The importance of malapposition in angiographically optimized stenting in contemporaneous interventions.

INTRODUCTION: Stenting has advanced the treatment of coronary artery disease, with angiography being historically the gold standard to assure adequate stent deployment. However, intravascular imaging modalities including intravascular ultrasound and optical coherence tomography have shown high rates of inadequate stent deployment in angiographically optimized stents. The association of malapposition with adverse clinical outcomes remains controversial. Areas covered: The definition, types, and risk factors for metallic stent malapposition, the natural history, and significance of stent strut malapposition and its correlation with short- and long-term outcomes were reviewed. Expert commentary: Using intravascular imaging, acute stent strut malapposition is very common, occurring in >75% in some studies. Malapposition may be a result of inadequate stent deployment technique or the atherosclerotic process itself. The preponderance of available data suggests that acute malapposition is not associated with worsened outcomes. Late acquired malapposition may be associated with a relatively increased event rate for stent thrombosis and myocardial infarction but the increased risk is quite small (<0.01%) in absolute terms. Use of a classification system based on cause rather than simple presence of malapposition may clarify some of the uncertainties regarding the clinical significance of strut malapposition.

Interventricular Septal Hematoma and Coronary-Ventricular Fistula: A Complication of Retrograde Chronic Total Occlusion Intervention.

Interventricular septal hematoma is a rare complication of retrograde chronic total occlusion (CTO) percutaneous coronary interventions (PCI) with a typically benign course. Here we report two cases of interventricular septal hematoma and coronary-cameral fistula development after right coronary artery (RCA) CTO-PCI using a retrograde approach. Both were complicated by development of ST-segment elevation and chest pain. One case was managed actively and the other conservatively, both with a favorable outcome.

Prevalence and outcomes of intermediate saphenous vein graft lesions: findings from the stenting of saphenous vein grafts randomized-controlled trial.

BACKGROUND: We sought to examine the prevalence and progression rate of intermediate saphenous vein graft (SVG) lesions in the Stenting Of Saphenous vein grafts (SOS) trial. METHODS: The baseline and follow-up angiograms of 80 patients participating in the SOS trial were analyzed to determine the prevalence of intermediate (30-60% angiographic diameter stenosis) SVG lesions and their progression rate. RESULTS: At least one intermediate SVG lesion was present in 31 of 143 (22%) SVGs in 27 of 80 (34%) patients. Most intermediate lesions were present in the SOS stented SVGs (20 grafts in 19 patients). During a median follow-up of 35 months, angiographic follow-up was available for 28 grafts in 25 patients. Progression (defined as percent diameter stenosis ≥ 70% but <100% at follow-up angiography) was seen in 11 of 28 SVGs (39%) in 11 of 25 patients (44%). Progression rate at 12, 24 and 36 months was 28% and 47% and 84%, respectively. Seven of 11 patients (64%) with intermediate SVG lesion progression presented with an acute coronary syndrome and 8 (73%) underwent PCI. Four of the 28 grafts with intermediate lesions at baseline were 100% occluded at follow-up; all of those SVGs had received a stent in another location in the SVG as part of the SOS trial. CONCLUSIONS: Intermediate SVG lesions are common in patients undergoing SVG stenting, have high rates of progression and frequently present with an acute coronary syndrome. Further study of pharmacologic and mechanical treatments to prevent progression of these lesions is needed.

Association of coronary lipid core plaque with intrastent thrombus formation: a near-infrared spectroscopy and optical coherence tomography study.

BACKGROUND: Optical coherence tomography (OCT) and near-infrared spectroscopy (NIRS) allow assessment of the anatomy (OCT) and composition (NIRS) of coronary lesions. We sought to examine the association between pre-stenting lipid core plaque (LCP), as assessed by NIRS and post-stenting thrombus formation, as assessed by OCT. METHODS: We reviewed the angiograms of nine patients who underwent coronary stenting in association with NIRS and OCT imaging. A large LCP by NIRS was defined as at least three 2-mm yellow blocks on the NIRS block chemogram with >200° angular extent. Intracoronary thrombus was defined as a mass of medium reflectivity protruding into the vessel lumen, discontinuous from the surface of the vessel wall. RESULTS: Mean age was 67 ± 7 years, and all patients were men, presenting with stable angina (56%), unstable angina (11%), or acute myocardial infarction (33%). The mean vessel lipid core burden index (LCBI) was 120 ± 45, and the mean highest 6-mm LCBI was 386 ± 190. Three patients had a large LCP and two of them (66%) developed intrastent thrombus after stent implantation compared to none of six patients without large LCPs (0%, P = 0.02). The thrombus resolved after intracoronary glycoprotein IIb/IIIa administration and balloon postdilation. Postprocedural myocardial infarction occurred in 33% versus 17% of patients with and without large LCP, respectively (P = 0.57). CONCLUSION: Stenting of large LCPs may be associated with intrastent thrombus formation, suggesting that more intensive anticoagulant and/or antiplatelet therapy may be beneficial in such lesions. © 2012 Wiley Periodicals, Inc.

