Cardiovascular Outcome and Mortality in Patients Undergoing Endovascular Treatment for Symptomatic Peripheral Artery Disease　- Short-Term Results of the Toma-Code Registry.

BACKGROUND: The present study was performed to clarify whether the preoperative clinical symptoms for endovascular therapy (EVT) can predict post-EVT death and cardiovascular prognosis in Japanese patients with peripheral artery disease (PAD), including acute disease.Methods and Results:The TOkyo taMA peripheral vascular intervention research COmraDE (Toma-Code) Registry is a Japanese prospective cohort of 2,321 consecutive patients with PAD treated with EVT, in 34 hospitals in the Kanto and Koshin'etsu regions, from August 2014 to August 2016. In total, 2,173 symptomatic patients were followed up for a median of 10.4 months, including 1,370 with claudication, 719 with critical limb ischemia (CLI), and 84 with acute limb ischemia (ALI) for EVT. The all-cause death rates per 100 person-years for claudication, CLI and ALI were 3.5, 26.2, and 24.5, respectively. Similarly, major adverse cardiac and cerebrovascular events (MACCE) rates per 100 person-years for claudication, CLI, ALI, and others were 5.2, 31.2, and 29.7, respectively. After adjusting for the predictors of all-cause death and MACCE, namely, age, body mass index <18, diabetes mellitus, dialysis, cerebrovascular disease, and low left ventricular ejection fraction, it was determined that the preoperative indication for EVT was strongly associated with all-cause death and MACCE. CONCLUSIONS: The preoperative clinical symptoms for EVT can predict the prognosis in patients with PAD undergoing EVT.

Independent predictors of retrograde failure in CTO-PCI after successful collateral channel crossing.

OBJECTIVES: To evaluate factors for predicting retrograde CTO-PCI failure after successful collateral channel crossing. BACKGROUND: Successful guidewire/catheter collateral channel crossing is important for the retrograde approach in percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). METHODS: A total of 5984 CTO-PCI procedures performed in 45 centers in Japan from 2009 to 2012 were studied. The retrograde approach was used in 1656 CTO-PCIs (27.7%). We investigated these retrograde procedures to evaluate factors for predicting retrograde CTO-PCI failure even after successful collateral channel crossing. RESULTS: Successful guidewire/catheter collateral crossing was achieved in 77.1% (n = 1,276) of 1656 retrograde CTO-PCI procedures. Retrograde procedural success after successful collateral crossing was achieved in 89.4% (n = 1,141). Univariate analysis showed that the predictors for retrograde CTO-PCI failure were in-stent occlusion (OR = 1.9829, 95%CI = 1.1783 - 3.3370 P = 0.0088), calcified lesions (OR = 1.9233, 95%CI = 1.2463 - 2.9679, P = 0.0027), and lesion tortuosity (OR = 1.5244, 95%CI = 1.0618 - 2.1883, P = 0.0216). On multivariate analysis, lesion calcification was an independent predictor of retrograde CTO-PCI failure after successful collateral channel crossing (OR = 1.3472, 95%CI = 1.0614 - 1.7169, P = 0.0141). CONCLUSIONS: The success rate of retrograde CTO-PCI following successful guidewire/catheter collateral channel crossing was high in this registry. Lesion calcification was an independent predictor of retrograde CTO-PCI failure after successful collateral channel crossing. Devices and techniques to overcome complex CTO lesion morphology, such as lesion calcification, are required to further improve the retrograde CTO-PCI success rate. © 2016 Wiley Periodicals, Inc.

Comparison of percutaneous coronary intervention for chronic total occlusion outcome according to operator experience from the Japanese retrograde summit registry.

