Practice differences and knowledge gaps in complex and high-risk interventions between Japan and the USA: A case-based discussion.

Advances in percutaneous coronary intervention (PCI) devices and techniques have expanded the pool of eligible patients for revascularization, including those with comorbidities, reduced left ventricular function, or anatomical complexity (defined as CHIP: complex and high-risk interventions in indicated patients). CHIP interventions are typically performed by selected operators who specialize in complex PCI. This review presents two cases performed in the USA, to discuss the similarities and differences in practice patterns between CHIP operators in Japan and the USA. The first case involves a 58-year-old male presenting with myocardial infarction and cardiogenic shock, and the second case involves a 51-year-old female with a history of coronary artery bypass grafting presenting with a chronic total occlusion and PCI complicated by vessel perforation. The discussion focuses on appropriate patient selection, the role of the heart team approach for decision-making, the use of hemodynamic support devices, and other relevant factors. By comparing practices in Japan and the USA, this review highlights opportunities for knowledge exchange and potential areas for improving patient outcomes.

A Systematic Review of Periprocedural Risk Prediction Scores in Chronic Total Occlusion Percutaneous Coronary Intervention.

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with high incidence of complications. We queried PubMed and the Cochrane Library (last search: October 26, 2022) for CTO PCI-specific periprocedural complication risk scores. We identified 8 CTO PCI-specific risk scores: (1) Angiographic coronary artery perforation (OPEN-CLEAN [Outcomes, Patient Health Status, and Efficiency iN (OPEN) Chronic Total Occlusion (CTO) Hybrid Procedures - CABG, Length (occlusion), EF <50%, Age, CalcificatioN] perforation, c-statistic 0.75): previous coronary artery bypass graft surgery, occlusion length 20 to 60 mm or ≥60 mm, left ventricular ejection fraction (LVEF) <50%, age 50 to 70 years or ≥70 years, heavy calcification. (2) Major adverse cardiovascular events (MACE) (PROGRESS-CTO complication, c-statistic 0.76): age >65 years, lesion length ≥23 mm, retrograde strategy, and (3) MACE (PROGRESS-CTO MACE, c-statistic 0.74): age ≥65 years, female gender, moderate/severe calcification, blunt/no stump, anterograde dissection and re-entry (ADR) or retrograde strategy. (4) All-cause mortality (PROGRESS-CTO mortality, c-statistic 0.80): age ≥65, moderate/severe calcification, LVEF ≤45%, ADR or retrograde strategy. (5) Perforation requiring pericardiocentesis (PROGRESS-CTO pericardiocentesis, c-statistic 0.78): age ≥65 years, moderate/severe calcification, female gender, ADR or retrograde strategy. (6) Acute myocardial infarction (PROGRESS-CTO acute myocardial infarction, c-statistic 0.72): previous coronary artery bypass graft surgery, atrial fibrillation, blunt/no stump. (7) Perforation requiring any treatment (PROGRESS-CTO perforation, c-statistic 0.74): age ≥65 years, moderate/severe calcification, blunt/no stump, ADR, or retrograde strategy. (8) Contrast-induced acute kidney injury (c-statistic 0.84): age ≥75, LVEF <40%, serum creatinine >1.5 mg/100 ml, serum albumin ≤30, 3040 g/L. There are 8 CTO PCI periprocedural risk scores that may facilitate risk assessment and procedural planning in patients who underwent CTO PCI.

Techniques to Overcome the Pushability of Robotic-Assisted PCI.

Robotic-assisted percutaneous coronary intervention (PCI) was developed with a safety system that limits pushability as compared to manual PCI, thus preventing inadvertent deep delivery of the device and avoiding complications. This safety feature may limit robotic completion when performing intervention to more complex lesions that may require device delivery through calcified or previously stented lesions. In this article, we report three cases that highlight techniques to overcome this limited pushability, resulting in successful robotic completion of the procedures.

Implementation of Robotic-Assisted Percutaneous Coronary Intervention Into a High-Risk PCI Program.