Frequency, treatment, and consequences of device loss and entrapment in contemporary percutaneous coronary interventions.

BACKGROUND: Device loss and entrapment are infrequent but potentially grave complications of percutaneous coronary interventions (PCI). There are limited contemporary data on the frequency, treatment, and consequences of these complications. METHODS: We reviewed 2338 consecutive PCI cases performed between 1/2005 and 5/2010 at our institution to identify cases of device loss or entrapment. The angiograms and outcomes of these patients were reviewed. RESULTS: During the study period, device loss occurred in 9 cases (0.38%; 95% confidence interval [CI], 0.18%-0.73%) and entrapment in 4 cases (0.17%; 95% CI, 0.05%-0.44%). The lost devices were stents (n = 5; 0.21%), a coronary balloon shaft (n = 1; 0.04%), a femoral arterial sheath (n = 1; 0.04%), an arterial catheter (n = 1; 0.04%), and an Ostial Pro catheter (Ostial Solutions) distal tip (n = 1; 0.04%). Entrapped devices included a coronary guidewire (n = 2; 0.08%), a Tornus catheter (Abbott Vascular; n = 1; 0.04%) and a Filterwire (Boston Scientific; n = 1; 0.04%). All patients with device loss were successfully managed percutaneously (1 patient experienced periprocedural myocardial infarction). Retrieval of the lost devices was attempted in 7 of 9 cases (78%) and was successful in 6 cases (86%). Retrieval was successful with the initial attempt in 2 patients but required >1 attempt in 4 patients. In contrast, 3 of 4 patients (75%) with device entrapment required emergency surgical removal and coronary artery bypass grafting. CONCLUSIONS: Device loss or entrapment is an infrequent complication of contemporary PCI. Device loss can be successfully managed percutaneously, whereas device entrapment often requires emergency cardiac surgery.

Embolic protection device utilization during stenting of native coronary artery lesions with large lipid core plaques as detected by near-infrared spectroscopy.

BACKGROUND: Stenting of large lipid core plaques (LCPs), as assessed by near-infrared spectroscopy (NIRS), has been associated with periprocedural myocardial infarction (MI), possibly due to distal embolization. METHODS: An embolic protection device (EPD) was inserted before stenting in nine native coronary arteries with large LCP, as assessed by NIRS. Embolized material was assessed by histopathology. RESULTS: Mean age was 64 ± 7 years and all patients were men. The target lesion was located in the right (67%) or left anterior descending (33%) coronary artery. A filter was utilized in eight patients (89%) and proximal embolic protection in one (11%). In one patient two filters were required because the originally placed filter became obstructed with debris after initial stent placement. The mean percent angiographic stenosis prestenting and poststenting was 87% ± 9% and 2% ± 4%, respectively and final TIMI 3 flow was achieved in all patients. Embolized material was retrieved in eight of nine patients (89%) and consisted mainly of platelet and fibrin thrombi. The mean target segment lipid core burden index decreased from 395 ± 114 before stenting to 152 ± 106 after stenting (P < 0.001) and the lesion angular extent decreased from 312° ± 70° to 240° ± 90° (P = 0.07). Postprocedural MI occurred in two of nine patients (22%), in one of whom two filters were required. CONCLUSION: Use of EPDs frequently resulted in embolized material retrieval after stenting of native coronary artery lesions with large LCPs. These findings support further study of EPDs as a means to prevent poststenting MI.

Role of embolic protection devices in ostial saphenous vein graft lesions.