OBJECTIVES: This study was performed to evaluate the acute outcomes of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) based on operator experience. BACKGROUND: Despite developments in both technology and techniques, PCI procedures for CTO's remain challenging. METHODS: A total of 3,229 eligible subjects who underwent CTO-PCI were enrolled from 56 centers by a retrograde summit using a web registry system. To compare the acute outcomes of the CTO data, 18 centers were classified as higher volume centers (HC) and 38 centers as lower volume centers (LC) depending on the CTO-PCI experience of the operator. RESULTS: The mean procedural success rate of all centers was 88.4%. The overall procedural success rate was significantly higher in HC than LC (90.6% vs. 85.6%, respectively; P < 0.0001). In addition, overall antegrade success rate was also higher in HC than LC (91.0% vs. 83.9%, respectively; P < 0.0001). Although the overall retrograde approach success rate was significantly higher in HC than LC (85.0% vs. 77.6%, respectively; P < 0.0001), there was no significant difference in that of the retrograde alone (89.0% vs. 93.7%, respectively; P = 0.051). Major in-hospital adverse events were observed in 0.53% of cases, and the rates were similar between the two groups (0.45% vs. 0.62%, respectively; P = 0.25). CONCLUSIONS: Although CTO-PCI was safe in both groups, the procedural success rate was significantly higher in HC than LC, even in this new era of CTO-PCI. This difference was attributed to the difference in the antegrade procedural success rate. © 2015 Wiley Periodicals, Inc.

Complications during retrograde approach for chronic coronary total occlusion: Sub-analysis of Japanese multicenter registry.

OBJECTIVES: This study was performed to determine the complications occurring during retrograde percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) based on analysis of the multicenter, prospective, nonrandomized Retrograde Summit registry. BACKGROUND: Retrograde PCI for CTO has improved treatment success rates, but several complications related to the retrograde approach have been reported, including collateral channel injury and donor artery injury due to their use as retrograde roots. METHODS: This registry included data from 1,166 patients who underwent retrograde PCI for CTO in 28 Japanese centers between January 2009 and December 2011. RESULTS: Overall procedure success and retrograde procedure success were achieved in 985 (84.5%) and 838 (71.9%) of the 1,166 patients, respectively. In-hospital major adverse cardiac and cerebrovascular events (MACCE) occurred in 18 (1.5%) of the 1,166 patients. With regard to complications related to the retrograde approach, channel injury occurred in 111 (9.5%) of the 1,166 patients, but treatment was required in only 24 (2.1%) patients and subsequent cardiac tamponade occurred in only 4 (0.3%) patients. Donor artery problems occurred in only 10 (0.9%) of the 1,166 patients. In sub-analysis regarding the types of collateral channels, the septal channel was significantly safer than epicardial channel because of the lower frequency of non-Q-wave myocardial infarction (non-QMI) and channel injury requiring treatment. CONCLUSIONS: The MACCE rate during retrograde PCI for CTO determined from the Retrograde Summit registry was low and the frequency of complications related to the retrograde approach was acceptable. © 2015 Wiley Periodicals, Inc.

Japanese multicenter registry evaluating the retrograde approach for chronic coronary total occlusion.

OBJECTIVES: This registry evaluated the current trends and outcomes associated with retrograde percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). BACKGROUND: Since its introduction, several techniques and technologies have been introduced for retrograde PCI for CTO. METHODS: Eight hundred and one patients who underwent retrograde PCI for CTO in 28 Japanese centers between January 2009 and December 2010 were enrolled in this registry. RESULTS: Overall procedural and clinical success rates were 84.8 and 83.8%, respectively, of which, retrograde procedures accounted for 71.2 and 70.3%, respectively. The use of channel dilators increased in 2010 compared to that in 2009 (36 vs. 95.3%, P < 0.0001), attributed improving collateral channel crossing using a wire and catheter (70.6% vs. 81.1%, P = 0.0005) and increased availability of epicardial channels (27.6% vs. 36.9%). The use of the reverse controlled antegrade and retrograde tracking technique also increased (41.9 vs. 66.5%). Although these changes decreased procedure time (203.3 min vs. 187.9 min, P = 0.024), they did not significantly improve overall procedural success rate (84.1% vs. 85.3%, P = 0.63). Multivariate analysis identified age 65 years or more and lesion calcification as unfavorable factors and the use of a channel dilator as a favorable factor for retrograde procedural success. CONCLUSIONS: Increased availability of channel dilators has altered strategies for retrograde PCI for CTO. However, retrograde PCI for CTO could be improved by overcoming its main obstacle of severe calcification.

