Outcomes of Percutaneous Revascularization in Severe Ischemic Left Ventricular Dysfunction.

PURPOSE OF REVIEW: This article presents a comprehensive review of coronary revascularization versus optimal medical therapy (OMT) in patients with severe ischemic left ventricular dysfunction. RECENT FINDINGS: The REVIVED-BCIS2 trial randomized 700 patients with extensive coronary artery disease and left ventricular (LV) ejection fraction (LVEF) ≤ 35% and viability in more than four dysfunctional myocardial segments to percutaneous coronary intervention (PCI) plus OMT versus OMT alone. Over a median duration of 41 months, there was no difference in the composite of all-cause mortality, heart failure hospitalization, or improvement in LVEF with PCI plus OMT versus OMT alone at 6 and 12 months, quality of life scores at 24 months, or fatal ventricular arrhythmia. The STICH randomized trial was conducted between 2002 and 2007, involving patients with LV dysfunction and coronary artery disease. The patients were assigned to either CABG plus medical therapy or medical therapy alone. At the 5-year follow-up, the trial showed that CABG plus medical therapy reduced cardiovascular disease-related deaths and hospitalizations but no reduction in all-cause mortality. However, a 10-year follow-up showed a significant decrease in all-cause mortality with CABG. The currently available evidence showed no apparent benefit of PCI in severe ischemic cardiomyopathy as compared to OMT, but that CABG improves outcomes in this patient population. The paucity of data on the advantages of PCI in this patient population underscores the critical need for optimization of medical therapy for better survival and quality of life until further evidence from RCTs is available.

Antegrade Crossing Techniques for Hard Proximal Occlusion Caps Without the Use of Dedicated Chronic Total Occlusion Devices: A Pictorial Review.

CLINICAL IMPACT: Infra-inguinal Chronic Total Occlusions recanalisation is considered technically challenging. The conventional manipulation of standard guidewires and catheters has proven to be successful in a considerable percentage of cases but success rate could dramatically drop in presence of challenging lesions. The additional use of retrograde access and re-entry devices could increase technical success but could negatively affect procedural time and overall costs. Twenty different techniques of Chronic Total Occlusions antegrade crossing are hereby described with appropriate schematic representations. The aim is to help operators to apply them in specific anatomy subsets and clinical presentations and ultimately to increase procedural success rate.

Zeroing on Gadolinium to Complement Intravascular Ultrasound in Zero-Contrast Percutaneous Coronary Interventions.

BACKGROUND: Many techniques have been developed to minimize the risk of contrast-induced nephropathy (CIN) in patients with chronic kidney disease (CKD) through drastic reductions in iodinated contrast volume and the use of intravascular ultrasound (IVUS). While some of the described techniques completely avoid contrast use and rely on transthoracic echocardiography to check for potential pericardial bleeding, this strategy may miss or delay the treatment of potentially life-threatening complications. We hereby propose the use of group II gadolinium (Gd)-based contrast agents, instead of iodinated contrast, to complement IVUS, in order to achieve the goal of zero-contrast percutaneous coronary intervention, without raising the risk of CIN. These agents have been shown to be relatively safe in the setting of advanced CKD, with an overall reported risk of nephrogenic systemic fibrosis of <0.07% and no significant nephrotoxicity. Combining the use of Gd with the "live IVUS technique" in patients with advanced CKD seems to achieve the goal of high-precision PCI, without significantly compromising procedural safety.

Coronary stent positioning under live IVUS guidance in low contrast percutaneous coronary interventions: The live IVUS stenting technique.

In patients with renal insufficiency, advanced techniques have been described to achieve ultra-low contrast or zero contrast percutaneous coronary interventions (PCI). However, these techniques use intra-coronary imaging before stent placement to determine adequate landing zones, by correlating them with saved fluoroscopic landmarks. Still, this leaves the operator with a certain degree of uncertainty about the exact lesion coverage, which is checked with post-stent intra-coronary imaging. We hereby describe a novel technique which takes away the concern of uncertainty regarding stent-landing zones and allows for the highest amount of precision in stent positioning, arguably even better than with the use of angiography. This technique involves positioning coronary stents under the live guidance of an intravascular ultrasound (IVUS) catheter which is positioned simultaneously, side by side to a stent. This technique takes advantage of all the benefits of IVUS based PCI without losing the precision in stent positioning when compared to traditional angiography. It simplifies the application of low contrast PCI by the interventional cardiology community, while maintaining the confidence in precise stenting. It has also the potential to decrease the incidence of contrast-induced nephropathy, hence procedural morbidity, while allowing for optimal long-term image based PCI outcomes. Obviously, it applies to moderate or larger coronary segments, without significant tortuosity. It also comes at the expense of slightly larger guide catheters, which is compensated for by the use of thin walled sheaths or sheathless catheter systems. Finally, radial access is still applicable depending on radial artery size and available equipment.

