Pooled diagnostic accuracy of resting distal to aortic coronary pressure referenced to fractional flow reserve: The importance of resting coronary physiology.

INTRODUCTION: Both resting and hyperemic physiologic methods to guide coronary revascularization improve cardiovascular outcomes compared with angiographic guidance alone. Fractional flow reserve (FFR) remains underutilized due to concerns regarding hyperemia, prompting study of resting distal to aortic coronary pressure (Pd/Pa). Pd/Pa is a vasodilator-free resting index unlike FFR. While Pd/Pa is similar to another resting index, instantaneous wave-free ratio (iFR), it is a whole-cycle measurement not limited to the wave-free diastolic period. Pd/Pa is not validated clinically although multiple accuracy studies have been performed. Our meta-analysis examines the overall diagnostic accuracy of Pd/Pa referenced to FFR, the accepted invasive standard of ischemia. METHODS: We searched PubMed, EMBASE, Central, ProQuest, and Web of Science databases for full text articles published through August 9, 2017 addressing the diagnostic accuracy of Pd/Pa referenced to FFR < 0.80. The following keywords were used: "distal coronary artery pressure" OR "Pd/Pa" AND "fractional flow reserve" OR "FFR." RESULTS: In total, 14 studies comprising 7004 lesions were identified. Pooled diagnostic accuracy estimates of Pd/Pa versus FFR < 0.80 were: sensitivity, 0.77 (95% CI, 0.75-0.78); specificity, 0.82 (0.81-0.83); positive likelihood ratio, 4.7 (3.3-6.6); negative likelihood ratio, 0.29 (0.24-0.34); diagnostic odds ratio, 18.1 (14.4-22.6); area under the summary receiver-operating characteristic curve of 0.88; and diagnostic accuracy of 0.80 (0.76-0.83). CONCLUSIONS: Pd/Pa shows adequate agreement with FFR as a resting index of coronary stenosis severity without the undesired effects and cost of hyperemic agents. Pd/Pa has the potential to guide coronary revascularization with easier application and availability compared with iFR and FFR.

Prevalence and management of coronary chronic total occlusions in a tertiary Veterans Affairs hospital.

OBJECTIVES: We sought to determine the contemporary prevalence and management of coronary chronic total occlusions (CTO) in a veteran population. BACKGROUND: The prevalence and management of CTOs in various populations has received limited study. METHODS: We collected clinical and angiographic data in consecutive patients that underwent coronary angiography at our institution between January 2011 and December 2012. Coronary artery disease (CAD) was defined as ≥50% diameter stenosis in ≥1 coronary artery. CTO was defined as total coronary artery occlusion of ≥3 month duration. RESULTS: Among 1,699 patients who underwent angiography during the study period, 20% did not have CAD, 20% had CAD and prior coronary artery bypass graft surgery (CABG), and 60% had CAD but no prior CABG. The prevalence of CTO among CAD patients with and without prior CABG was 89 and 31%, respectively. Compared to patients without CTO, CTO patients had more co-morbidities, more extensive CAD and were more frequently referred for CABG. Percutaneous coronary intervention (PCI) to any vessel was performed with similar frequency in patients with and without CTO (50% vs. 53%). CTO PCI was performed in 30% of patients without and 15% of patients with prior CABG with high technical (82 and 75%, respectively) and procedural success rates (80 and 73%, respectively). CONCLUSIONS: In a contemporary veteran population, coronary CTOs are highly prevalent and are associated with more extensive co-morbidities and higher likelihood for CABG referral. PCI was equally likely to be performed in patients with and without CTO.

Impact of contrast agent viscosity on coronary balloon deflation times: bench testing results.