Coronary computed tomography angiography-based coronary risk stratification in subjects presenting with no or atypical symptoms.

BACKGROUND: Coronary computed tomography angiography (CTA) findings of positive vessel remodeling and low-attenuation plaque, referred to as computed tomography-verified high-risk plaque (CT-HRP), have been reported to be associated with the development of subsequent acute coronary syndromes. The aim of this study was to examine the usefulness of coronary CTA for coronary risk re-stratification of patients with asymptomatic and atypical chest symptoms. METHODS AND RESULTS: A total of 1,139 subjects (M/F 602/537; mean age, 61.5±9.3 years) who were either asymptomatic or presented with atypical chest symptoms underwent coronary 64- or 320-slice multidetector computed tomography angiography and Agatston score. Age, sex, coronary risk factors, including hypertension, diabetes mellitus (DM), dyslipidemia, and smoking were investigated as predictors for CT-HRP on multivariate analysis using logistic regression analysis. CT-HRP was observed in 72 patients (6.3%). Based on Framingham risk scores (FRS), CT-HRP was observed in 0/94 subjects (0.0%) in the low-risk group, 35/806 (4.3%) in the intermediate-risk group, and 37/239 (15.5%) in the high-risk group. On logistic regression analysis significant predictors for CT-HRP in intermediate- and high-risk subjects were male sex (odds ratio [OR] 2.829; 95% confidence interval [CI] 1.460-5.479, P=0.0021), DM (OR 2.418; 95% CI 1.420-4.116, P=0.0011), and current smoking (OR 1.922; 95% CI 1.096-3.371, P=0.0160). CT-HRP prevalence for Agatston scores >500 and >250 was lower in the intermediate- and high-risk groups, respectively. CONCLUSIONS: In asymptomatic subjects and those presenting with atypical chest pain who have a more than an intermediate risk, coronary CTA is contributory to FRS. Male sex, DM and smoking were independent predictors of vulnerable plaque in the more than intermediate-risk group.

Single injection protocol for coronary and lower extremity CT angiographies in patients suspected for peripheral arterial disease.

To evaluate the feasibility of a single injection protocol for coronary CT angiography (CTA) and lower extremity CTA in patients suspected for peripheral arterial disease (PAD).This prospective observational study included a total of 103 patients who showed an ankle brachial index ≤0.9 and underwent the single injection protocol for coronary and lower extremity CTA. All CTAs used iodinated contrast (weight × 0.06 mL/s × 20 seconds). A prospective Electrocardiogram (ECG)-gated coronary CTA was performed, followed by helical lower extremity CTA beginning 9 seconds after coronary CTA. Using catheter angiography as reference standard, diagnostic ability of CTA was evaluated.The mean total volume of iodinated contrast used was 70 ±â€Š14 mL. Contrast opacification in the superficial femoral artery was adequate (408 ±â€Š97  Hounsfield Units [HU]) and PAD was detected in 72.8% (75/103). The estimated radiation doses for lower extremity and coronary CTA were 3.6 ±â€Š1.2 and 5.5 ±â€Š4.5 mSv. A significant coronary stenosis was detected in 47 patients (45.6%). Coronary CT image quality was recorded as excellent in 86.4%, acceptable in 11.7%, and unacceptable for 1.9%. Contrast opacification within the superficial femoral artery was adequate in all cases while 27.2% needed an additional scan below the calf to capture the contrast bolus arrival in the smaller lower extremity vessels. Segment based sensitivity, specificity, positive, and negative predictive values were 57.9%, 97.9%, 73.8%, and 95.9% for the coronary CTA, and 63.4%, 91.5%, 76.3%, and 85.3% for peripheral CTA.A single injection protocol for coronary CTA and lower extremity CTA is feasible with a relatively small volume of iodinated contrast.