Dry Field Closure of Large-Bore Access With Iliac Artery Angioplasty Through the Ipsilateral Sheath: The Single-Access Dry-Closure Technique.

The use of large-bore sheaths has risen exponentially in the last decade partly due to the growth of structural heart interventions and various mechanical circulatory support options. Meanwhile, the interventional community has gradually shifted from an open surgical to endovascular closure. However, vascular access complications and bleeding still remain a significant risk. Various techniques involving an additional access site have been described to allow for endovascular bailout of potential complications. However, these by themselves create an additional burden to procedural morbidity. Furthermore, the weight of additional procedural time, contrast, radiation and the need for advanced peripheral endovascular skills constitute considerable downsides to the "second arterial access" strategy. For that reason, we propose an alternative strategy, the "single-access dry-closure" technique, which provides vascular access control without the additional burden and risk of a second arterial access. This involves the use of low-pressure iliac artery occlusive angioplasty, delivered through the ipsilateral sheath during the endovascular closure. We hereby describe the steps, advantages and disadvantages of this novel technique. We also include the description of multiple technical variations depending on the use of one or two preclosed Proglide devices. This novel approach seems to be a safe, effective, simple, fast and economical technique that has the potential to decrease procedural morbidity by avoiding an additional arterial access. It also lowers contrast volume and radiation exposure while improving the overall set-up and operator ergonomics.

Pulmonary Artery Intervention for Submassive Pulmonary Embolism From an Arm Superficial Venous Access.

BACKGROUND: Pulmonary embolism (PE) endovascular interventions are often approached from an internal jugular or femoral venous access. There are multiple advantages of right basilic vein (RBV) access for both patient and operator, especially in the setting of morbid obesity. We hereby describe the case of a 48-year-old, morbidly obese man who presented with acute respiratory insufficiency and was found to have bilateral submassive subocclusive PE, worse on the right. The right ventricular to left ventricular ratio was 2.1 and troponin was elevated. A 7 Fr sheath was placed in the RBV under ultrasound guidance. Selective bilateral pulmonary arteriography was then performed. A 106 x 12 cm EKOS catheter was placed in the segment of highest thrombotic burden for a 6-hour protocol of catheter-directed ultrasound-facilitated thrombolytic therapy. The patient recovered well on a direct oral anticoagulant and his acute symptoms resolved. Treating massive/submassive PE from a RBV access offers the convenience and safety of superficial venous access (for patient and operator), better patient comfort, less venous stasis during therapy with ability to ambulate, less potential for bleeding and vascular complications, less potential for operator radiation exposure when compared with the jugular approach, and better operator ergonomics.

Right Heart Catheterization: Right From the Anatomical Snuffbox.

We present two cases where a right heart catheterization was performed from the anatomical snuffbox through the distal cephalic vein along with a left heart catheterization from the distal radial artery.

The "lend a hand" external bypass technique: External radial to femoral bypass for antegrade perfusion of an ischemic limb with occlusive large bore sheath - A novel and favorable approach.

An occlusive large bore sheath is a frequently encountered situation in cases of cardiogenic shock (CS) requiring mechanical circulatory support (MCS). Resultant acute limb ischemia could be a catastrophic complication which significantly affects the prognosis of an already sick patient population. A novel, yet simple, technique using the radial artery, instead of the ipsilateral or contralateral common femoral artery (CFA), as a donor vessel of an external bypass which provides antegrade perfusion to a limb with an occlusive large bore sheath is hereby described. Radial access (RA) has been shown to improve mortality in acute coronary syndrome; however, it is sometimes avoided by some operators in CS cases due to the possible appropriate need for MCS. This technique offers a substitution of a second CFA access for a RA in order to provide adequate ipsilateral limb perfusion. Hence, one can start a CS case with a default RA and perform peripheral angiography after diagnostic cardiac catheterization. If the peripheral vasculature is inappropriate for MCS, the patient would have already benefited from the mortality advantage of RA. If obstructive PAD is absent, then an occlusive Impella sheath can be placed in a CFA after antegrade ipsilateral superficial femoral artery (SFA) access is obtained for an external radial to femoral bypass, while the PCI is performed through the Impella sheath according to the single access PCI technique. Finally, the advantages and disadvantages of this new approach are described and compared with each of the traditionally known external and internal femoral bypass techniques.