Cost effectiveness analysis of drug coated balloon only angioplasty for de novo coronary artery disease.

AIMS: We aimed to perform a cost analysis of drug coated balloon (DCB)-only angioplasty versus drug eluting stent (DES), for de novo disease of all vessel sizes and all clinical indications. BACKGROUND: DCB angioplasty is an emergent technology for the treatment of coronary artery disease. There is lack of data regarding the cost-effectiveness of DCB-only angioplasty for treatment of de novo coronary artery disease as compared with second generation DES. METHODS: We compared total costs of patients treated with DCB or DES for first presentation of ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, or stable angina due to de novo disease between January 1, 2018 and November 15, 2019. We defined total cost as the sum of (1) procedural devices-cost, (2) procedural staff-cost, (3) post-percutaneous coronary intervention hospital stay cost, and (4) antiplatelet regime cost. A cost minimization analysis was performed to compare the costs of DCB and DES. RESULTS: We present 1952 all-comer, consecutive patients; 902 (1064 lesions) treated with DCB and 1050 (1236 lesions) treated with DES for de novo coronary artery disease. The cost per patient was estimated to be £9.02 more expensive in the DCB group (£3153.00 vs. £3143.98). However, the cost per lesion treated was calculated to be £15.51 cheaper in the DCB group (£3007.56 vs. £3023.07). The results were consistent irrespective of duration of long-term antiplatelet medications. CONCLUSION: We have compared the cost-effectiveness of DCB-only angioplasty to DES-angioplasty and showed that the per patient and per lesion results were not different and hence cost should not be implicated in the decision to choose DCB or DES.

Assessment of Post-Dilatation Strategies for Optimal Stent Expansion in Calcified Coronary Lesions: Ex Vivo Analysis With Optical Coherence Tomography.

INTRODUCTION: Interventional cardiologists make adjustments in the presence of coronary calcifications known to limit stent expansion, but proper balloon sizing, plaque-modification approaches, and high-pressure regimens are not well established. Intravascular optical coherence tomography (IVOCT) provides high-resolution images of coronary tissues, including detailed imaging of calcifications, and accurate measurements of stent deployment, providing a means for detailed study of stent deployment. OBJECTIVE: Evaluate stent expansion in an ex vivo model of calcified coronary arteries as a function of balloon size and high-pressure, post-dilatation strategies. METHODS: We conducted experiments on cadaver hearts with calcified coronary lesions. We assessed stent expansion as a function of size and pressure of non-compliant (NC) balloons (i.e., nominal, 0.5, 1.0, and 1.5 mm balloons at 10, 20 and 30 atm). IVOCT images were acquired pre-stent, post-stent, and at all post-dilatations. Stent expansion was calculated using minimum expansion index (MEI). RESULTS: We analyzed 134 IVOCT pullbacks from ten ex-vivo experiments. The mean distal and proximal reference lumen diameters were 2.2 ± 0.5 mm and 2.5 ± 0.7 mm, respectively, 80% of times using a 3.0 mm diameter stent. Overall, based on stent sizing, a good expansion (MEI ≥ 80%) was reached using the 1:1 NC balloon at 20 atm, and expansion > 100% was reached using the 1:1 NC balloon at 30 atm. In the subgroup analysis, comparing low-calcified and high-calcified lesions, good expansion (MEI ≥ 80%) was reached using the 1:1 NC balloon at nominal pressure (10 atm) versus using 1:1 NC balloon at 30 atm, respectively. Significant vessel rupture was identified in all the vessels mainly upon post-dilatation with larger balloons, and 60% of the experiments (6 vessels, 3 in each calcium subgroup) presented rupture with the +1.0 mm NC balloon at 20 atm. CONCLUSION: When treating calcified lesions, good stent expansion was reached using smaller balloons at higher pressures without coronary injuries, whereas bigger balloons yielded unpredictable expansion even at lower pressures and demonstrated potential harmful damages to the vessels. As these findings could help physicians with appropriate planning of stent post-dilatation for calcified lesions, it will be important to clinically evaluate the recommended protocol.