Prevention of no-reflow phenomenon in culprit lesions involving a large side branch.

No-reflow/slow-flow phenomenon (NF) is a poor prognostic factor in patients undergoing percutaneous coronary intervention. Distal protection devices (DPDs) prevent myocardial injury due to microembolic debris. When the target lesion involves a large side branch, DPDs can only protect the main vessel but not the side branch. In the present report, we describe the use of a two-step deflation in kissing-balloon technique for preventing NF in 4 patients (M/F = 4/0, 65 ± 6 years) in which the culprit lesions with NF risk involved a bifurcation. The procedures were uneventful and the 4 patients were discharged ≤24 h without ECG change and elevation of serum level of creatine kinase. The sequential deflation of kissing-balloon technique may constitute a possible solution for the NF related with the side branch on bifurcation lesions.

Contemporary retrograde approach for the recanalisation of coronary chronic total occlusion: on behalf of the Japanese Retrograde Summit Group.

AIMS: The retrograde approach to CTO is promising, but questions remain with regard to its wider application and the potential risks. This study evaluated the feasibility and efficacy of retrograde recanalisation of chronic total occlusion (CTO) of the coronary arteries. METHODS AND RESULTS: A total of 378 consecutive patients (previously failed PCI 32.0%) who enrolled in 27 institutions in Japan underwent retrograde recanalisation for CTO. We analysed the data on lesion characteristics, procedural materials, technique used, complications and clinical outcomes. Successful retrograde recanalisation was achieved in 70.4% and the overall procedural success was 83.6%. Collateral crossing was achieved via a septal route in 68.9%, epicardial in 27.2% and bypass grafts in 2.6%, respectively. The retrograde approach was completed with implementation of reverse CART in 42.5%, direct wire crossing in 23.1%, bilateral wiring in 22.7%, and CART in 11.7%. Major and minor collateral injuries and coronary perforations were noted in 1.3%, 10.3% and 2.9% of cases, respectively. Stroke occurred in 0.3%, QWMI and emergency PCI in 0.3% of patients with successful recanalisation. CONCLUSIONS: Wider application of retrograde CTO PCI achieved a high rate of success in recanalisation with an acceptable rate of complications in Japan.

Computed tomographic angiography-verified plaque characteristics and slow-flow phenomenon during percutaneous coronary intervention.

OBJECTIVES: This study sought to identify whether computed tomographic angiographic (CTA) plaque characteristics are associated with slow-flow phenomenon (SF) during percutaneous coronary intervention (PCI). BACKGROUND: SF during PCI is associated with myocardial damage and prolonged hospitalization. Intracoronary ultrasound-verified large echolucent lesions have been reported to predict SF. METHODS: The authors evaluated pre-PCI CTA plaque characteristics in 40 consecutive patients (male/female, 31/9; age, 69 ± 10 years) with stable angina pectoris who developed SF during PCI; patients with ≥ 600 Agatston coronary artery calcium score were not included. They were compared with 40 age-, sex-, and culprit coronary artery-matched patients (male/female, 31/9; age, 69 ± 9 years) who underwent PCI during the same period and did not develop SF. Plaque characteristics, including vascular remodeling, plaque consistency, including low-attenuation plaques representing lipid-rich lesions and high-attenuation plaque patterns of calcium deposition, were analyzed. RESULTS: Calcium deposition in the perimeter of a plaque, or circumferential plaque calcification (CPC), was significantly more frequent in the SF group (25 of 40, 63%) than the no-SF group (2 of 40, 5.0%) (p < 0.001). Presence of CPC on CTA was confirmed at the same location in the nonenhanced CT during Agatston coronary artery calcium score calculation. The positive remodeling index was significantly higher (1.5 [1.3 to 1.8] vs. 1.2 [1.0 to 1.5]; p < 0.001) and plaque density significantly lower (23.5 [9.5 to 40] HU vs. 45 [29 to 86] HU; p = 0.001) in the SF group. The conditional logistic regression analysis revealed that CPC, plaque density, and dyslipidemia were the predictors of SF, with CPC being the strongest (odds ratio: 79; 95% confidence interval: 8 to 783, p < 0.0001). CONCLUSIONS: CTA-verified CPC with low-attenuation plaque and positive remodeling were determinants of SF during PCI. If CTA findings are available in patients undergoing PCI, the interventionists should be aware of the likelihood of SF.