BACKGROUND: Although embolic protection devices (EPDs) have been shown to be beneficial in saphenous vein graft (SVG) lesions, their role in the subgroup of ostial SVG lesions has received limited study. METHODS: The coronary angiograms and procedural outcomes of 109 patients undergoing stenting of 113 ostial SVG lesions were retrospectively reviewed to determine the frequency of EPD use and the periprocedural outcomes. RESULTS: Ninety-eight (87%) of the 113 lesions were suitable for EPD use, that was used in 70 lesions (71%). A Filterwire (Boston Scientific) or a SPIDER (ev3) filter were used in 54 (77%) and 16 (23%) of lesions, respectively. Difficulty retrieving the filter post stenting was encountered in eight lesions (11%) and led to stent thrombosis causing cardiac arrest in one patient (1%). Angiographic success was achieved in 111 (98%) of 113 lesions. CONCLUSIONS: EPDs can be utilized in the majority of ostial SVG lesions, but in 11% of cases filter retrieval can be challenging and may rarely (in approximately 1%) lead to a significant complication.

Contemporary approaches to saphenous vein graft interventions: a survey of 275 interventional cardiologists.

BACKGROUND: We sought to examine contemporary practice patterns of saphenous vein graft (SVG) interventions. METHODS: A link to a 10-item online questionnaire was completed in June 2009 by 275 (7%) of 3,771 US interventional cardiologists surveyed. RESULTS: Sixty-five percent of the respondents use an embolic protection device (EPD) in >75% of SVG interventions. The main reason for not using an EPD was "anatomic difficulties" (55%), followed by device complexity (20%). Filter-based EPDs were the most widely available, well known, and commonly used EPDs, whereas the Guardwire (Medtronic Vascular) was the least commonly used EPD. The main factors underlying EPD selection were lesion location (83%), familiarity with devices (72%), and SVG diameter (64%). Factors that could increase EPD use included availability of simpler to use devices (63%), and more studies demonstrating benefit from EPD use (37%). Compared with interventionalists who used EPDs in most cases (>75%), those who utilized EPDs less frequently were less likely to be familiar with each EPD and had less EPDs available for use. Many interventionalists (84%) administer intragraft vasodilators during SVG interventions, prefer drug-eluting stents (63%) and administer >12 months antiplatelet therapy poststent implantation. CONCLUSIONS: During SVG interventions (1) "anatomic difficulties" are the most common reason for not utilizing an EPD; (2) filter-based EPDs are most commonly used; (3) lesion location is the most important factor for EPD selection; (4) availability of simpler to use devices could increase EPD use; and (5) intragraft vasodilators, drug-eluting stents and prolonged antiplatelet therapy are commonly utilized.

In vivo characterization of coronary plaques: novel findings from comparing greyscale and virtual histology intravascular ultrasound and near-infrared spectroscopy.

AIMS: To test the hypothesis that near-infrared spectroscopy (NIRS) combined with intravascular ultrasound (IVUS) would provide novel information of human coronary plaque characterization. METHODS AND RESULTS: Greyscale-IVUS, virtual histology (VH)-IVUS, and NIRS were compared in 131 native lesions (66 vessels) that were interrogated during catheterization by all three modalities. Greyscale-IVUS detected attenuated and echolucent plaques correlated with NIRS-detected lipid-rich areas. Attenuated plaques contained the highest NIRS probability of lipid core, followed by echolucent plaques. By VH-IVUS, 93.5% of attenuated plaques contained confluent necrotic core (NC) and were classified as VH-derived fibroatheromas (FAs). Although 75.0% of echolucent plaques were classified as VH-FAs, VH-NC was seen surrounding an echolucent zone, but not within any echolucent zone; and echolucent zones themselves contained fibrofatty and/or fibrous tissue. All calcified plaques with arc >90° contained >10% VH-NC (range 16.0-41.2%) and were classified as calcified VH-FAs, but only 58.5% contained NIRS-detected lipid core. A positive relationship between VH-derived %NC and NIRS-derived lipid core burden index was found in non-calcified plaques, but not in calcified plaques. CONCLUSION: Combining NIRS with IVUS contributes to the understanding of plaque characterization in vivo. Further studies are warranted to determine whether combining NIRS and IVUS will contribute to the assessment of high-risk plaques to predict outcomes in patients with coronary artery disease.

Paclitaxel-eluting stents reduce neointimal hyperplasia compared to bare metal stents in saphenous vein grafts: intravascular ultrasonography analysis of the SOS (Stenting of Saphenous Vein Grafts) trial.