BACKGROUND: How to implement robotic-assisted PCI safely and when to escalate to more complex cases has not been previously described. We sought to evaluate clinical outcomes in patients undergoing robotic-assisted PCI in the first year of a newly established robotic-assisted PCI program. METHODS: All patients who underwent robotic-assisted PCI in the first 12 months at a single academic center were included in the study. Lesion complexity was characterized as "PRECISE-like", "CORA-PCI-like", or "CORA-PCI excluded" based on established criteria. The primary outcome was clinical success, defined as <30% residual stenosis after stenting with a final TIMI flow grade 2-3 and no procedural complications. Secondary outcomes included robotic success, defined as clinical success with robotic completion, unintentional manual conversion rate, procedure time, and procedural complications. RESULTS: Of the 57 consecutive lesions treated, 12 (22.6%) had a PRECISE-like lesion complexity while 32 (56.1%) had a CORA- PCI-like, and 13 (22.8%) a CORA-PCI excluded lesion complexity. There was no significant difference in clinical success (100.0% vs. 96.7% vs. 100.0%, p = 1.00) among the groups but robotic success was numerically lower as complexity increased (100.0% vs. 80.0% vs. 72.7%, p = 0.15), with an increased frequency of manual conversion. There was no significant difference in procedural complication rates among the groups. The robotic completion rate improved during the study period. CONCLUSION: Robotic-assisted PCI, can be safely implemented in a moderate-sized academic center, with a rapid escalation in patient and lesion complexity.

Totally Robotic Three-Vessel Percutaneous Coronary Intervention With Total Occlusion Using Robotic Automation.

Robotic-assisted percutaneous coronary intervention (PCI) has emerged as an alternative to manual PCI to mitigate the risk of occupational hazards for operators, and to increase precision of device placement. Previous studies have reported the safety and efficacy of robotic-assisted PCI in simpler lesions, and recently the safety and efficacy of robotic-assisted chronic total occlusion PCI have been reported. Herein, we report two cases with three-vessel disease, including total occlusions, successfully treated robotically utilizing newer guidewire and device automation.

Perforation Mechanisms, Risk Stratification, and Management in the Post-Coronary Artery Bypass Grafting Patient.

Coronary perforations during chronic total occlusion percutaneous coronary intervention (CTO PCI) is a most frequent major complication and the incidence is significantly higher compared with non-CTO PCI. Patients with prior history of coronary bypass have more major adverse events when perforation occurs compared with patients without prior bypass surgery. In this article, the authors discuss the unique challenges in identification and timely treatment of perforations in patients with prior bypass surgery.

Outcomes of retrograde chronic total occlusion percutaneous coronary intervention: A report from the OPEN-CTO registry.

OBJECTIVES: We sought to assess in-hospital and long-term outcomes of retrograde compared with antegrade-only percutaneous coronary intervention for chronic total occlusion (CTO PCI). BACKGROUND: Procedural and clinical outcomes following retrograde compared with antegrade-only CTO PCI remain unknown. METHODS: Using the core-lab adjudicated OPEN-CTO registry, we compared the outcomes of retrograde to antegrade-only CTO PCI. Primary endpoints included were in-hospital major adverse cardiac and cerebrovascular events (MACCE) (all-cause death, stroke, myocardial infarction [MI], emergency cardiac surgery, or clinically significant perforation) and MACCE at 1-year (all-cause death, MI, stroke, target lesion revascularization, or target vessel reocclusion). RESULTS: Among 885 single CTO procedures from the OPEN-CTO registry, 454 were retrograde and 431 were antegrade-only. Lesion complexity was higher (J-CTO score: 2.7 vs. 1.9; p < .001) and technical success lower (82.4 vs. 94.2%; p < .001) in retrograde compared with antegrade-only procedures. All-cause death was higher in the retrograde group in-hospital (2 vs. 0%; p = .003), but not at 1-year (4.9 vs. 3.3%; p = .29). Compared with antegrade-only procedures, in-hospital MACCE rates (composite of all-cause death, stroke, MI, emergency cardiac surgery, and clinically significant perforation) were higher in the retrograde group (10.8 vs. 3.3%; p < .001) and at 1-year (19.5 vs. 13.9%; p = .03). In sensitivity analyses landmarked at discharge, there was no difference in MACCE rates at 1 year following retrograde versus antegrade-only CTO PCI. Improvements in Seattle Angina Questionnaire Quality of Life scores at 1-year were similar between the retrograde and antegrade-only groups (29.9 vs 30.4; p = .58). CONCLUSIONS: In the OPEN-CTO registry, retrograde CTO procedures were associated with higher rates of in-hospital MACCE compared with antegrade-only; however, post-discharge outcomes, including quality of life improvements, were similar between technical modalities.