Treatment of In-Stent Restenosis by Excimer Laser Coronary Atherectomy and Drug-Coated Balloon: Serial Assessment with Optical Coherence Tomography.

OBJECTIVES: We aimed to compare the results of neointimal modification before drug-coated balloon (DCB) treatment with excimer laser coronary atherectomy (ELCA) plus scoring balloon predilation versus scoring balloon alone in patients presenting with in-stent restenosis (ISR). BACKGROUND: Treatment of ISR with ELCA typically results in superior acute gain by neointima debulking. However, the efficacy of combination therapy of ELCA and DCB remains unknown. METHODS: A total of 42 patients (44 ISR lesions) undergoing DCB treatment with ELCA plus scoring balloon (ELCA group, n = 18) or scoring balloon alone (non-ELCA group, n = 24) were evaluated via serial assessment by optical coherence tomography (OCT) performed before, after intervention, and at 6 months. RESULTS: Although there was significantly greater frequency of diffuse restenosis and percent diameter stenosis (%DS) after intervention in the ELCA group, comparable result was shown in %DS, late lumen loss, and binary angiographic restenosis at follow-up. On OCT analysis, a decreased tendency in the minimum lumen area and a significant decrease in the minimum stent area were observed in the ELCA group between 6-month follow-up and after intervention (-0.89 ± 1.36 mm2 vs. -0.09 ± 1.25 mm2, p = 0.05, -0.49 ± 1.48 mm2 vs. 0.28 ± 0.78 mm2, p = 0.03, respectively). The changes in the neointimal area were similar between the groups, and target lesion revascularization showed comparable rates at 1 year (11.1% vs. 11.4%, p = 0.85). CONCLUSIONS: Despite greater %DS after intervention, ELCA before DCB had possible benefit for late angiographic and clinical outcome.

Clinical Outcomes and Cost-Effectiveness Analysis of FFR Compared with Angiography in Multivessel Disease Patient / Impacto Clínico e Custo-Efetividade da FFR em Comparação à Angiografia em Pacientes com Doenças Multiarteriais Submetidos à ICP

Abstract Background: In multivessel disease patients with moderate stenosis, fractional flow reserve (FFR) allows the analysis of the lesions and guides treatment, and could contribute to the cost-effectiveness (CE) of non-pharmacological stents (NPS). Objectives: To evaluate CE and clinical impact of FFR-guided versus angiography-guided angioplasty (ANGIO) in multivessel patients using NPS. Methods: Multivessel disease patients were prospectively randomized to FFR or ANGIO groups during a 5 year-period and followed for < 12 months. Outcomes measures were major adverse cardiac events (MACE), restenosis and CE. Results: We studied 69 patients, 47 (68.1%) men, aged 62.0 ± 9.0 years, 34 (49.2%) in FFR group and 53 (50.7%) in ANGIO group, with stable angina or acute coronary syndrome. In FFR, there were 26 patients with biarterial disease (76.5%) and 8 (23.5%) with triarterial disease, and in ANGIO, 24 (68.6%) with biarterial and 11 (31.4%) with triarterial disease. Twelve MACEs were observed - 3 deaths: 2 (5.8%) in FFR and 1 (2.8%) in ANGIO, 9 (13.0%) angina: 4(11.7%) in FFR and 5(14.2%) in ANGIO, 6 restenosis: 2(5.8%) in FFR and 4 (11.4%) in ANGIO. Angiography detected 87(53.0%) lesions in FFR, 39(23.7%) with PCI and 48(29.3%) with medical treatment; and 77 (47.0%) lesions in ANGIO, all treated with angioplasty. Thirty-nine (33.3%) stents were registered in FFR (0.45 ± 0.50 stents/lesion) and 78 (1.05 ± 0.22 stents/lesion) in ANGIO (p = 0.0001), 51.4% greater in ANGIO than FFR. CE analysis revealed a cost of BRL 5,045.97 BRL 5,430.60 in ANGIO and FFR, respectively. The difference of effectiveness was of 1.82%. Conclusion: FFR reduced the number of lesions treated and stents, and the need for target-lesion revascularization, with a CE comparable with that of angiography.