AIMS: To compare the intravascular ultrasonography (IVUS) findings between saphenous vein grafts (SVG) treated with paclitaxel-eluting stents (PES) vs. bare metal stents (BMS) in the Stenting Of Saphenous Vein Grafts (SOS) trial. METHODS AND RESULTS: Of the 80 SOS trial patients, 38 had both baseline and follow-up IVUS examination and were included in this substudy: 17 patients received 28 BMS in 26 lesions and 21 patients received 30 PES in 28 lesions. Quantitative IVUS analysis was performed to determine the volume of in-stent neointimal hyperplasia (NIH) - defined as the difference between stent volume and lumen volume in the stented segments. Baseline characteristics were similar between patients who did and did not undergo baseline and follow-up IVUS. Patients receiving BMS and PES had similar stent and lumen volumes immediately after stenting. At 12-month follow-up, compared to BMS, PES-treated lesions had significantly less NIH volume (3.4 vs. 21.9 mm³, p<0.001) and neointima hyperplasia progression (1.6 vs. 17.1 mm³, p<0.001). No significant differences were seen in the 5 mm segment proximal and distal to the stent. CONCLUSIONS: Compared to BMS, use of PES in SVG lesions is associated with significantly lower NIH formation, which may help explain the improved clinical outcomes with PES in these lesions.

Contemporary outcomes of percutaneous intervention in chronic total coronary occlusions due to in-stent restenosis.

BACKGROUND: Limited data exist on the treatment of chronic total occlusions (CTO) due to in-stent restenosis (ISR). METHODS: We reviewed the procedural techniques and outcomes of 21 consecutive interventions in CTOs due to ISR. RESULTS: Mean age was 60±8 years, and all patients were men. The target lesion was located in the right coronary artery in 38%, left anterior descending or diagonal in 48%, or circumflex/obtuse marginal in 14%. One CTO lesion was treated in each patient. Two patients (10%) had prior unsuccessful attempt for CTO intervention and 14% had prior coronary artery bypass graft surgery. The average CTO age was 6.3±4.6 years. The overall ISR CTO procedural success rate was 71%. Procedural failure was due to inability to cross the CTO lesion in all unsuccessful cases. Failure to cross in CTOs located in the left anterior descending artery was due to the presence of a large side branch proximal to the CTO, whereas in the right coronary artery it was due to tortuosity. Retrograde interventions were attempted in four patients and were successful in one. CONCLUSION: Success rates for ISR CTO interventions remain relatively low due to failure to cross the lesion. Several factors, such as long occlusion time, tortuosity, and presence of a large side branch proximal to the CTO may be associated with ISR CTO crossing failure.

Recurrent cardiovascular events with paclitaxel-eluting versus bare-metal stents in saphenous vein graft lesions: insights from the SOS (Stenting of Saphenous Vein Grafts) trial.

UNLABELLED: The Stenting of Saphenous Vein Grafts (SOS) trial demonstrated a reduction in clinical and angiographic adverse events with paclitaxel-eluting stents (PES) compared to bare-metal stents (BMS) in saphenous vein graft (SVG) lesions, but the rate of recurrent adverse events has not been described. METHODS: We performed a post hoc, landmark analysis to evaluate the risk of event recurrence following a non-fatal initial event among the SOS trial patients (pts). RESULTS: During a median follow-up of 35 months, the 80 pts enrolled in SOS experienced a total of 78 major cardiovascular events (MACE): 51 in the BMS group and 27 in PES group. No MACE were found in 28 pts (35%) while 52 pts (65%) had at least one event. The initial event was death in 13 pts (16%). Among the 39 pts whose initial event was not fatal, 12 (31%) had one or more subsequent MACE (50% of which were definitely related to the study SVG). The mean and median number of MACE per patient was significantly higher in patients receiving BMS versus PES (1.3 ± 1.2 and 1 ± 1.26 versus 0.6 ± 0.7 and 1 ± 0.825, p = 0.005 and p = 0.008, respectively). The rate of a second MACE following an initial event was 17% in the PES group and 37% in the BMS group (p = 0.24). Ten of 12 pts with recurrent events had received a BMS (83%). CONCLUSION: Pts undergoing SVG stenting had a high rate of recurrent events after an initial non-fatal event. These events were often related to the target vessel and most occurred in pts who had received a BMS, further supporting the benefit of PES over BMS in SVG lesions.

Catastrophic left main coronary artery occlusion following diagnostic coronary angiography: salvage by emergency left main coronary artery stenting.

Acute occlusion of left main coronary artery after diagnostic angiography can be rapidly fatal. We describe two patients with left main disease that developed cardiac arrest shortly after diagnostic coronary angiography. They were both successfully treated with emergency left main stenting while cardiopulmonary resuscitation was being performed. Patients with left main disease should be carefully monitored after diagnostic angiography to allow prompt recognition of acute occlusion. Emergency stenting may be required for salvaging the patients.