Impact of body mass index on outcome and health status after chronic total occlusion percutaneous coronary intervention: Insights from the OPEN-CTO study.

BACKGROUND: The effect of body mass index (BMI) on the procedural outcomes and health status (HS) change after chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is largely unknown. METHODS: Thousand consecutive patients enrolled in a 12-center prospective CTO PCI study (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion Hybrid Procedures [OPEN-CTO]) were categorized into three groups by baseline BMI (obese ≥30, overweight 25-30, and normal 18.5-25), after excluding seven patients with BMI <18.5. Baseline and follow-up HS at 1 year were quantified using the Seattle Angina Questionnaire, Rose Dyspnea Score, and Personal Health Questionnaire-8 (PHQ-8). Hierarchical, multivariable logistic, and repeated measures linear regression models were used to assess procedural success, major adverse cardiovascular and cerebrovascular events (MACCE), and HS outcomes, as appropriate. RESULTS: The obese and overweight were 47.6% and 37.4%, respectively. While procedure time and contrast dose were similar among the groups, total radiation dose (mGy) was higher with increased BMI (3,019 ± 2,027, 2,267 ± 1,714, 1,642 ± 1,223, p < .01). Procedural success rates, as well as MACCE rates, were similar among the three groups (obese 83.1%, overweight 79.8%, normal 81.9%, p = .47 and 5.1, 8.4, and 8.7%, p = .11). These rates remained similar after adjustment for baseline characteristics. The HS improvement from baseline to 12 months after adjustment was similar in obese and overweight patients compared to normal weight patients. CONCLUSIONS: CTO PCI in obese and overweight patients can be performed with similar success and complication rates. Obese and overweight patients derive similar HS benefit from CTO PCI compared to normal weight patients.

Residual SYNTAX Score After Advanced Hybrid Robotic Totally Endoscopic Coronary Revascularization.

BACKGROUND: Advanced hybrid coronary revascularization (AHCR) combines multivessel robotic beating-heart totally endoscopic coronary artery bypass with percutaneous coronary intervention. The aim of this study was to quantify the remaining coronary artery disease after AHCR using the residual Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) study score. METHODS: From July 2013 to September 2017, patients who had postoperative angiography after AHCR were reviewed. The cohort was divided into two groups: group 1, complete or near-complete revascularization (residual SYNTAX score of 8 or less); and group 2, incomplete revascularization (residual SYNTAX score more than 8). RESULTS: Among 308 patients who underwent totally endoscopic coronary artery bypass, 57 patients received AHCR and 51 patients had postoperative angiograms that allowed calculations of residual SYNTAX score. Mean baseline and residual SYNTAX scores were 33.1 ± 11.0 and 4.6 ± 6.5 respectively. There were 44 patients (86%) in the complete or near-complete revascularization group, and of these, 16 patients (31%) achieved true complete revascularization (residual SYNTAX score = 0). Overall graft patency was 96.2%. There were no differences in preoperative characteristics or postoperative outcomes between the two groups. Two-year survival rate and freedom from major adverse cardiac events (death, myocardial infarction, and repeat revascularization) were significantly higher in the complete or near-complete revascularization group compared with the incomplete revascularization group. CONCLUSIONS: Advanced hybrid coronary revascularization at our institution was safely performed with excellent early outcomes, graft patency, and high achievement of complete or near-complete revascularization. Residual SYNTAX score might predict long-term ischemic events after hybrid coronary revascularization.

