Antegrade Crossing Techniques for Hard Proximal Occlusion Caps Without the Use of Dedicated Chronic Total Occlusion Devices: A Pictorial Review.

CLINICAL IMPACT: Infra-inguinal Chronic Total Occlusions recanalisation is considered technically challenging. The conventional manipulation of standard guidewires and catheters has proven to be successful in a considerable percentage of cases but success rate could dramatically drop in presence of challenging lesions. The additional use of retrograde access and re-entry devices could increase technical success but could negatively affect procedural time and overall costs. Twenty different techniques of Chronic Total Occlusions antegrade crossing are hereby described with appropriate schematic representations. The aim is to help operators to apply them in specific anatomy subsets and clinical presentations and ultimately to increase procedural success rate.

A systematic review of the ipsilateral retrograde approach to the treatment of femoropopliteal arterial lesions.

OBJECTIVE: The endovascular treatment of femoropopliteal lesions is an integral part of managing peripheral arterial disease. The antegrade approach is the most widely used technique with good evidence for its safety and efficacy. However, crossing a lesion, particularly chronic total occlusions (CTO), can be technically challenging and so the retrograde approach is increasingly used to maximize the chances of procedural success. The objective of this systematic review was, therefore, to assess the safety and effectiveness of the ipsilateral retrograde approach to femoropopliteal lesions. METHODS: A systematic review conforming to the PRISMA standards was undertaken. MEDLINE, EMBASE, and The Cochrane Register were searched between January 1, 1988, and January 1, 2020. Full-text, English-language, peer-reviewed articles pertaining to peripheral arterial disease, endovascular intervention and access site were included. RESULTS: A total of 8599 articles were screened, of which 38, involving 1940 patients undergoing 2184 retrograde procedures, were included. The mean number of patients per study was 51.1, with three studies including fewer than 10 and four more than 100 patients. The reported follow-up ranged from 30 days to 3 years, and six articles did not report any long-term outcome data. A retrograde approach was used as the primary access route in 45.% of procedures (648/1438) with relevant data. Primary technical success was achieved in 88% (1920/2184; 64%-100%) with a reported complication rate of 11% (235/2117; 0%-27%). Overall, the quality of evidence was poor, with just seven articles deemed to be of high quality with a low risk of bias. A meta-analysis was not deemed appropriate owing to heterogeneity of data. CONCLUSIONS: An ipsilateral retrograde approach to femoropopliteal lesions has good primary technical success and a low rate of complications. It has a promising role as a bailout, or even a primary access technique, in complex lesions. Patient positioning, puncture site and technique, lesion anatomy, and the size of catheters and devices used are important considerations to achieve the best outcomes. There remains a paucity of robust evidence for its superiority over traditional antegrade approaches, and further work is required to identify the optimal technique and those patients who would benefit most from the approach.

A giant left atrial appendage: a case report on the feasibility of closure with a custom-made device.

Background: Transcatheter left atrial appendage occlusion (LAAO) is a valuable therapeutic option for stroke prevention in patients with atrial fibrillation (AF) at high bleeding risk. However, complex LAA anatomies sometimes preclude the adoption of commercially available LAAO devices. The design of a custom-made LAAO device is a promising strategy in these cases. However, few examples of custom-made devices in case of giant LAAs have been reported. Case summary: An 85-year-old man with permanent AF with CHA2DS2-VASc 4 and recurrent active gastrointestinal major bleedings was referred for transcatheter LAAO at Parma University Hospital after multidisciplinary team evaluation. Pre-procedural coronary computed tomography angiography revealed a giant windsock LAA, with a maximum ostium diameter of 44 mm, a landing zone diameter of 34 mm, and maximal length of 49 mm. Patient's management was particularly challenging given that available LAAO devices were too small to completely exclude the LAA. In accordance with the manufacturer, a custom-made LAmbre™ Closure System (Lifetech Scientific, Shenzhen, China), which specifically fitted with patient's LAA anatomy, was designed and successfully deployed under transoesophageal echocardiography (TEE) and fluoroscopic guidance. Periprocedural TEE confirmed the appropriate position of the device and the absence of peri-device leaks. No adverse ischaemic and haemorrhagic events were reported at 3-months follow-up. Discussion: We present a case of a successful transcatheter LAAO procedure by deploying a custom-made LAmbre device 38/46 mm to mechanically exclude a giant windsock LAA. This case illustrates the effectiveness of a custom-made device strategy, which potentially enables the closure of all complex LAA anatomies.