Prevalence of anomalous origin of coronary artery detected by multi-detector computed tomography at one center.

BACKGROUND: Anomalous origin of coronary artery (AOCA) has been described by coronary angiography or autopsy. However the actual prevalence of such abnormalities is unknown. Multi-detector computed tomography (MDCT) offers the possibility to visualize AOCA non-invasively. The purpose of this study was to report the prevalence AOCA by MDCT. METHODS AND RESULTS: In 5869 consecutive subjects who underwent coronary MDCT (Aquilion 64, Toshiba Medical Systems Corporation, Otowara, Japan) at one center, the prevalence of AOCA was 89 (1.52%) patients. The most common abnormality (33 cases, 0.56%) was the origin of the coronary artery or branch from the opposite or non-coronary sinus. The right coronary arteries (RCA) arising from the left coronary artery sinus (LCS) was observed in 27 cases (0.46%). Vascular cross-sectional area of such RCA arising from LCS was significantly smaller in 11 patients with angina than in 10 patients without symptoms [3.02 (1.68-7.67) mm² vs 5.93 (2.54-12.04) mm² p < 0.05]. The left coronary artery arising from the non-coronary sinus was observed in 2 cases (0.03%), and the left anterior descending coronary artery (LAD) or left circumflex coronary artery (LCX) arising from the right coronary sinus was observed in 4 cases (0.07%). Single coronary arteries were found in 5 cases (0.09%). Fifteen patients (0.26%) presented multiple coronary ostia, all of 15 (0.26%) had the LAD and LCX separately arising from the left coronary sinus. High take off was found in 36 cases (0.60%). CONCLUSION: MDCT can accurately detect and characterize the type of AOCA.

A novel modification of the retrograde approach for the recanalization of chronic total occlusion of the coronary arteries intravascular ultrasound-guided reverse controlled antegrade and retrograde tracking.

OBJECTIVES: The study evaluates the feasibility and efficacy of the novel modification of the retrograde recanalization of the chronic total occlusion (CTO) of the coronary arteries by using intravascular ultrasound (IVUS)-guided reverse controlled antegrade and retrograde tracking (CART). BACKGROUND: Despite improvement in the techniques and materials, CTO recanalization is still suboptimal. The CART procedure has improved success rates, but there are certain inherent technical uncertainties and risk with this procedure. METHODS: This first series involves 31 patients, with 22 patients having previous failed attempts at CTO recanalization. All patients were treated with bilateral approach and using IVUS-guided reverse CART concept. RESULTS: Successful recanalization of the CTO was achieved in all cases (100%). The access route was septal collateral in 20 (70%) cases and epicardial collateral in 11 (30%) cases. IVUS guidance was used successfully in 30 cases, and the channel dilator (microcatheter) was used in 27 cases. Guidewire injury and grade 1 perforation was seen in 3 (9%) cases, which were managed conservatively. There was no death, coronary artery bypass surgery, or pericardiocentesis in this group of patients. Mean fluoroscopy time was 65.84 +/- 23.16 min, ranging from 31 to 106 min and total contrast volume used 321.32 +/- 137.77 ml (range 115 to 650 ml). CONCLUSIONS: This first series describes a high success rate of CTO recanalization with IVUS-guided reverse CART in selected patients performed by an experienced operator.

Significance of PQ interval in acquisition of coronary multidetector row computed tomography.

