and efficacy of a radial hemostatic band to achieve hemostasis post procedure without compromising the integrity of the accessed tibial artery. METHODS: This study included 20 patients with PAD requiring endovascular revascularization on whom the RadAR band device (Advanced Vascular Dynamics) was applied for postprocedure hemostasis following transpedal access between December 2011 and May 2014. All patients underwent routine postprocedure ankle-brachial indices (ABIs) following hemostasis to determine outcomes of the overall ABI and that of the accessed pedal artery. RESULTS: Mean patient age was 77 years and mean patient weight was 80.9 kg. Mean follow-up was 11 months post procedure. Lesions were located as follows: 3 popliteal, 13 superficial femoral, 3 posterior tibial, and 1 anterior tibial. Nine procedures were performed on the left leg and 11 on the right leg. All patients received heparin as anticoagulation, with a targeted activated clotting time between 250-300 seconds. Access was made into the posterior tibial in 15 patients and in the anterior tibial in 5 patients. RadAR band was deployed in a fashion similar to its deployment on the radial artery. Hemostasis was achieved in all 20 cases without complication. Postprocedure ABI and pedal-brachial index (PBI) improved significantly compared with the preprocedure values. There was an average improvement of approximately 50% in ABIs, improving from 0.59 to 0.88. The PBI also improved from 0.59 before the procedure to 0.87 post procedure. There was, however, no significant difference in ABI or PBI in anterior vs posterior tibial artery access patients. CONCLUSION: Transpedal tibial arterial access is an effective technique for revascularization in the lower extremity, and postprocedure access-vessel hemostasis and patency are reliably and safely achieved using a hemostatic band device.

Utility of Imaging Modalities in Coronary Lesions With Borderline Fractional Flow Reserve.

BACKGROUND: Coronary intervention is routinely deferred in intermediate lesions with fractional flow reserve (FFR) ≥ 0.80. Patients with borderline FFR (0.80-0.85) who were initially deferred, have been shown to have higher risk of future interventions; however, the data is limited, and the long term prognosis in these patients remains unknown. We assessed the utility of adjunctive imaging modalities to determine the need for intervention in lesions with borderline FFR. METHODS: We retrospectively evaluated consecutive patients who underwent coronary angiography at Einstein Medical Center from January 2013 to April 2016. All patients with borderline FFR (0.80-0.85) were included. Patients were divided into Defer or Perform intervention groups based on additional available or procured clinical data. The Perform group was further stratified into intervention With or Without adjunctive imaging guidance (including intravascular ultrasound, optical coherence tomography, echocardiography, and exercise or pharmacologic stress test). Follow-up data was collected for all patients, which included future target lesion revascularization (TLR) and major adverse cardiac events (MACE; all-cause and cardiovascular mortality and acute coronary syndromes). RESULTS: A total of 196 patients were eligible. Median (IQR) FFR in Perform and Defer groups was 0.81 (0.8-0.83) and 0.84 (0.82-0.85) respectively. Median (IQR) follow up was 21 (13-29) and 25 (15-36) months respectively. Overall MACE rate in Perform group (n = 101) was 20.8% (n = 21) and Defer group (n = 95) was 15.8% (n = 15). The stratified MACE rate in Perform group With imaging guidance (n = 57) was 17.5% (n = 10) and Without imaging guidance (n = 44) was 25% (n = 11). Overall, the FFR only guided management (n = 196) led to MACE rate of 18.4% (n = 36); whereas, FFR With imaging guidance (n = 136) led to MACE rate of 16.2% (n = 22). The p values were non-significant in each of the above group comparisons due to relatively low numbers with trends as noted. CONCLUSIONS: Our study suggests that intervention of coronary lesions with borderline FFR under imaging guidance, although not significant, trends towards improved cardiovascular outcomes compared with intervention in this group without adjunctive imaging. These findings are merely speculative without achieving statistical significance in a small subset and need to be further validated in a large scale prospective study.

Femoral Artery Chronic Total Occlusion Revascularization (FACTOR) Score and Algorithm: Feasibility and Validation in a Single-Center Study of Femoropopliteal Occlusions.

OBJECTIVES: To develop and validate a hybrid algorithm to approach complex superficial femoral artery (SFA) chronic total occlusions (CTOs) in a step-wise fashion. BACKGROUND: SFA-CTO represents one of the most challenging subsets of lower-extremity peripheral arterial disease. Depending on lesion characteristics, successful percutaneous crossing of the occluded segment may prove to be very difficult. METHODS: We retrospectively evaluated all consecutive patients with SFA-CTO at our institution. The included patients had baseline Rutherford category (2-4) symptoms and were graded using the femoral artery chronic total occlusion revascularization (FACTOR) score. Multiple modalities (wire-based strategies, CTO devices, re-entry devices) were used to cross the occlusions based on the proposed FACTOR algorithm. Primary endpoint was technical success, defined as successful CTO crossing. RESULTS: A total of 150 patients (mean age, 71 years) with SFA-CTO were retrospectively reviewed to evaluate the feasibility and utility of the FACTOR score and algorithm in a single center across multiple experienced operators. Following the FACTOR algorithm, overall procedural success was achieved in 143 out of 150 patients (95%). Successful antegrade CTO crossing occurred in 59%; success rates increased to 85% when additional retrograde popliteal, tibiopedal, and direct SFA accesses were used. In multivariate analysis, retrograde wire crossing, stent placement, and atherectomy were independent predictors of successful revascularization. CONCLUSIONS: The results of our study show that utilization of the FACTOR score and algorithm can result in high rates of successful SFA-CTO revascularization.