OBJECTIVES: To assess the impact of viscosity on angioplasty balloon deflation times. BACKGROUND: Lower contrast viscosity could result in more rapid coronary balloon deflation times. METHODS: We performed a bench comparison of coronary balloon deflation times using 2 contrast agents with different viscosity (ioxaglate and iodixanol), 3 contrast dilutions, and 2 inflation syringe filling volumes. Ten identical pairs of coronary angioplasty balloons were used to conduct each comparison after balloon inflation to 12 atmospheres. Simultaneous deflations were performed under cineangiography. The time to full contrast extraction and the area of contrast remaining after 5 seconds of deflation (quantified by opaque pixel count) were compared between groups. RESULTS: The mean time to full contrast extraction during balloon deflation was 8.3 ± 2.5 seconds for ioxaglate (lower viscosity) versus 10.1 ± 2.9 seconds for iodixanol (higher viscosity) (17.4% decrease, P = 0.005), with a 35.6% (P = 0.004) reduction in contrast area at 5 seconds. Compared to 1:1 ioxaglate-saline mixture, 1:2 and 1:3 ioxaglate/saline mixes resulted in 26.7% (P < 0.001) and 39.0% (P < 0.001) reduction in mean balloon deflation time, respectively, but at the expense of decreased balloon opacity. Filling the inflation syringe with 5 versus 15 ml of contrast/saline solution was associated with 7.5% decrease in balloon deflation time (P = 0.005), but no difference in contrast area at 5 seconds (P = 0.749). CONCLUSIONS: Use of a lower viscosity contrast agent and higher contrast dilution significantly reduced coronary balloon deflation times, whereas use of lower syringe filling volume had a modest effect. Rapid coronary balloon deflation could improve the safety of interventional procedures.

Long-term outcomes of successful chronic total occlusion percutaneous coronary interventions using the antegrade and retrograde approach.

OBJECTIVE: To compare long-term clinical outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using the retrograde and antegrade approach. BACKGROUND: There is limited long-term clinical outcomes data on the retrograde approach to CTO PCI. METHODS: We performed a retrospective analysis of the long-term clinical outcomes of 193 consecutive patients who underwent successful CTO PCI at our institution between March 2008 and December 2011. RESULTS: Mean age was 63.6 ± 8.3 years. The target vessel was right coronary artery in 52.6%, left anterior descending artery in 24.5% and circumflex in 21.4% of cases. The retrograde approach was used in 41 patients (21.2%). The mean stent length was longer in the retrograde group (83 ± 32 vs. 64 ± 32 mm, P = 0.001). Two major procedural complications occurred, both in the retrograde group (P = 0.012). During a median follow-up of 2.0 years compared to the antegrade CTO PCI group, patients who underwent retrograde CTO PCI were more likely to undergo target lesion revascularization (TLR) (45.6% vs. 25.7%, P = 0.006). No significant difference was observed in the incidence of all-cause mortality, myocardial infarction, non-target vessel revascularization, or coronary artery bypass graft surgery between the 2 groups. On multivariate analysis, stent length was the only independent predictor of TLR during follow-up. CONCLUSIONS: Retrograde CTO PCI was associated with higher incidence of TLR, but similar incidence of death and myocardial infarction compared to antegrade CTO PCI. These findings likely reflect the higher complexity of CTO lesions treated with the retrograde approach.

Application of the "hybrid approach" to chronic total occlusion interventions: a detailed procedural analysis.

OBJECTIVE: To assess the outcomes of the "hybrid" approach to chronic total occlusion (CTO) percutaneous coronary interventions (PCIs). BACKGROUND: The "hybrid approach" to CTO PCI advocates appropriate and early change of crossing strategy to maximize success, safety, and efficiency. METHODS: We prospectively recorded and analyzed detailed step-by-step procedural data in 73 consecutive CTO PCI cases performed by a single operator between July 2011 and August 2012. RESULTS: Technical success was achieved in 66 of 73 cases (90.4%). Mean patient age was 65 ± 7 years, and 30% had prior coronary artery bypass surgery. Dual injection was used in 78%. The primary approach was retrograde in 9 cases (12.5%) and antegrade in 64 cases (87.5%), of whom 25 cases (39.1%) underwent retrograde attempt after failed antegrade approach. The initial crossing approach was successful in 40 cases (54.8%), but 32 cases (44%) required 3.6 ± 1.4 approach changes (range 2-7). Antegrade wire escalation, antegrade dissection/reentry, and retrograde crossing were utilized in 97.2%, 46.6%, and 46.6% of cases, respectively. Among successful cases, the final CTO crossing technique was antegrade wire escalation in 50.0%, antegrade dissection/reentry in 24.2%, and retrograde in 25.8%. The mean procedure time, fluoroscopy time, and air kerma radiation exposure until CTO crossing or stopping the procedure were 66 ± 55 minutes, 25 ± 23 minutes, and 2.3 ± 1.9 Gray, respectively. Three patients (4.1%) had a major complication. CONCLUSION: In the "hybrid approach" to CTO PCI, changes in crossing strategy were needed in approximately half the cases, resulting in high success and low complication rates.