Resumo Fundamentos: Em pacientes multiarteriais e lesões moderadas, a reserva de fluxo fracionada (FFR) avalia cada lesão e direciona o tratamento, podendo ser útil no custo-efetividade (CE) de implante de stents não farmacológicos (SNF). Objetivos: Avaliar CE e impacto clínico da angioplastia + FFR versus angioplastia + angiografia (ANGIO), em multiarteriais, utilizando SNF. Métodos: pacientes com doença multiarteriais foram randomizados prospectivamente durante ±5 anos para FFR ou ANGIO, e acompanhados por até 12 meses. Foram avaliados eventos cardíacos maiores (ECAM), reestenose e CE. Resultados: foram incluídos 69 pacientes, 47(68,1%) homens, 34(49,2%) no FFR e 35(50,7%) no ANGIO, idade 62,0 ± 9,0 anos, com angina estável e Síndrome Coronariana Aguda estabilizada. No FFR, havia 26 com doença (76,5%) biarterial e 8 (23,5%) triarterial, e no grupo ANGIO, 24(68,6%) biarteriais e 11(31,4%) triarteriais. Ocorreram 12(17,3%) ECAM - 3(4,3%) óbitos: 2(5,8%) no FFR e 1(2,8%) no ANGIO, 9(13,0%) anginas, 4(11,7%) no FFR e 5(14,2%) no ANGIO, 6 reestenoses: 2(5,8%) no FFR e 4 (11,4%) no ANGIO. Angiografia detectou 87(53,0%) lesões no FFR, 39(23,7%) com ICP e 48(29,3%) com tratamento clínico; e 77(47,0%) lesões no ANGIO, todas submetidas à angioplastia. Quanto aos stents, registrou-se 39(33,3%) (0,45 ± 0,50 stents/lesão) no FFR e 78(66,6%) (1,05 ± 0,22 stents/lesão) no ANGIO (p = 0,0001); ANGIO utilizou 51,4% a mais que o FFR. Análise de CE revelou um custo de R$5045,97 e R$5.430,60 nos grupos ANGIO e FFR, respectivamente. A diferença de efetividade foi 1,82%. Conclusões: FFR diminuiu o número de lesões tratadas e de stents e necessidade de revascularização do vaso-alvo, com CE comparável ao da angiografia.

Assessment of the myocardial area at risk: comparing T2-weighted cardiovascular magnetic resonance imaging with contrast-enhanced cine (CE-SSFP) imaging-a DANAMI3 substudy.

AIMS: Myocardial salvage following treatment for ST-segment elevation myocardial infarction is prognostic for morbidity and mortality. Studies with myocardial salvage as endpoint rely on valid assessment of the myocardial area at risk (AAR). T2-weighted cardiovascular magnetic resonance (CMR) imaging is the preferred method to assess the AAR. However, T2-weighted imaging can be of poor image quality and uninterpretable. Contrast-enhanced (CE) cine imaging can also show AAR and our aim was to investigate if CE-cine can replace T2-weighted imaging. Cine imaging is part of a standard CMR-protocol and implementing CE-cine imaging for assessment of the AAR would mean shorter investigation time. METHODS AND RESULTS: As a DANAMI-3 substudy, we performed successful dual imaging of the AAR in 166 participants using both T2-weighted short tau inversion recovery (T2-STIR) and CE-cine imaging. T2-STIR imaging was non-diagnostic in nine and CE-cine in one scan during the period. CE-cine measured 4.7% of left ventricle (LV) [95% confidence interval 3.2-6.2%] smaller AAR compared with T2-STIR images (P < 0.001). Visual analysis of a plot of infarct size vs. AAR showed an overestimation of the AAR when measured with T2-STIR images. There was no difference in AAR with CE-cine in an interobserver analysis of 46 scans [1.2 g (standard deviation 9.5), P = 0.42]. CONCLUSIONS: CE-cine imaging shows good internal consistency in assessment of the AAR. A visual inspection reveals possible overestimation of AAR with T2-STIR images. There is good interobserver agreement in the analysis of CE-cine imaging. CE-cine can replace T2-STIR imaging resulting in a more valid assessment of the myocardial AAR.