Continued benefit from paclitaxel-eluting compared with bare-metal stent implantation in saphenous vein graft lesions during long-term follow-up of the SOS (Stenting of Saphenous Vein Grafts) trial.

OBJECTIVES: This study sought to report the long-term outcomes after drug-eluting stent (DES) implantation in saphenous vein graft (SVG) lesions in the SOS (Stenting of Saphenous Vein Grafts) trial. BACKGROUND: The long-term outcomes after DES implantation in SVGs are poorly studied. Apart from the SOS trial, the only other randomized trial comparing DES with bare-metal stents (BMS) in SVGs reported higher mortality in the DES group at 32 months. METHODS: In the SOS trial, 80 patients with 112 lesions in 88 SVGs were randomized to a BMS or paclitaxel-eluting stent (PES) and demonstrated improved short-term angiographic and clinical outcomes with PES. Extended clinical follow-up was subsequently obtained. RESULTS: Mean age was 67 ± 9 years, and all patients were men. The indications for stenting included acute coronary syndrome in 60% and stable angina in 31% of patients. The mean SVG age was 12 ± 6 years. The baseline characteristics of the patients in the 2 study groups were similar. Procedural success was achieved in 77 patients (96%). During a median follow-up of 35 months, compared with patients randomized to BMS, those receiving PES had a lower incidence of myocardial infarction (hazard ratio [HR]: 0.32, p = 0.01), target lesion revascularization (HR: 0.20, p = 0.004), target vessel revascularization (HR: 0.41, p = 0.03), and target vessel failure (HR: 0.34, p = 0.001) as well as a trend toward less definite or probable stent thrombosis (HR: 0.15, p = 0.08). All-cause mortality (HR: 2.04, p = 0.19) and cardiac mortality (HR: 0.62, p = 0.51) did not differ between groups. CONCLUSIONS: During long-term follow-up, use of PES was associated with significantly better clinical outcomes than BMS in SVG lesions. (Stenting of Saphenous Vein Grafts Trial [SOS]; NCT00247208).

Frequency and risk of noncardiac surgery after drug-eluting stent implantation.

BACKGROUND: Few studies have described the frequency and risk of surgery after drug-eluting stent (DES) implantation. METHODS: The medical records of 827 consecutive patients who received a DES at our institution between January 1, 2005 and July 1, 2008 were retrospectively reviewed to determine the outcomes of patients who subsequently underwent noncardiac surgery. RESULTS: During a median follow-up of 21 months, 135 patients underwent 191 noncardiac surgeries. The incidence of noncardiac surgery was 7% at 1 year, 18% at 2 years, and 22% at 3 years. Mean age was 62 years and 96% were men. A perioperative complication occurred in 19 surgeries (10%): excessive bleeding in 11 patients (6%), myocardial infarction in four patients (2%), acute renal failure in one patient (0.5%), hypotension and syncope in one patient (0.5%) and postoperative death in three patients (1.6%). Stent thrombosis occurred in one patient (0.5%). A complication occurred in six of 58 surgeries (10%) in which patients received perioperative clopidogrel vs. 13 of 133 surgeries (10%) in which patients did not receive perioperative clopidogrel (P = 0.90). Complications occurred in three of 25 surgeries performed within 6 months (16%), in four of 37 surgeries performed between 6 and 12 months (11%), and in 12 of 129 surgeries performed after >12 months (9%) from DES implantation (P = 0.90). CONCLUSION: Noncardiac surgery is frequently needed in the years after DES implantation and appears to carry a low risk of stent thrombosis and perioperative complications.

Intercatheter reproducibility of near-infrared spectroscopy for the in vivo detection of coronary lipid core plaques.