Combined Radial and Femoral Access Strategy and Radial-Femoral Rendezvous in Patients With Long and Complex Iliac Occlusions.

We present cases of complex, calcified iliac occlusive disease revascularized via a combined radial-femoral access strategy. Through a 6-French, 125-cm transradial guiding catheter, antegrade guidewires and catheters are advanced into the iliac occlusion, while retrograde devices are advanced transfemorally. The transradial and transfemoral channels communicate, allowing the devices to cross the occlusion into the true lumen (radial-femoral antegrade-retrograde rendezvous).

Physiologic assessment of moderate coronary lesions: a step towards complete revascularization in coronary artery bypass grafting.

BACKGROUND: An accurate diagnostic assessment of coronary artery disease is crucial for patients undergoing coronary artery bypass grafting (CABG). Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) to guide complete revascularization have not been adequately studied in patients prior to CABG. We compared an anatomic to a physiologic assessment of moderate coronary lesions (40-70% stenosis) in patients referred for CABG. METHODS: We retrospectively reviewed 109 medical records of patients who underwent CABG at Tulane Medical Center from 2014 to 2016. Patients were divided into an FFR/iFR-guided and an angiography-guided group. Clinical characteristics, procedural outcomes, and clinical outcomes for the two groups were compared over an 18-month follow-up period. RESULTS: There were significantly higher rates of three-vessel anastomoses (85.7% vs. 74.7%, P<0.05) and venous grafting (85.7% vs. 76.8%, P<0.05) in the FFR/iFR group. The FFR/iFR group had a lower rate of grafts placed to the left anterior descending artery (LAD) distribution than the angiography group (7.1% vs. 29.5%, P<0.05). The FFR/iFR group had a higher rate of grafts placed to the left circumflex (LCx) artery distribution than the angiography group (28.6% vs. 9.5%, P<0.05). We observed a trend toward reduction in major adverse cardiac events (MACEs) (7.1% vs. 11.6%, P=0.369) and angina (0.0% vs. 6.3%, P=0.429) in the FFR/iFR group compared to the angiography group over 18 months. CONCLUSIONS: Physiologic assessment of coronary lesions can effectively guide complete revascularization in patients undergoing CABG. Moreover, FFR/iFR-guided CABG was associated with significantly higher rates of three-vessel anastomoses, venous grafting, and graft distribution to the circumflex system.

Drug coated balloon angioplasty for subclavian artery stenosis: A potential novel indication.

Subclavian artery stenosis is associated with increased cardiovascular disease mortality. It remains an important treatable cause of upper extremity, brain and cardiac ischemia. Endovascular treatment with angioplasty and stenting has become the preferred modality of treatment. Surgical revascularization is reserved for difficult cases with unfavorable anatomy to endovascular approach. Here we describe a case of subclavian artery stenosis causing subclavian steal syndrome with unfavorable anatomy to stenting treated successfully with drug coated balloon angioplasty with maintenance of patency at 6months.

Clinical, angiographic, and procedural predictors of periprocedural complications during chronic total occlusion percutaneous coronary intervention.