Initial report of safety and procedure duration of robotic-assisted chronic total occlusion coronary intervention.

BACKGROUND: No previous reports have examined the impact of robotic-assisted (RA) chronic total occlusion (CTO) PCI on procedural duration or safety compared to totally manual CTO PCI. METHODS: Among 95 patients who underwent successful PCI of a single CTO lesion at two centers, 49 (52%) were performed RA and were performed 46 (48%) totally manually. Cockpit time was the time the primary operator entered to robotic cockpit until the procedure was complete. "Theoretical" cockpit time in the control group was time the primary operator would have entered the cockpit after lesion crossing until the procedure was complete. Major adverse events (MAEs) were the composite of death, myocardial infarction, clinical perforation, significant vessel dissection, arrhythmia, acute thrombosis, and stroke. RESULTS: The lesion characteristics, procedural time, and contrast dose were similar. All procedures except for one (2%) selected for robotic completion after lesion crossing were completed successfully. The frequency of MAE was similar between groups and there were no in-hospital deaths. The cockpit time was 8 min longer in RA CTO PCI than the theoretical cockpit time in totally manual CTO PCI (40.6 ± 12.7 vs. 32.1 ± 17.8, p < .01). CONCLUSION: RA CTO PCI was not associated with excess adverse events compared with totally manual CTO PCI and resulted in an average 41 min cockpit time equaling to 48% of procedure time without radiation exposure or requirement for the primary operator to wear a lead apron. Understanding the relationship between cockpit time and reductions in radiation exposure and lead apron-related orthopedic complications for operators requires future study.

Patient Characteristics Associated With Antianginal Medication Escalation and De-Escalation Following Chronic Total Occlusion Percutaneous Coronary Intervention.

Background Prior research has shown that providers may infrequently adjust antianginal medications (AAMs) following chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Patient characteristics associated with AAM titration and the variation in postprocedure AAM management after CTO PCI across hospitals have not been reported. We sought to determine the frequency and potential correlates of AAM escalation and de-escalation after CTO PCI. Methods and Results Using the 12-center OPEN CTO registry (Outcomes, Patient Health Status, and Efficiency iN Chronic Total Occlusion Hybrid Procedures), we assessed AAM use at baseline and 6 months after CTO PCI. Escalation was defined as any addition of a new class of AAM or dose increase, whereas de-escalation was defined as a reduction in the number of AAMs or dose reduction. Angina was assessed 6 months after the index CTO PCI attempt using the Seattle Angina Questionnaire Angina Frequency domain. Potential correlates of AAM escalation (vs no change) or de-escalation (vs no change) were evaluated using multivariable modified Poisson regression models. Adjusted variation across sites was evaluated using median rate ratios. AAMs were escalated in 158 (17.5%), de-escalated in 351 (39.0%), and were unchanged at 6-month follow-up in 392 (43.5%). Patient characteristics associated with escalation included lung disease, ongoing angina, and periprocedural major adverse cardiac and cerebral events (periprocedural myocardial infarction, stroke, death, emergent cardiac surgery, or clinically significant perforation), whereas de-escalation was more frequent among patients taking more AAMs, those treated with complete revascularization, and after treatment of non-CTO lesions at the time of the index procedure. There was minimal variation in either escalation (median rate ratio, 1.11; P=0.36) or de-escalation (median rate ratio, 1.10; P=0.20) compared to no change of AAMs across sites. Conclusions Escalation or de-escalation of AAMs was less common than continuation following CTO PCI, with little variation across sites. Further research is needed to identify patients who may benefit from AAM titration after CTO PCI and develop strategies to adjust these medications in follow-up. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT02026466.

De-escalation of antianginal medications after successful chronic total occlusion percutaneous coronary intervention: Frequency and relationship with health status.