OBJECTIVES: To evaluate the intercatheter reproducibility of catheter-based intracoronary near-infrared spectroscopy (NIRS) for the detection of coronary lipid core plaques (LCPs). BACKGROUND: The intercatheter in vivo reproducibility of coronary NIRS findings has not been evaluated. METHODS: NIRS assessment using an automated pullback catheter was performed in triplicates in 10 patients using two different NIRS catheters to evaluate the reproducibility of the lipid core burden index (LCBI). RESULTS: Mean age was 62 ± 7 years, and all patients were men with high prevalence of hypertension (90%), hyperlipidemia (90%), diabetes (50%), and current smoking (50%). The mean LCBI measured by the first and second catheters was 64 ± 55 and 69 ± 47, respectively (intraclass correlation coefficient, 0.97; 95% confidence interval, 0.90-0.99; and Spearman's ρ, 0.95; P < 0.001 for both). The mean LCBI measured again with the second catheter was 71 ± 63 (intraclass correlation coefficient, 0.96; 95% confidence interval, 0.84-0.99; and Spearman's ρ, 0.95; P < 0.001 for both). The mean number of LCPs detected by the first and second catheters was 1.9 ± 1.2 and 2.0 ± 1.5, respectively (intraclass correlation coefficient, 0.75, P = 0.005 and Spearman's ρ, 0.74, P = 0.01). The mean number of LCPs at reimaging with the second catheter was 2.0 ± 1.76 (intraclass correlation coefficient, 0.96 and Spearman's ρ, 0.98; P < 0.001 for both). CONCLUSION: NIRS measurements of LCP with two different catheters have high reproducibility. The findings support the use of NIRS to assess the status of LCP in patients over time and to assess LCP changes in response to novel treatments.

Hairpin-trap: a novel stent retrieval technique.

We report a novel technique for retrieving lost stents or other equipment from the intravascular space. A hairpin is formed at the distal part of a 0.014 inch coronary guidewire, inserted through the Touhy valve, and used to "hook" the lost stent. The distal tip of the wire is then pulled back into the guiding catheter, where it is trapped by a balloon, forming a "hairpin-trap." The entire system is subsequently withdrawn. © 2010 Wiley-Liss, Inc.

Percutaneous intervention of acutely occluded saphenous vein grafts: contemporary techniques and outcomes.

OBJECTIVES: To examine the contemporary acute and long-term outcomes after percutaneous coronary interventions (PCI) of acutely occluded saphenous vein grafts (SVGs). BACKGROUND: PCI of acutely thrombosed SVGs carries low success rates. It is unknown whether outcomes have improved with contemporary PCI techniques. METHODS: We reviewed the acute and long-term outcomes of 34 consecutive patients who underwent PCI of 36 acutely occluded SVGs at our institution between 2003 and 2009. RESULTS: Mean patient age was 70 +/- 10 years and 39% had stent thrombosis. Mean SVG age was 14 +/- 6 years. SVG PCI was successful in 81%. In 3 patients, PCI of the target vessel native chronic total occlusion (CTO) was attempted after SVG PCI failed and was successful in 2, increasing the overall target myocardial territory revascularization success rate to 86%. Adjunctive PCI techniques were used as follows: mechanical thrombectomy (69%), rheolytic thrombectomy (39%), embolic protection devices (25%) and laser (14%). Stents (61% drug-eluting) were implanted in 78% of the treated lesions. Mean follow up was 2.3 +/- 1.9 years. At 1 and 3 years, mortality was 8% and 42%, an acute coronary syndrome occurred in 15% and 41% and repeat coronary revascularization was required in 28% and 38%, respectively. CONCLUSIONS: In this particular population of thrombosed SVG PCIs, a high incidence of stent thrombosis was observed and procedural success rate was 81% with an additional 5% undergoing successful native coronary artery CTO PCI. Patients presenting with thrombosed SVGs were at high risk for recurrent events.

Use of the venture wire control catheter for the treatment of coronary artery chronic total occlusions.

BACKGROUND: The Venture catheter (St Jude, Minneapolis, MN) has a deflectable tip for facilitating wire steering and a stiff body. Both properties can be useful in percutaneous coronary interventions (PCI) of coronary chronic total occlusions (CTOs). METHODS: We reviewed 26 consecutive patients in whom the Venture catheter was utilized during coronary CTO PCI at our institution between May 2008 and September 2009. RESULTS: Mean age was 63 ± 9 years and 96% of the patients were men. The CTO target lesion was located in the right coronary artery (35%), left anterior descending artery (27%), circumflex (27%) or a saphenous vein graft (4%). A prior attempt for CTO PCI had been done in 19%. The primary CTO PCI approach was antegrade in 92% and retrograde in 8%, but a retrograde approach was used in an additional 27% of the patients after antegrade approach failed. The Venture catheter was used to overcome vessel tortuosity (73%), for CTOs with side branch at the occlusion site (15%), to facilitate collateral branch wiring during retrograde PCI (8%), and to provide extra support (4%). The overall CTO PCI success rate was 77% and was 92% in patients with upfront Venture catheter use and in 64% of patients in whom the Venture was used after PCI attempts using other equipment failed. Procedural failure was due to inability to cross the lesion in all cases. CONCLUSIONS: The Venture catheter can facilitate CTO PCI, especially in patients with marked coronary tortuosity or when additional support is required.