OBJECTIVES: To identify clinical, angiographic, and procedural factors associated with increased risk of periprocedural complications during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BACKGROUND: Successful CTO PCI can provide significant clinical benefit; however, procedural risks have received limited study. We sought to identify factors associated with increased CTO PCI periprocedural risk that could be utilized to guide patient and lesion selection. METHODS: The clinical, angiographic, and procedural records of 336 consecutive CTO PCI procedures performed at a single center from May 2005 through 2012 were reviewed, and data on periprocedural complications were recorded. Logistic regression was performed to identify independent predictors of periprocedural complications during CTO PCI. RESULTS: The incidence of major and minor complications was 3.9% and 10.4%, respectively. Minor bleeding and vascular events were the most common complications (4.8%), followed by perforation (2.4%), contrast-induced nephropathy (1.8%), and transient hypotension (0.6%). Major complications were uncommon: death (0.3%); emergency coronary artery bypass grafting (0.6%); stroke (0.3%); tamponade (0.3%); clinical myocardial infarction (0.9%); donor vessel injury (0.6%); and major bleeding or vascular events (0.9%). Patients who experienced any complication had higher preprocedure troponin levels and were more likely to undergo treatment using the retrograde approach. In multivariable analysis, use of the retrograde approach was independently associated with increased risk of periprocedural complications (odds ratio, 2.057; 95% confidence interval, 1.045-4.051; P=.04). CONCLUSIONS: Major complications of CTO PCI are infrequent, but are more common with use of the retrograde approach.

Angiographic success and procedural complications in patients undergoing retrograde percutaneous coronary chronic total occlusion interventions: a weighted meta-analysis of 3,482 patients from 26 studies.

BACKGROUND: The efficacy and safety profile of retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We sought to perform a weighted meta-analysis of the success and complication rates of retrograde CTO PCI. METHODS: We conducted a meta-analysis of 26 studies published between 2006 and April 2013 reporting in-hospital outcomes of retrograde CTO PCI. Data on procedural success, frequency of death, emergent coronary artery bypass graft surgery (CABG), stroke, myocardial infarction (MI), perforation, tamponade, stent thrombosis, major vascular or bleeding events, contrast nephropathy, and radiation skin injury were collected. RESULTS: A total of 26 studies with 3482 patients and 3493 target CTO lesions were included. Primary retrograde CTO PCI was attempted in 52.4%. Pooled estimates of outcomes were as follows: procedural success 83.3% [95% confidence interval (CI): 79.0% to 87.7%]; death 0.7% (95% CI: 0.5% to 1.2%); urgent CABG 0.7% (95% CI: 0.4% to 1.2%); tamponade 1.4% (95% CI: 1.0% to 2.2%); collateral perforation 6.9% (95% CI: 4.6% to 10.4%); coronary perforation 4.3% (95% CI: 1.2% to 15.4%); donor vessel dissection 2% (95% CI: 0.9% to 4.5%); stroke 0.5% (95% CI: 0.2% to 1.0%); MI 3.1% (95% CI: 0.2% to 5.0%); Q wave MI 0.6% (95% CI: 0.4% to 1.1%); vascular access complications 2% (95% CI: 0.9% to 4.5%); contrast nephropathy 1.8% (95% CI: 0.8% to 3.7%); and wire fracture and equipment entrapment 1.2% (95% CI: 0.6% to 2.5%). CONCLUSIONS: Retrograde CTO PCI is associated with high procedural success rate and acceptable risk for procedural complications.

Fast virtual functional assessment of intermediate coronary lesions using routine angiographic data and blood flow simulation in humans: comparison with pressure wire - fractional flow reserve.