Clinical Outcomes and Cost-Effectiveness Analysis of FFR Compared with Angiography in Multivessel Disease Patient.

BACKGROUND: In multivessel disease patients with moderate stenosis, fractional flow reserve (FFR) allows the analysis of the lesions and guides treatment, and could contribute to the cost-effectiveness (CE) of non-pharmacological stents (NPS). OBJECTIVES: To evaluate CE and clinical impact of FFR-guided versus angiography-guided angioplasty (ANGIO) in multivessel patients using NPS. METHODS: Multivessel disease patients were prospectively randomized to FFR or ANGIO groups during a 5 year-period and followed for < 12 months. Outcomes measures were major adverse cardiac events (MACE), restenosis and CE. RESULTS: We studied 69 patients, 47 (68.1%) men, aged 62.0 ± 9.0 years, 34 (49.2%) in FFR group and 53 (50.7%) in ANGIO group, with stable angina or acute coronary syndrome. In FFR, there were 26 patients with biarterial disease (76.5%) and 8 (23.5%) with triarterial disease, and in ANGIO, 24 (68.6%) with biarterial and 11 (31.4%) with triarterial disease. Twelve MACEs were observed - 3 deaths: 2 (5.8%) in FFR and 1 (2.8%) in ANGIO, 9 (13.0%) angina: 4(11.7%) in FFR and 5(14.2%) in ANGIO, 6 restenosis: 2(5.8%) in FFR and 4 (11.4%) in ANGIO. Angiography detected 87(53.0%) lesions in FFR, 39(23.7%) with PCI and 48(29.3%) with medical treatment; and 77 (47.0%) lesions in ANGIO, all treated with angioplasty. Thirty-nine (33.3%) stents were registered in FFR (0.45 ± 0.50 stents/lesion) and 78 (1.05 ± 0.22 stents/lesion) in ANGIO (p = 0.0001), 51.4% greater in ANGIO than FFR. CE analysis revealed a cost of BRL 5,045.97 BRL 5,430.60 in ANGIO and FFR, respectively. The difference of effectiveness was of 1.82%. CONCLUSION: FFR reduced the number of lesions treated and stents, and the need for target-lesion revascularization, with a CE comparable with that of angiography.

Assessment of side branch patency using a jailed semi-inflated balloon technique with coronary bifurcation lesions.

OBJECTIVE: Many interventional cardiologists are concerned about the risk of side branch (SB) loss during main vessel (MV) stenting in complex bifurcation lesions. Therefore, novel techniques are required to reduce the risk of SB occlusion. The jailed semi-inflated balloon technique (JSBT) is one of these techniques. This article is a description of clinical experience with SB patency assessment using the JSBT. METHODS: A total of 64 patients with 82 distinct coronary bifurcation lesions underwent percutaneous coronary intervention (PCI) via JSBT at this institution. In the majority of patients, the SB balloon was inflated with a greater pressure (4.8±2.0 atm) than in the standard JSBT. Procedural and immediate clinical outcomes were reviewed via baseline and post-procedural quantitative coronary angiography analysis. RESULTS: The majority of the patients had acute coronary syndrome (60.9%) and almost one-third of the patients were Medina class 1.1.1. (32.8%). A jailed-balloon or wire was not entrapped during any PCI. SB ostial dissection was seen in only 2 patients. The minimal lumen diameter was improved in the MV and SB following PCI. There were no adverse cardiac events during in-hospital stay or at 1-month follow-up. CONCLUSION: JSBT provides maximum SB protection with bifurcation lesions and requires less time than a complex technique. There was no significant SB occlusion risk even though the SB balloon was inflated with a slightly higher pressure. The immediate clinical outcomes and procedural success of this study may encourage interventional cardiologists to use this technique safely with reliable preservation of SB patency.

Striving to meet targets for ideal treatment of acute myocardial infarction in Brazil: Data from the Midwest region.