BACKGROUND: Successful chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can markedly reduce angina symptom burden, but many patients often remain on multiple antianginal medications (AAMs) after the procedure. It is unclear when, or if, AAMs can be de-escalated to prevent adverse effects or limit polypharmacy. We examined the association of de-escalation of AAMs after CTO PCI with long-term health status. METHODS: In a 12-center registry of consecutive CTO PCI patients, health status was assessed at 6 months after successful CTO PCI with the Seattle Angina Questionnaire and the Rose Dyspnea Scale. Among patients with technical CTO PCI success, we examined the association of AAM de-escalation with 6-month health status using multivariable models adjusting for revascularization completeness and predicted risk of post-PCI angina (using a validated risk model). We also examined predictors and variability of AAMs de-escalation. RESULTS: Of 669 patients with technical success of CTO PCI, AAMs were de-escalated in 276 (35.9%) patients at 1 month. Patients with AAM de-escalation reported similar angina and dyspnea rates at 6 months compared with those whose AAMs were reduced (any angina: 22.5% vs 20%, P = .43; any dyspnea: 51.8% vs 50.1%, P = .40). In a multivariable model adjusting for complete revascularization and predicted risk of post-PCI angina, de-escalation of AAMs at 1 month was not associated with an increased risk of angina, dyspnea, or worse health status at 6 months. CONCLUSIONS: Among patients with successful CTO PCI, de-escalation of AAMs occurred in about one-third of patients at 1 month and was not associated with worse long-term health status.

Advanced Hybrid Complete Revascularization with TECAB and Impella-Assisted PCI of CTO.

An 80-year-old man was referred for multi-vessel coronary artery disease with baseline SYNTAX score of 45 after evaluation for persistent stable angina. He underwent complete hybrid revascularization combining total endoscopic coronary artery bypass utilizing bilateral internal mammary arteries (IMA) with sequential LIMA to left anterior descending artery and diagonal arteries, and RIMA to obtuse marginal after Impella-assisted chronic total occlusion percutaneous coronary intervention of the right coronary artery. This represents a successful case of advanced hybrid coronary revascularization.

First report of a hybrid robotic beating-heart quadruple totally endoscopic coronary artery bypass: toward complete revascularization.

To the best of our knowledge, this is the first report describing robotic beating-heart quadruple all-arterial totally endoscopic coronary artery bypass combined with percutaneous coronary intervention attempting complete revascularization (residual SYNTAX score 0). A 66-year-old male with severe triple-vessel coronary artery disease underwent percutaneous coronary intervention for a sub-total occlusion of the right coronary artery as the initial component of a hybrid revascularization strategy. Subsequently, the left coronary system was revascularized via robotic beating-heart totally endoscopic coronary artery bypass with bilateral internal mammary artery grafts.

Hybrid coronary revascularization: Midterm outcomes of robotic multivessel bypass and percutaneous interventions.

OBJECTIVE: The purpose of this study was to investigate the outcomes of patients undergoing advanced hybrid coronary revascularization, defined as robotic beating-heart multivessel totally endoscopic coronary artery bypass combined with percutaneous coronary intervention. METHODS: This is a retrospective study. Among 308 consecutive patients who underwent totally endoscopic coronary artery bypass, 57 who underwent advanced hybrid coronary revascularization (mean age, 65.6 years) from July 2013 to September 2017 were included. Midterm survival and freedom from major adverse cardiac events, including death, myocardial infarction, and repeat revascularization, were analyzed. RESULTS: Multivessel totally endoscopic coronary artery bypass was successfully performed without conversion to thoracotomy. Bilateral internal thoracic artery grafting was used in 50 patients (87.7%). The mean operative time was 318.4 ± 51.0 minutes. The mean length of hospital stay was 3.0 ± 1.3 days. There was no 30-day mortality. Percutaneous coronary intervention was planned after totally endoscopic coronary artery bypass in 51 patients (89.4%). The target lesions were the right coronary artery only in 38 patients, the left circumflex artery only in 4 patients, and multiple lesions in 13 patients. Eventually, 2 patients did not receive percutaneous coronary intervention. Percutaneous coronary intervention attempt was unsuccessful in 8 lesions. Patency of the left/right internal thoracic artery was 95.2% (60/63) and 95.7% (45/47), respectively. Graft patency was 95.2% (40/42) in the left circumflex artery and 93.3% (14/15) in the diagonal branch. Three-year survival was 92.8%, and 3-year freedom from major adverse cardiac events was 80.2%. CONCLUSIONS: Advanced hybrid coronary revascularization is a safe and less-invasive approach with short hospital stay and good midterm outcomes.