AIMS: To develop a simplified approach of virtual functional assessment of coronary stenosis from routine angiographic data and test it against fractional flow reserve using a pressure wire (wire-FFR). METHODS AND RESULTS: Three-dimensional quantitative coronary angiography (3D-QCA) was performed in 139 vessels (120 patients) with intermediate lesions assessed by wire-FFR (reference standard: ≤0.80). The 3D-QCA models were processed with computational fluid dynamics (CFD) to calculate the lesion-specific pressure gradient (ΔP) and construct the ΔP-flow curve, from which the virtual functional assessment index (vFAI) was derived. The discriminatory power of vFAI for ischaemia- producing lesions was high (area under the receiver operator characteristic curve [AUC]: 92% [95% CI: 86-96%]). Diagnostic accuracy, sensitivity and specificity for the optimal vFAI cut-point (≤0.82) were 88%, 90% and 86%, respectively. Virtual-FAI demonstrated superior discrimination against 3D-QCA-derived % area stenosis (AUC: 78% [95% CI: 70- 84%]; p<0.0001 compared to vFAI). There was a close correlation (r=0.78, p<0.0001) and agreement of vFAI compared to wire-FFR (mean difference: -0.0039±0.085, p=0.59). CONCLUSIONS: We developed a fast and simple CFD-powered virtual haemodynamic assessment model using only routine angiography and without requiring any invasive physiology measurements/hyperaemia induction. Virtual-FAI showed a high diagnostic performance and incremental value to QCA for predicting wire-FFR; this "less invasive" approach could have important implications for patient management and cost.

Long-term outcomes with use of the CrossBoss and stingray coronary CTO crossing and re-entry devices.

BACKGROUND: The Boston Scientific CrossBoss and Stingray Coronary CTO Crossing and Re-Entry devices (formerly the BridgePoint Medical System) can improve success rates in chronic total occlusion (CTO) percutaneous coronary intervention (PCI), but there are no published data on long-term clinical outcomes. METHODS: The acute and long-term outcomes of 170 consecutive patients who underwent CTO PCI at our institution were reviewed, including 60 patients in whom the CrossBoss and Stingray devices were used and 110 patients treated with other crossing strategies. RESULTS: Baseline characteristics were similar between the two cohorts. Patients in whom the CrossBoss/Stingray was utilized had more prior CTO PCI attempts (13.1% vs 1.6%; P=.003), required longer fluoroscopy times (46 ± 22 minutes vs 35 ± 20 minutes; P<.001), higher contrast dose (390 ± 141 mL vs 323 ± 132 mL; P>.99), and more guidewires for lesion crossing (8.0 ± 6.5 vs 4.7 ± 2.3; P<.001), but procedural success (75.8% vs 76.2%; P>.99) and major complication rates (4.8% vs 3.2%; P=.69) were similar. During a median follow-up of 1.81 years, the CrossBoss/Stingray group had no difference in target lesion revascularization (40.9% vs 29.6%; P=.13) and major adverse clinical events (40.3% vs 35.2%; P=.42). CONCLUSIONS: Use of the CrossBoss/Stingray devices for CTO PCI is associated with equally high success and equally low complication rates as other techniques, both immediately post procedure and during long-term follow-up, in spite of its use in higher complexity cases.

Circadian variation of stent thrombosis and the effect of more robust platelet inhibition: a post hoc analysis of the TRITON-TIMI 38 trial.

BACKGROUND: The well-described morning peak in the onset of acute coronary syndromes has been partly attributed to increased platelet activity upon arising. It has been suggested that stent thrombosis (ST) exhibits a similar pattern. We assessed whether a diurnal variation in ST occurs, and whether more robust antiplatelet therapy with prasugrel (vs clopidogrel) can attenuate a morning excess. METHODS AND MATERIALS: Patients from the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-Thrombolysis in Myocardial Infarction (TRITON-TIMI) 38 trial (N = 13 608) with adjudicated ST classified per the Academic Research Consortium definitions of definite (N = 135) and probable (N = 27) were grouped into prespecified 8-hour intervals by time of onset: early (6 am-2 pm), late-day (2 pm-10 pm), and overnight (10 pm-6 am). We compared the rates per 1000 patients of ST across time intervals and stratified by treatment and stent type. RESULTS: A diurnal variation in definite/probable ST was observed with rates of 6.5, 3.7, and 2.1 for early, late-day, and overnight intervals, respectively (P < .001), per 1000 patients treated. A sensitivity analysis excluding periprocedural acute-ST (<24 hours after index percutaneous coronary intervention [PCI]) resulted in similar findings (5.2, 2.5, and 1.8 per 1000, P < .001). The circadian variation in ST was observed in patients on clopidogrel (9.7, 4.8, and 3.1 per 1000, P < .001) with the highest rate of ST early in the day. Patients on prasugrel also demonstrated a circadian variation with particularly low rates of overnight ST (3.4, 3.0, and 1.1 per 1000, P = .020). CONCLUSIONS: In TRITON-TIMI 38 trial, the timing of ST exhibited a significant diurnal variation similar to that seen with onset of other acute coronary syndromes. ST occurred less frequently among patients randomized to prasugrel compared to clopidogrel with the greatest absolute reduction (6.2 per 1000 patients) in events earlier in the day when platelet activity is known to be highest.