OBJECTIVES: To evaluate the systematic chain of care for patients with acute ST-elevation myocardial infarction (STEMI) referred for primary angioplasty in a capital city in Midwestern Brazil. BACKGROUND: Acute myocardial infarction is recognized as an important cause of morbidity and mortality and as a public health problem worldwide. Early specialized care is crucial for a good prognosis. METHODS: All STEMI patients receiving care through the public health system at two tertiary care centers from March 2012 to June 2014 were retrospectively analyzed. Symptom onset-to-balloon time and door-to-balloon time were analyzed and compared with current guideline recommendations. RESULTS: A total of 835 patients were included. Median symptom onset-to-balloon time was 32 h. A total of 783 (94%) patients had had symptoms for more than 12 h and 507 (61%) for more than 24 h. Only 51 (6%) patients arrived within 12 h of symptom onset and were treated with primary angioplasty. Among these patients, median door-to-balloon time was 37 min, in accordance with guideline recommendations. CONCLUSION: Treatment of STEMI through the public health system in a capital city in Midwestern Brazil falls short of the recommended guidelines due to failure in the initial links of the chain of care. This potentially reversible failure has an important impact on patient outcomes and on health care burden.

Cost assessment of treatment of acute myocardial infarction and angiographically visible coronary thrombus.

AIM: Study was aimed to assess the real-world costs of manual thrombectomy (MT) in selected ST-segment elevation myocardial infarction patients with intracoronary thrombus (IT). METHODS: Study group (IT+) comprised 51 patients with MT applied and control group (IT-) comprised 56 patients without IT who underwent angioplasty alone. Costs comprised hospital care and cost of disposable materials used during primary angioplasty. RESULTS: Complex management of patients with IT is more expensive, though allows to achieve clinical outcomes comparable to low-risk ST-segment elevation myocardial infarction patients without IT. CONCLUSION: A complex pharmaco-interventional strategy, with glycoprotein IIB/IIIA inhibitor and MT, though more expensive, may prove cost-effective.

Avaliação Temporal dos Procedimentos de Revascularização Coronariana pelo Sistema Único de Saúde (SUS) no Brasil: Um Panorama de 20 Anos / Temporal Evaluation of Coronary Revascularization Procedures Performed through the Unified Health System (SUS) in Brazil: a 20-year overview

Fundamento: As taxas de mortalidade relacionadas à doença aterosclerótica coronariana (DAC) vêm reduzindo nas últimas décadas devido, em parte, aos avanços nas técnicas de revascularização. Objetivos: O objetivo deste estudo foi apresentar um visão dos últimos 20 anos do tratamento da DAC pelo Sistema Único de Saúde (SUS) no Brasil. Métodos:Os dados foram obtidos através dos sistemas TABNET e SIGTAP do SUS e através do IBGE. Os procedimentos foram agrupados nas categorias de revascularização percutânea, cirúrgica e percutânea primária. Foram analisados o número de autorizações de internação hospitalar (AIH), duração média de permanência hospitalar, mortalidade hospitalar, valor do repasse total por procedimento e valores médios da AIH e dos serviços profissional e hospitalar. Resultados:Entre 1995 e 2015, houve aumento no número de revascularizações cirúrgicas (de 13.198 a 22.559) e percutâneas (de 10.522 a 66.345). De modo semelhante, o número de angioplastias primárias apresentaram aumento entre 2004 e 2015 (de 1.901 a 8.524). Houve uma queda no tempo médio de permanência hospitalar (de 14,4 a 12,8 dias) e da mortalidade hospitalar (de 7,6% a 5,9%) nas revascularizações cirúrgicas e queda da permanência hospitalar (de 5,3 dias a 3,7 dias) mas manutenção da taxa de mortalidade (2,2%) nas revascularizações percutâneas. Nas angioplastias primárias, o tempo médio de permanência hospitalar variou de 5,3 a 5,6 dias e a taxa de mortalidade variou de 7,94% a 7,43% entre 2004 e 2015, respectivamente. O valor médio do repasse total para as revascularização cirúrgicas variou de R$ 4.327,57 para R$ 12.839,13 e para as revascularizações percutâneas de R$ 2.615,81 a R$ 6.187,87 entre 1995 e 2015, respectivamente. Os valores equivalentes para as angioplastias primárias foram de R$ 5.415,58 em 2004 a R$ 6.581,51 em 2015. Conclusões: O número de procedimentos de revascularização aumentou no Brasil nos últimos 20 anos, juntamente com uma melhora nas taxas de mortalidade e redução no tempo de permanência hospitalar. Observou-se importante defasagem de valores financeiros em relação à inflação acumulada neste período