Broken arrow: Successful retrieval of a dislodged coronary orbital atherectomy microtip.

A 68-year-old female with a history of coronary artery disease and prior bypass surgery presented for staged percutaneous coronary intervention (PCI) to a calcified and angulated ostial left circumflex (LCX) artery lesion after PCI of the anastomosis of the left internal mammary artery - to left anterior descending artery. Orbital atherectomy of the LCX was performed at a speed of 80,000 RPM with multiple passes, and was complicated by device microtip dislodgement and entrapment within the vessel. After advancing a "buddy" wire beyond the microtip, a tapered microcatheter was advanced over the ViperWire and into the edge of the broken microtip and torqued into the microtip with forward pressure using the 0.014 in ViperWire tip as a "backstop." The guidewire, microcatheter, and microtip were then successfully removed as a unit and the intervention with stent placement was completed over the "buddy" wire. Scanning electron microscopy of the shaft revealed evidence of cyclic fatigue, indicating that the fracture occurred while spinning. The fracture when performing atherectomy in a model coronary artery with a radius of approximately 6 mm. This represents a first case of microtip dislodgement and entrapment during the use of a coronary orbital atherctomy device.short.

Syncope from radiation-induced baroreceptor failure.

Orthostatic hypotension has a vast differential that has been previously described throughout the literature. However, baroreceptor failure as a sequela of head and neck radiation is not often recognised as an important cause of dramatic haemodynamic variability. As a result, individuals suffering from baroreceptor failure likely have been undertreated. Herein, we report a case of a patient with a history of radiation to the neck for squamous cell carcinoma of the tongue and resultant baroreceptor failure resulting in syncope.

Evaluation of Variable Thin-Cap Fibroatheroma Definitions and Association of Virtual Histology-Intravascular Ultrasound Findings With Cavity Rupture Size.

The accepted definition of virtual histology intravascular ultrasound (IVUS-VH) thin-cap fibroatheroma (TCFA) is only a modest predictor of plaque rupture (PR). We sought to determine the relation between IVUS-VH findings and culprit lesions with PR using computational analysis. A total of 80 culprit lesions from 80 patients with stable angina (n = 37), unstable angina (n = 20), and myocardial infarction (n = 23) were divided into those with (n = 15) and without PR (n = 65). By use of automated computational analysis, the standard IVUS-VH TCFA criterion and 124 additional criteria were compared. The standard TCFA definition demonstrated modest ability to discriminate lesions with and without PR (sensitivity 87%, specificity 37%, PPV 0.24, and NPV 0.92). Of 124 additional IVUS-VH TCFA definitions, only 2 improved the discriminative ability even modestly. However, a positive correlation was demonstrated between cavity size and necrotic core percentage (r = 0.78, p <0.01) and a negative correlation with percentage of fibrous tissue (r = -0.81, p <0.01). In conclusion, IVUS-VH criteria were only modestly associated with PR, without significant improvement by varying IVUS-VH TCFA features, but IVUS-VH features of ruptured plaques were strongly correlated with cavity size.

Late-Onset Screw Migration into Iliac Vessels 21 years after Hip Arthrodesis.

Iatrogenic injuries to the vascular system are a rare but serious complication of hip surgery. We report a case of an 83-year-old man who presented with intrapelvic migration of a screw into the space between the external iliac artery and vein 21 years after hip arthrodesis. The patient was treated with laparotomy, and the damaged artery was excised and sutured. This is the first case of a late vascular complication secondary to screw migration after hip arthrodesis.