A randomized comparison of the transradial and transfemoral approaches for coronary artery bypass graft angiography and intervention: the RADIAL-CABG Trial (RADIAL Versus Femoral Access for Coronary Artery Bypass Graft Angiography and Intervention).

OBJECTIVES: This study sought to compare and contrast use and radiation exposure using radial versus femoral access during cardiac catheterization of patients who had previously undergone coronary artery bypass graft (CABG) surgery. BACKGROUND: Limited information is available on the relative merits of radial compared with femoral access for cardiac catheterization in patients who had previously undergone CABG surgery. METHODS: Consecutive patients (N = 128) having previously undergone CABG surgery and referred for cardiac catheterization were randomized to radial or femoral access. The primary study endpoint was contrast volume. Secondary endpoints included fluoroscopy time, procedure time, patient and operator radiation exposure, vascular complications, and major adverse cardiac events. Analyses were by intention-to-treat. RESULTS: Compared with femoral access, diagnostic coronary angiography via radial access was associated with a higher mean contrast volume (142 ± 39 ml vs. 171 ± 72 ml, p < 0.01), longer procedure time (21.9 ± 6.8 min vs. 34.2 ± 14.7 min, p < 0.01), greater patient air kerma (kinetic energy released per unit mass) radiation exposure (1.08 ± 0.54 Gy vs. 1.29 ± 0.67 Gy, p = 0.06), and higher operator radiation dose (first operator: 1.3 ± 1.0 mrem vs. 2.6 ± 1.7 mrem, p < 0.01; second operator 0.8 ± 1.1 mrem vs. 1.8 ± 2.1 mrem, p = 0.01). Fewer patients underwent ad hoc percutaneous coronary intervention (PCI) in the radial group (37.5% vs. 46.9%, p = 0.28) and radial PCI procedures were less complex. The incidences of the primary and secondary endpoints was similar with femoral and radial access among PCI patients. Access crossover was higher in the radial group (17.2% vs. 0.0%, p < 0.01) and vascular access site complications were similar in both groups (3.1%). CONCLUSIONS: In patients who had previously undergone CABG surgery, transradial diagnostic coronary angiography was associated with greater contrast use, longer procedure time, and greater access crossover and operator radiation exposure compared with transfemoral angiography. (RADIAL Versus Femoral Access for Coronary Artery Bypass Graft Angiography and Intervention [RADIAL-CABG] Trial; NCT01446263).

Relation between time of symptom onset of ST-segment elevation myocardial infarction and patient baseline characteristics: from the National Cardiovascular Data Registry.