Introduction: The mortality rates associated with coronary atherosclerotic disease (CAD) have been declining over the past decades driven, in part, by advances in revascularization techniques. Objective: The aim of this study was to provide an overview of the past 20 years in the treatment of CAD delivered by the Brazilian Unified Health Care System (SUS). Methods:The data were obtained from SUS's TABNET and SIGTAP systems and IBGE. The procedures were grouped into the categories percutaneous, surgical, and primary percutaneous revascularizations. The analysis included the number of hospital admission authorizations (AIH), mean length of hospital stay, in-hospital mortality, mean total amount paid by procedure, and mean values paid per AIH and for professional and hospital services. Results: Between 1995 and 2015, there were increases in the number of surgical revascularizations (from 13,198 to 22,559) and percutaneous revascularizations (from 10,522 to 66,345). Similarly, the number of primary angioplasties increased between 2004 and 2015 (from 1,901 to 8,524). There was a decrease in the mean length of hospital stay (from 14.4 to 12.8 days) and hospital mortality (from 7.6% to 5.9%) for surgical revascularizations, and decrease in mean length of hospital stay (from 5.3 days to 3.7 days) but maintenance of the mortality rates (2.2%) for percutaneous revascularizations. In primary angioplasties, the mean length of hospital stay varied from 5.3 to 5.6 days and the mortality rate varied from 7.94% to 7.43% between 2004 and 2015, respectively. The mean total amount paid for surgical revascularization varied from R$ 4,327.57 to $12,839.13 and for percutaneous revascularizations from R$ 2,615.81 to $6,187.87 between 1995 and 2015, respectively. Corresponding values for primary angioplasties were R$ 5,415.58 in 2004 to R$ 6,581.51 in 2015. Conclusions: The number of revascularization procedures increased in Brazil over the past 20 years, with an improvement in mortality rates and decrease in length of hospital stay. There was a substantial lag in economic values relative to the inflation accumulated during the period

The effectiveness of super-selective injection with anchor balloon technique for collateral channel assessment.

The careful assessment of collateral channels is important for a retrograde approach for a chronic total coronary occlusion (CTO). This case report describes a percutaneous coronary intervention for CTO of the distal right coronary artery with good collateral circulation. All visible collateral channels failed by the retrograde approach; however, the procedure was successful using the distal atrial circumflex (AC) channel. Although this distal channel was poorly visualized on standard coronary angiography, it was clearly contrasted retrogradely from the CTO exit using a super-selective injection through the proximal AC channel as the antegrade flow was obstructed by the anchor balloon. This case highlights a unique super-selective injection with anchor balloon technique for collateral channel assessment.

Optical coherence tomography assessment of a complex bifurcation lesion treated with double kissing Crush technique: A case report.

The DEFINITION (Impact of the complexity of bifurcation lesions treated with drug-eluting stents) study has provided a novel classification to evaluate the complexity of coronary bifurcation lesion according to coronary angiography, but angiographic imaging due to its low resolution and inherited limitation may result in an inaccurate adjudication.We used optical coherence tomography (OCT) to further evaluate the coronary characteristics in a patient with "simple" bifurcation lesion which was classified by the DEFINITION criteria. However, a "complex" bifurcation lesion was defined and confirmed according to the OCT results.A double kissing Crush stenting approach was adopted to treat this "complex" case finally. The immediate and long-term angiographic and OCT results were excellent.OCT may be useful imaging modality to classify complexity of coronary bifurcation lesion and subsequently guide its treatment strategy.

Simplifying electrocardiographic assessment in STEMI reperfusion management: Pros and cons.