BACKGROUND: Since image quality obtained in the mid-diastolic [or slow filling (SF)] phase is generally superior to end-systolic image in coronary multidetector row computed tomography (MDCT), low heart rate (HR) comprises the most important factor for acquisition of high-quality images. However, despite HR <70 and optimum breath-hold, sometimes high quality images cannot be obtained in SF. We assessed the significance of PQ interval in acquisition of coronary MDCT. METHODS AND RESULTS: Of 541 consecutive patients who underwent coronary MDCT, 7 patients with incomplete breath-hold, 62 HR ≥70, and 70 arrhythmias were excluded. The remaining 402 patients (M: 222, 66±11 years), including 38 with first-degree atrioventricular block (1° AVB, PQ >200 ms) were evaluated. RR and PQ were measured on electrocardiogram and systolic and SF phase with 4-chamber cine cardiac computed tomography. SF significantly (p<0.0001) correlated with RR (SF=-471+0.720RR, r=0.887) in all subjects. The SF of without 1° AVB (292±97 ms) was significantly (p<0.0147) longer than that of with 1° AVB (251±121 ms), although RR was not significantly different between the two groups. The SF/RR of without 1° AVB (27.2±6.1%) was also significantly (p<0.0001) higher than that of with 1° AVB (22.7±8.0%). The coefficient of correlation between (RR-PQ) and SF [r=0.915, p<0.0001, SF=-362+0.742(RR-PQ)] was significantly (p<0.034) higher than that of correlation between RR and SF in all subjects. The SF of rank A image quality was significantly longer than that of rank B (p<0.0001) or rank C (p=0.0042). In critical HR (60-69 bpm), the optimum phase was ES in 7/139 patients without 1° AVB, and SF in 3/13 patients with 1° AVB (chi(2), p<0.0416). CONCLUSION: Since SF depends on (RR-PQ), if PQ is long in critical HR, it might be difficult to reconstruct high quality images in the SF phase.

The efficacy of a bilateral approach for treating lesions with chronic total occlusions the CART (controlled antegrade and retrograde subintimal tracking) registry.

OBJECTIVES: The aim of this study was to evaluate the safety and feasibility of a new concept for chronic total occlusion (CTO) recanalization-using a bilateral approach that utilizes a Controlled Antegrade and Retrograde subintimal Tracking (CART) technique. BACKGROUND: Successful percutaneous recanalization of coronary CTOs results in improved long-term outcomes. The recanalization of CTOs in native coronary arteries no doubt represents one of the most technically challenging of interventional procedures. METHODS: A total of 224 consecutive patients (mean age 61 +/- 9 years; 86.2% men) were enrolled in this prospective multicenter registry. This technique combines the simultaneous use of antegrade and retrograde approaches. A subintimal dissection is created in both antegrade and retrograde fashion, thereby limiting the extension of the subintimal dissection within the CTO portion. RESULTS: Of 224 CTO lesions (>3 months in duration) undergoing attempted recanalization using the CART technique, 145 cases (64.7%) had undergone previous CTO recanalization attempts. The success rates of crossing in a retrograde fashion with a wire and a balloon were 87.9% and 79.9%, respectively. The overall technical and procedural success rates achieved in this registry were 92.4% and 90.6%, respectively. CONCLUSIONS: A bilateral approach for CTO lesions using the CART technique is feasible, safe, and has a higher success rate than previous approaches. These results indicate that a bilateral technique can solve a major dilemma that commonly affects CTO procedures.

ECG-edit function in multidetector-row computed tomography coronary arteriography for patients with arrhythmias.

