Evaluation of the distal radial approach in percutaneous coronary interventions. A controlled, randomized non-inferiority trial.

INTRODUCTION: The conventional radial approach (CRA), the gold standard approach for percutaneous coronary interventions (PCI), is associated with the risk of radial artery occlusion (RAO). The distal radial approach (DRA) is an effective alternative with fewer complications. AIM: To evaluate the efficacy in terms of puncture success and safety by RAO rate of the DRA in elective PCI in Tunisian patients. METHODS: It was a randomized controlled non-inferiority trial including patients hospitalized for elective PCI. The protocol was previously published (Tunis Med 2022; 100(3): 192-202). The primary endpoints were puncture success and RAO rate at 30 days. RESULTS: Overall, 250 patients were included and the groups were comparable. The preprocedural examination of the radial pulse and the Barbeau test were similar. The majority of PCIs were coronary angiography (82%). In ITT, respectively in CRA versus DRA, puncture success rates were similar (97.6% versus 96.8%; p≤0.500). RAO rates were similar (2.4% versus 3.2%; p≤0.500). Crossovers were similar. PCI through DRA lasted longer but was not more irradiating, however it required more contrast. Overall bleeding and vascular complications were similar. CONCLUSION: This study demonstrated the non-inferiority of DRA compared to CRA for elective PCIs in a Tunisian population regarding puncture success and RAO rate at 30 days. Multicenter trials including urgent PCI with systematic ultrasound screening for RAO are needed.

Clinical Outcomes of Patients Treated With the Bioresorbable Scaffold.

INTRODUCTION: Bioresorbable scaffold (BRS) is a novel device to treat coronary lesions. It may induce a revolution in percutaneous coronary intervention (PCI) and a novel treatment termed vascular restoration therapy. These devices provide short-term scaffolding of the vessel and then dissolve, which would treat the plaque and coronary lumen without inflicting a permanent foreign body in the coronary artery. AIM: This study sought to describe scaffolding in a cohort of Tunisian coronary diseased patients and assess its immediate and mid-term outcomes. METHODS: Twenty nine patients with 42 lesions were enrolled. Mean age was 51.4 years. Mean number of scaffolds per patient was 1.57. RESULTS: Our population was at high cardiovascular risk cumulating at least 3 risk factors. Most of them presented with an acute coronary syndrome (66.6%). In 76.1% there were type A/B1 lesions. Moderate calcification was present in 42.2%. Bifurcation lesions were present in 21.3% and just one chronic total occlusion was treated. Clinical device success and clinical procedural success were respectively 93.1% and 90.3%.Using Kaplan-Meier methods. At 18 months : - The major adverse cardiac events (MACE) rate was 44.8%. - The probability of survival without target lesion revascularization (TLR) was 59.5%. - Definite or Possible scaffold thrombosis rate was 6.9%. In our study, BRS implantation was associated with a high rate of adverse events in the longer term except in case of IVUS guidance with respect of Predilatation + Sizing + Postdilatation (PSP) protocol. CONCLUSION: The theoretical concept of Scaffolding is attractive. One must put into perspective that it is still significantly evolving and improving.

Stent implantation for ostial left anterior descending coronary artery stenosis: clinical particularities, therapeutic strategies, and medium-term outcomes.

BACKGROUND: The stenosis of the ostial left anterior descending artery represents one of the challenges for the interventional cardiologist. The aim of our study was to define the characteristics of this population and to analyze their results in medium term. METHODS: We had undertaken a retrospective study of 76 patients treated in the Cardiology Department of the Military Hospital of Tunis, between January 2014 and March 2017. Percutaneous coronary revascularizations of de novo ostial lesions of the left anterior descending artery were included. RESULTS: The mean age was 59.8 years with a male predominance. Two dilation strategies were adopted: 39% of patients had a "provisional-T-stenting" of the left main coronary artery versus 61% of patients who had a floating stent technic. The main immediate complication was acute occlusion of the circumflex artery ostium. After 12 months, the thrombosis and restenosis rates were 5,2% and 6,5%. Predictors of MACE were: Insulin-requiring diabetes(p=0.05), chronic renal failure(p=0.02), a low-pressure stent deployment(p=0.01), or the presence of signs of left ventricular failure (p<10-3). The predictive factors for stent thrombosis were the alteration of the left ventricular ejection fraction (p<0.01) and the eccentricity of the lesion (p<10-3). Finally, the predictive factors of restenosis were: acute per procedural occlusion of the ostial circumflex artery (p=0.01) or the presence of an associated lesion of distal IVA (p<0,001). CONCLUSION: Ostial lesions of the interventricular artery can be re-vascularized by percutaneous angioplasty with acceptable rates of major cardiovascular events. However, the risk of iterative revascularization remains significant.