Current guidelines on STEMI reperfusion management do not incorporate further electrocardiographic details over the presence of significant ST elevation. Fibrinolysis is considered an alternative therapy to primary PCI if there is a long PCI-related delay, but the 2 therapies should not be combined. Meanwhile, reperfusion for ischemic stroke has evolved on mechanistic understanding - reperfusion benefit being greatest in the patient with small "core" infarct and large ischemic "penumbra". Fibrinolysis is not regarded as an alternative to mechanical thrombectomy, and the 2 therapies can be combined. In this article describing how reperfusion regimes have evolved along different paths for STEMI and for ischemic stroke, a new concept is made that in STEMI infarct lead Q waves can be the counterpart of the "core" and ST elevation the "penumbra". Suggestions to modify STEMI treatment algorithms are made, exploring further the relative role of (pre-hospital) fibrinolysis versus PCI particularly in younger patients presenting at the onset of their STEMI (no Q waves). In contrast, some patients particularly the older ones with more evolved STEMI (large Q waves present) may be much more suited for PCI despite expecting a long delay. The article finishes by describing potential future alterations in the method of reperfusion. Despite primary PCI being the well-established therapy, there are rooms for further research to optimize STEMI outcomes.

Prevalence, indications and management of balloon uncrossable chronic total occlusions: Insights from a contemporary multicenter US registry.

BACKGROUND: Balloon uncrossable lesions can be challenging to treat, requiring specialized techniques and equipment. METHODS: We examined the prevalence, clinical and angiographic characteristics, management and procedural outcomes of balloon uncrossable lesions in a multicenter chronic total occlusion (CTO) percutaneous coronary intervention (PCI) registry. RESULTS: Between 2012 and 2016, 718 CTO PCIs (in which the occlusion was successfully crossed with a guidewire) were performed in 701 patients at 11 US centers. Mean age was 65.6 ± 10 years and 84% of the patients were men. Balloon uncrossable lesions represented 9% of all CTOs. Balloon uncrossable CTOs had more moderate/severe calcification (82% vs. 52%, P < 0.0001), moderate/severe tortuosity (61% vs. 35% P < 0.0001) and higher J-CTO score (2.95 ± 1.32 vs. 2.43 ± 1.23, P = 0.005) as compared with the remaining lesions. Technical and procedural success was significantly lower for balloon uncrossable lesions (90.5% vs. 98.3%, P < 0.0001 and 88.9% vs. 96.6% P = 0.004), respectively, but the incidence of major adverse events was similar (1.6% vs. 2.2%, P = 0.751). Balloon uncrossable lesions required longer procedure (208 [interquartile range: 135, 258] vs. 135 [94, 194] min, P < 0.0001) and fluoroscopy (77 [52, 100] vs. 45 min [27, 75], P < 0.0001) time. Techniques used to treat balloon uncrossable lesions included balloon-assisted microdissection (23%), excimer laser atherectomy (18%), and rotational atherectomy (16%). Excimer laser atherectomy and balloon-assisted microdissection were associated with the highest technical and procedural success rates. CONCLUSIONS: Balloon uncrossable CTOs are common, are associated with high rates of technical failure, and require specialized techniques for successful treatment. © 2016 Wiley Periodicals, Inc.

Endogenous Technology Adoption and Medical Costs.

Despite the claim that technology has been one of the most important drivers of healthcare spending growth over the past decades, technology variables are rarely introduced explicitly in cost equations. Furthermore, technology is often considered exogenous. Using 1996-2007 panel data on Swiss geographical areas, we assessed the impact of technology availability on per capita healthcare spending covered by basic health insurance whilst controlling for the endogeneity of health technology availability variables. Our results suggest that medical research, patent intensity and the density of employees working in the medical device industry are influential factors for the adoption of technology and can be used as instruments for technology availability variables in the cost equation. These results are similar to previous findings: CT and PET scanner adoption is associated with increased healthcare spending, whilst increased availability of percutaneous transluminal coronary angioplasty facilities is associated with reductions in per capita spending. However, our results suggest that the magnitude of these relationships is much greater in absolute value than that suggested by previous studies that did not control for the possible endogeneity of the availability of technologies. Copyright © 2016 John Wiley & Sons, Ltd.