BACKGROUND: ECG-gating is necessary for cardiac computed tomography, but is not suitable for arrhythmias, so the aim of this study was to evaluate the usefulness of the ECG-edit function for this purpose. METHODS AND RESULTS: Of 1,221 patients undergoing 64-row multidetector-row computed tomography coronary angiography (coronary MDCT), 123 patients (28 atrial fibrillation (Af), 39 premature atrial contractions (PAC), 42 premature ventricular contractions (PVC), 3 PAC + PVC, 10 sinus arrhythmias (SA), and a second-degree atrioventricular block (2 degrees AVB)) had arrhythmias necessitating the ECG-edit function. Short R-R interval was deleted and mid-diastolic phases were selected from the long R-R intervals using the "R+absolute time" method. In the present study, the reconstructed images were evaluated using a triple-grade scale A-C, representing excellent, acceptable, and unacceptable image quality. Image quality, categorized as A, B and C, respectively, was 50%, 36% and 14% for the 28 patients with Af; 56%, 36% and 8% for the 39 PAC patients, and 65%, 33% and 2% in the 42 PVC patients. None of the scans of the PAC + PVC, SA, and 2 degrees AVB patients was ranked as C. CONCLUSIONS: The ECG-edit function is useful for reconstructing coronary MDCT images in many arrhythmias, and provides clinically acceptable images in most cases.

New concept for CTO recanalization using controlled antegrade and retrograde subintimal tracking: the CART technique.

OBJECTIVES: To demonstrate the safety and feasibility of a new concept for CTO recanalization using a controlled antegrade and retrograde subintimal tracking technique (CART technique). BACKGROUND: A successful percutaneous recanalization of chronic coronary occlusions results in improved survival, as well as enhanced left ventricular function, reduction in angina, and improved exercise tolerance. However, successful recanalization of CTOs is still not optimal, and needs further improvements. METHODS: Ten patients with a CTO underwent the CART procedure. This technique combines the simultaneous use of the antegrade and retrograde approaches. A subintimal dissection is created antegradely and retrogradely, which allows the operator to limit the extension of the subintimal dissection in the CTO portion. A retrograde approach means that the occlusion site is approached in a retrograde fashion through the best collateral channel from any other patent coronary artery. RESULTS: The occlusion site was located in the RCA in 9 patients, and in the LAD in 1 patient. CTO duration varied from 7 to 84 months. Vessel recanalization was achieved in all patients. In all cases, the subintimal dissection was limited to the CTO region. No complications occurred in the collateral channel used for the retrograde approach. There were no in-hospital major adverse cardiac events. CONCLUSIONS: The CART technique is feasible, safe, and has a high success rate.

Comparison of the effects of a distal embolic protection device and an aspiration catheter during percutaneous coronary intervention in patients with acute myocardial infarction.

BACKGROUND: The beneficial effect of percutaneous coronary intervention (PCI) using stents for acute myocardial infarction (AMI) has already been demonstrated, but there is the problem that mechanical microvascular occlusion can occur because of thrombus/atheroma embolization when the PCI was performed. The aim of the present study was to retrospectively test and compare the effects of an aspiration catheter or distal embolic protection with a distal occlusion balloon catheter to prevent peripheral vascular embolization. METHODS AND RESULTS: The subjects consisted of 135 patients who underwent PCI with stenting within 12 h of the onset of chest pain caused by their first AMI. They were divided into 2 groups; the aspiration group, consisted of 81 consecutively seen patients who underwent aspiration catheter treatment between January 2001 and May 2002, and the distal protection group was the next group of 54 consecutively seen patients treated with a distal protection device between June 2002 and February 2003. The results were as follows. Thrombolysis in Myocardial Infarction (TIMI) score of 3 was obtained significantly more frequently in the distal protection group (94.4%) than in the aspiration group (79.0%). Additionally, the intensity of the cardiac muscle stain (blush score) was evaluated on coronary angiography and the rate of cases showing a blush score of 3, which indicates favorable blood perfusion at the tissue level, in the distal protection group (56.6%) was significantly greater than in the aspiration group (33.3%, p<0.01). The time to peak blood concentration of creatinine kinase was also significantly shorter in the distal protection group. CONCLUSIONS: The distal embolism protection method is superior to the aspiration method for prevention of embolization after PCI with stenting for AMI, in terms of tissue level reperfusion in myocardial recanalization therapy.