BACKGROUND: The presence of a morning excess of ST-segment elevation myocardial infarction (STEMI) has been observed. The relation between patient characteristics and timing of STEMI may provide insight into the biological processes responsible for this phenomenon. HYPOTHESIS: Patient baseline characteristics will vary with timing of STEMI. METHODS: We performed an analysis using a large national registry of unselected patients with STEMI (N=45,218). Patients were categorized by time of symptom onset: early (6 am-2 pm), late day (2 pm-10 pm), and overnight (10 pm-6 am) then evaluated for variations in characteristics. RESULTS: A circadian variation in the timing of symptom onset of STEMI was observed (early 41%, late day 32%, and overnight 26%, P<0.001). Circadian variations in factors known to alter timing of events were seen, including lower rates of home ß-blocker use, smoking, and diabetes, with early onset of STEMI symptoms. In addition, patients in the 6 am to 2 pm subgroup were more likely older, white race, and male, with higher rates of home aspirin use and lower rates of obesity. Higher rates of coexisting cardiovascular disease, including prior heart failure, 3-vessel coronary artery disease, and depressed left ventricular ejection fraction, were observed in the overnight group. More robust antiplatelet therapy with home clopidogrel use was not associated with a change in the timing of events. CONCLUSIONS: A morning excess of STEMI continues to exist and represents a potential target for preventative strategies. Patient baseline characteristics vary with the onset of STEMI and may reflect a physiologic relationship between these factors and the timing of events.

Angiographic success and procedural complications in patients undergoing percutaneous coronary chronic total occlusion interventions: a weighted meta-analysis of 18,061 patients from 65 studies.

OBJECTIVES: This study sought to perform a weighted meta-analysis of the complication risk during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BACKGROUND: The safety profile of CTO PCI has received limited study. METHODS: We conducted a meta-analysis of 65 studies published between 2000 and 2011 reporting procedural complications of CTO PCI. Data on the frequency of death, emergent coronary artery bypass graft surgery, stroke, myocardial infarction, perforation, tamponade, stent thrombosis, major vascular or bleeding events, contrast nephropathy, and radiation skin injury were collected. RESULTS: A total of 65 studies with 18,061 patients and 18,941 target CTO vessels were included. Pooled estimates of outcomes were as follows: angiographic success 77% (95% confidence interval [CI]: 74.3% to 79.6%); death 0.2% (95% CI: 0.1% to 0.3%); emergent coronary artery bypass graft surgery 0.1% (95% CI: 0.0% to 0.2%); stroke <0.01% (95% CI: 0.0% to 0.1%); myocardial infarction 2.5% (95% CI: 1.9% to 3.0%); Q-wave myocardial infarction 0.2% (95% CI: 0.1% to 0.3%); coronary perforation 2.9% (95% CI: 2.2% to 3.6%); tamponade 0.3% (95% CI: 0.2% to 0.5%); and contrast nephropathy 3.8% (95% CI: 2.4% to 5.3%). Compared with successful procedures, unsuccessful procedures had higher rates of death (0.42% vs. 1.54%, p < 0.0001), perforation (3.65% vs. 10.70%, p < 0.0001), and tamponade (0% vs. 1.65%, p < 0.0001). Among 886 lesions treated with the retrograde approach, success rate was 79.8% with no deaths and low rates of emergent coronary artery bypass graft surgery (0.17%) and tamponade (1.2%). CONCLUSIONS: CTO PCI carries low risk for procedural complications despite high success rates.

Procedural outcomes of revascularization of chronic total occlusion of native coronary arteries (from a multicenter United States registry).

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) is a rapidly evolving area of interventional cardiology. We sought to examine the immediate procedural and in-hospital clinical outcomes of native coronary artery CTO PCI from a multicenter United States (US) registry. We retrospectively examined the procedural outcomes of 1,361 consecutive native coronary artery CTO PCIs performed at 3 US institutions from January 2006 to November 2011. Mean age was 65 ± 11 years, 85% of patients were men, 40% had diabetes, 37% had previous coronary artery bypass graft surgery, and 42% had previous PCI. The CTO target vessel was the right coronary artery (55%), circumflex (23%), left anterior descending artery (21%), and left main or bypass graft (1%). The retrograde approach was used in 34% of all procedures. The technical and procedural success rates were 85.5% and 84.2%, respectively. The mean procedural time, fluoroscopy time, and contrast utilization were 113 ± 61 minutes, 42 ± 29 minutes, and 294 ± 158 ml, respectively. In multivariate analysis, female gender, no previous coronary artery bypass surgery, and years since initiation of CTO PCI at each center were independent predictors of procedural success. Major complications occurred in 24 patients (1.8%). In conclusion, among selected US-based institutions with experienced operators, native coronary artery CTO PCI can be performed with high success and low major complication rates.

