Validation and comparison of non-hyperemic pressure reserve to fractional flow reserve for assessment of coronary artery stenosis: A real world study.

BACKGROUND: The visual interpretation of an angiographic stenosis may not always reflect the physiological significance of a lesion. Fractional Flow Reserve (FFR) is a reliable index to assess the significance of a lesion during hyperemia. However, there are pitfalls that can lead to significant misinterpretation and adverse events. OBJECTIVE: This study sought to evaluate the accuracy and predictability of the non-hyperaemic pressure ratio (NHPR) without hyperemic stimuli, compared to hyperemic FFR. METHODS: We conducted a retrospective, multicenter study of 700 patients who underwent a pressure recording during coronary angiography using NHPR and FFR measurements. Receiver operator characteristic (ROC) curve was constructed. NHPR sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy test were calculated. The most accurate NHPR cutoff was determined. RESULTS: Of the 700 procedures, 449 cases were included. By ROC analysis, the optimal cut-point for NHPR was 0.93 to predict an FFR of ≤0.80 with an overall diagnostic accuracy of 78.84%. The sensitivity of this NHPR cutoff was 85.06%, specificity of 75.59%, PPV of 64.53% and a NPV of 90.65%. There was an overall accuracy of about 80% for predicting non-hyperemic index (FFR < 0.80) using a cutoff of NHPR ≤ 0.93. CONCLUSIONS: The use of NHPR can be considered in certain clinical scenarios where adenosine is contraindicated or there are other challenges; with the knowledge that hyperemia might be necessary if there is any high clinical suspicion as it still remains the reference standard for diagnostic certainty.

Management of common femoral artery occlusive disease: A review of endovascular treatment strategies and outcomes.

Isolated atherosclerotic lesions of the common femoral artery (CFA) are rare but can produce significant claudication and critical limb ischemia. To date, the "gold standard" treatment for this entity has been common femoral endarterectomy (CFE) with or without patch angioplasty. However, surgery does have significant early postoperative complications, with a 15% combined mortality/morbidity. This manuscript sought to perform a comprehensive review of all studies and available data on endovascular treatment of isolated CFA disease and compare its utility to the traditional gold standard treatment. Twenty-one studies from 1987 to 2018 were included exploring the various CFA endovascular therapies (percutaneous transluminal angioplasty, intravascular stenting, drug-coated balloons, and directional atherectomy employed to treat CFA disease, in terms of efficacy, safety, and complications). As a conclusion, endovascular interventions provide acceptable short-term technical outcomes for CFA disease while limiting procedural complications. While only two randomized controlled trials compare short and long-term outcomes of surgical versus endovascular treatment, further studies are required to clarify the role of endovascular therapy.

Routine Angiographic Follow-Up After Coronary Artery Disease Revascularization: Is Seeing Believing?

PURPOSE OF THE REVIEW: Coronary artery disease is a major cause of mortality and morbidity in the world, and PCI and CABG account for over a million procedures performed annually in the USA. The goal of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is to achieve complete revascularization (CR) if at all possible. However, restenosis and stent thrombosis (ST) remain the Achilles heel of contemporary PCI with restenosis rates between 10 and 30% with bare metal stents to 5-15% after drug-eluting stents and ST rates of around 0.8 vs 1.2%, respectively. Routine angiography after revascularization seems theoretically attractive as this may allow intervention before clinical events occur. In this manuscript, we review the literature regarding routine angiography after PCI or CABG and its outcomes. RECENT FINDINGS: According to the 2016 update from the American Heart Association (AHA), 15.5 million people above the age of 20 have coronary heart disease (CHD) in the USA. The prevalence of CHD is now almost similar in both men and women, and one American suffers from a myocardial infarction (MI) every 42 s. Recent data from randomized clinical trials and observational studies does not support the use of routine coronary angiography after revascularization in asymptomatic patients. There are some studies which show that routine angiography may have a role in left main or complex coronary interventions; however, these findings are exploratory and were not seen in randomized trials. After reviewing the data on routine angiography after coronary revascularization, we came to the conclusion that current data does not support the use of routine angiography for asymptomatic patients. However, there is a lack of randomized controlled trial in this field with only one recent trial reporting negative outcomes.

Navigating complex femoropopliteal and infrapopliteal anatomy in endovascular interventions.

Peripheral arterial disease (PAD) is a clinical manifestation of systemic atherosclerosis and is associated with significant morbidity and mortality. Vascular physicians come across PAD of different complexity and among them complex total occlusions present a formidable challenge to endovascular operators. Newer tools and techniques, particularly in the retrograde approach, have made endovascular therapy applicable to increasingly complex disease. In this article, we review various interventional devices and techniques that are key to achieving success in complex anatomic subsets.