Concordance of left ventricular volumes and function measurements between two human readers, a fully automated AI algorithm, and the 3D heart model.

Background: Echocardiography is essential in cardiovascular medicine for screening, diagnosis, and monitoring. Artificial intelligence (AI) has the potential to improve echocardiography by reducing variability and analysis time. While 3D echocardiography is becoming more accurate, 2D imaging still dominates clinical care. We aimed to evaluate agreement in measures of left ventricular (LV) volumes and function between human readers, a fully automated AI 2D algorithm, and the 3D Heart Model. Methods: A retrospective analysis was conducted on 109 patients who underwent 2D and 3D transthoracic echocardiography. LV end-diastolic and end-systolic volumes (LVEDV, LVESV) and ejection fraction (LVEF) were measured by two operators, a commercially available AI algorithm (US2ai), and the 3D Heart Model. Global longitudinal strain (GLS) was measured by the integrated semi-automated software and the AI algorithm. Outcomes included measures of agreement [bias, limit of agreement and Pearson's correlation (R)]. Results: For LV volume measurements, the AI algorithm was strongly correlated with the average of the human operators (r = 0.89 for LVEDV and r = 0.92 for LVESV), which was higher than between the operators (r = 0.74 and r = 0.84, respectively, p < 0.01). The same trend was seen for measures of reliability with respect to LVEDV, but not LVESV. AI demonstrated comparable performance to human operators in measuring LVEF, while the 3D Heart Model had a weaker correlation and reliability compared with human operators and AI measurements. The correlation between human operators and AI for GLS was only moderate. Conclusion: This study demonstrates AI-based echocardiography as a promising tool for accurately assessing LV volumes and LVEF in clinical practice. AI-based measures demonstrated a significantly lower inter-operator variability, thereby improving the consistency and reliability of these assessments. Moreover, AI may prove particularly effective for conducting retrospective bulk analyses, offering a valuable tool for comprehensive evaluations of past data.

Differences in total plaque burden between plaque rupture and plaque erosion: A combined computed tomography angiography and optical coherence tomography study.

BACKGROUNDS: Coronary computed tomography angiography (CTA) allows for the assessment of atherosclerotic plaque burden across the entire coronary vasculature. No studies have examined the relationship between the underlying pathology of the culprit lesion and total plaque burden in patients with acute coronary syndromes. The aim of this study was to compare the total plaque burden between patients with plaque rupture versus plaque erosion. METHODS: A total of 232 patients who presented with their first non-ST-segment elevation acute coronary syndrome and underwent both CTA and optical coherence tomography imaging before intervention were selected. Quantitative analysis was performed using semi-automated software (Autoplaque version 3.0, Cedars-Sinai Medical Center). An attenuation of <30 Hounsfield units defined low-density non-calcified plaque (LDNCP). All 3 vessels were assessed using the modified 17-segment American Heart Association model for coronary segment classification. RESULTS: Among 232 patients, 125 (53.9%) had plaque rupture and 107 (46.1%) had plaque erosion. Total plaque burden (48.2 [39.8-54.9] % vs. 44.1 [38.6-50.0] %, P â€‹= â€‹0.006), total non-calcified plaque (NCP) burden (46.6 [39.1-53.3] % vs. 43.0 [37.6-49.2] %, P â€‹= â€‹0.013), total LDNCP burden (2.3 [1.4-3.0] % vs. 1.7 [1.2-2.6] %, P â€‹= â€‹0.016), and total calcified plaque (CP) burden (0.8 [0.1-1.6] % vs. 0.4 [0.0-1.4] %, P â€‹= â€‹0.047) were significantly greater in patients with culprit plaque rupture than in those with culprit plaque erosion. CONCLUSION: Patients with plaque rupture, compared with those with plaque erosion, had a greater total plaque burden, NCP burden, LDNCP burden, and CP burden. CLINICAL TRIAL REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT04523194.