Circadian variation in patient characteristics and outcomes in ST-segment elevation myocardial infarction.

A morning peak in ST-segment elevation myocardial infarction (STEMI) has been described. The authors explored the relationship between variation of symptom onset, patient characteristics, and outcomes in two worldwide fibrinolytic trials. A total of 35 492 patients with STEMI were grouped into 8-h intervals by time of symptom onset: early (06:00 to 13:59 h), late-day (14:00 to 21:59 h), overnight (22:00 to 05:59 h). The authors correlated timing with patient characteristics and outcomes (adjusted for thrombolysis in myocardial infarction [TIMI] risk score) first in InTIME II-TIMI 17 trial (N = 15 031), and confirmed in the ExTRACT-TIMI 25 trial (N = 20 461). Timing was similar in the derivation (early 49%, late-day 30%, and overnight 21%; p < .001) and validation set (48%, 31%, and 21%, respectively; p < .001). Some patient characteristics consistently varied with time of symptom onset. Patients in the early cohort were older with poorer renal function. The late-day group had more smokers with higher initial heart rate and systolic blood pressure. Those with overnight symptom onset had higher rates of obesity, prior myocardial infarction, and treatment delays. Prior use of aspirin and beta-blockers was also highest in the overnight group. Relative to the early cohort, adjusted mortality was higher with late-day onset (derivation odds ratio [OR]: 1.19, p = .04; validation OR: 1.18, p = .01), but there was no excess in mortality overnight compared with early (derivation OR: .97, p = .72; validation OR: 1.01, p = .90). Composite endpoints followed similar patterns. This study indicates that circadian patterns in onset of STEMI continue to exist with patient characteristics differing by time of day. Despite a potential physiologic resistance to morning thrombolysis, outcomes were best in the early cohort, intermediate overnight, and worst with late-day symptom onset. Efforts to reduce smoking and improve control of blood pressure could reduce the number of patients with late-day onset of STEMI who experience the worst outcomes.

Endoscopic foreign body removal for treatment of chronic abdominal pain in patients after Roux-en-Y gastric bypass.

BACKGROUND: Common endoscopic findings in patients who have undergone Roux-en-Y gastric bypass (RYGB) with chronic abdominal pain have included marginal ulceration, gastrogastric fistula, and jejunal erosion. However, suture or staples eroding into the gastric pouch can also contribute to abdominal pain. Redundant suture is typically regarded as a normal part of the postoperative anatomy. The objectives of the present study were to assess the effects of endoscopic foreign body removal of partially exposed sutures and staples in post-RYGB patients with chronic abdominal pain at a university hospital in the United States. METHODS: We performed a retrospective study of consecutive patients from January 2006 to July 2007. Post-RYGB patients with chronic abdominal pain underwent endoscopic foreign body removal of exposed sutures/staples. Pain scores were obtained before the procedure, immediately after the procedure, and at the telephone follow-up (median 7.2 months). RESULTS: Of 21 patients, 15 (71%) reported immediate symptomatic improvement. Specific endoscopic accessories were found to be more useful than others in managing the various foreign materials. Of the 21 patients, 15 (71%) were available for telephone follow-up. Of these 15 patients, 13 (87%) reported continued symptomatic improvement, with 9 (60%) reporting complete pain resolution and 4 (27%) reporting partial improvement. Eroded foreign material was seen in association with marginal ulcers in 3 patients (14%), gastritis in 7 patients (33%), and an inflammatory polyp in 1 patient (5%). CONCLUSIONS: Eroded suture and staples can cause chronic abdominal pain in post-RYGB patients. In symptomatic patients, visible suture or staples should be considered a potential etiology of chronic pain, instead of normal postoperative findings. Endoscopic foreign body removal might be of therapeutic benefit in these patients.