Acute coronary syndromes and multivessel coronary artery disease.

Patients with acute coronary syndromes (ACS) and multivessel coronary artery disease are frequently encountered during clinical practice and those patients are at higher risk of subsequent acute cardiovascular events. In patients presenting with both ST-segment elevation myocardial infarction and non-ST-segment elevation acute coronary syndromes, complete revascularization is associated with decreased risk of major adverse cardiovascular events. Nevertheless, the optimal timing of the intervention and treatment modality are still in discussions. Furthermore, non-culprit lesions assessment based on stenosis severity, either on visual or on functional evaluation, may not provide information about vulnerable plaques prone to thrombosis. Therefore, insights from intracoronary imaging could further identify high-risk plaque and patients at higher risk of future adverse events. This article aims to provide an overview of current guideline recommendations, envisioning future perspectives for the treatment of patients with ACS and multivessel disease.

Calcified coronary lesions.

The treatment of calcific coronary lesions is still a major interventional issue in haemodynamics laboratories. The prevalence of the disease is even increasing, considering the general ageing of the population undergoing coronarography, as well as the often associated comorbidities. In recent years, new devices have been developed that allow both better identification and also better treatment of these lesions. The aim of this review is to summarize both imaging modalities and dedicated techniques and materials, thus providing a kind of compendium for the treatment approach.

Design of the PERSEO Registry on the management of patients treated with oral anticoagulants and coronary stent.

AIM: Percutaneous coronary intervention with stent implantation (PCI-S) in patients requiring chronic oral anticoagulant therapy (OAC) is associated with an increased risk of bleeding and ischemic complications. Different randomized studies showed a significant advantage of a double antithrombotic therapy and superiority of direct oral anticoagulant (DOAC) compared with warfarin, but real-world data are limited. Aim is to evaluate the antithrombotic management and clinical outcome of patients with an indication for OAC who undergo PCI-S in a 'real-world' setting. METHODS: The multicentre prospective observational PERSEO (PERcutaneouS coronary intErventions in patients treated with Oral anticoagulant therapy) Registry (ClinicalTrials.gov Identifier: NCT03392948) has been designed to enrol patients requiring OAC treated by PCI-S in 25 Italian centres. A target of at least 1080 patients will be followed for 1 year and data on thromboembolic and bleeding events and changes in antithrombotic therapy will be registered. The primary end point is a combined measure of efficacy and safety outcome (NACE), including major bleeding events and major adverse cardiac and cerebral events at 1-year follow-up in patients treated with DOAC (and dual or triple antiplatelet therapy) compared with the corresponding strategies with vitamin K antagonists. A secondary prespecified analysis has been defined to evaluate NACE in dual versus triple antithrombotic therapy after hospital discharge at 1-year follow-up. CONCLUSION: The PERSEO Registry will investigate in a 'real world' setting the safety and efficacy of DOAC versus warfarin and dual versus triple antithrombotic therapy in patients with indication for oral anticoagulant therapy who undergo PCI-S.

Long term follow-up of "full metal jacket" of de novo coronary lesions with new generation Zotarolimus-eluting stents.

BACKGROUND: Diffuse coronary artery disease treatment still remains a challenge for interventional cardiologists and cardiac surgeons. There are few data on full metal jacket (FMJ) stenting, especially with new-generation drug-eluting stents. We aimed to assess the efficacy and safety of FMJ with new-generation Zotarolimus-eluting stents (n-ZES). METHODS AND RESULTS: All patients who underwent FMJ with n-ZES (≥60mm stent length) in eleven Italian interventional centers participating in the Clinical Service® project were included in this analysis. The project population consisted of 120 patients and 122 lesions. Mean age was 67±10years and 95 (79.2%) patients were male. A chronic total occlusion was present in 34 lesions (27.9%). The number of stents implanted per lesion was 2.9±0.8, and the diameter of the stents was 3.0±0.5mm. Predilation and post-dilatation were performed in 107 (87.7%) and 92 (75.4%) patients, respectively. At 41±21month follow-up there were 2 patients with subacute definite stent thrombosis, 6 patients (5.0%) had cardiac death and 5 patients (4.2%) had non-fatal myocardial infarction. Seven patients (5.8%) underwent clinically-driven target lesion revascularization. Fourteen patients (11.7%) had at least one major adverse cardiac event. CONCLUSION: The treatment of diffuse coronary artery disease with FMJ stenting with n-ZES appears to be effective and safe. Late and very-late ST does not seem to be an issue and the rate of restenosis and of major cardiac adverse events after more than 3-year follow-up is rather low.

Percutaneous coronary interventions and antiplatelet therapy in renal transplant recipients.

Cardiovascular disease is the leading cause of mortality and morbidity following renal transplantation (RT), accounting for 40-50% of all deaths. After renal transplantation, an adverse cardiovascular event occurs in nearly 40% of patients; given the dialysis vintage and the average wait time, the likelihood of receiving coronary revascularization is very high. There is a significant gap in the literature in terms of the outcomes of prophylactic coronary revascularization in renal transplantation candidates. Current guidelines on myocardial revascularization stipulate that renal transplant patients with significant coronary artery disease (CAD) should not be excluded from the potential benefit of revascularization. Compared with percutaneous coronary intervention (PCI), however, coronary artery bypass grafting is associated with higher early and 30-day mortality. About one-third of renal transplant patients with CAD have to be treated invasively and so PCI is currently the most popular mode of revascularization in these fragile and compromised patients. A newer generation drug-eluting stent (DES) should be preferred over a bare metal stent (BMS) because of its lower risk of restenosis and improved safety concerns (stent thrombosis) compared with first generation DES and BMS. Among DES, despite no significant differences being reported in terms of efficacy, the newer everolimus and zotarolimus eluting stents should be preferred given the possibility of discontinuing, if necessary, dual antiplatelet therapy before 12 months. Since there is a lack of randomized controlled trials, the current guidelines are inadequate to provide a specifically tailored antiplatelet therapeutic approach for renal transplant patients. At present, clopidogrel is the most used agent, confirming its central role in the therapeutic management of renal transplant patients undergoing PCI. While progress in malignancy-related mortality seems a more distant target, a slow but steady reduction in cardiovascular deaths, improving pharmacological and interventional therapy, is nowadays an achievable medium-term target in renal transplant patients.

Frequency-domain optical coherence tomography findings in patients with bifurcated lesions undergoing provisional stenting.

AIMS: Bifurcations represent challenging lesions which may benefit from improved understanding of stent-related vessel complications. Since optical coherence tomography (OCT) allows us to detect post-stenting vessel injuries, we sought to assess the geographic pattern of stent-related complications occurring during provisional stenting of bifurcated lesions. METHODS AND RESULTS: Fifty-one patients with bifurcated lesions treated by provisional stenting and undergoing intra-procedural OCT assessment were enrolled. OCT images were acquired with the aim of guiding the percutaneous coronary intervention but were re-analysed off-line for the present study. The stented bifurcation was divided into four segments [three in the main vessel (MV) and one in the side branch (SB)]. The following acute post-stenting vessel injuries/complications at the different bifurcation segments were evaluated: (i) stent under-expansion, (ii) stent malapposition, (iii) stent edge dissection, (iv) side-branch ostium dissection, (v) tissue prolapse, (vi) intracoronary thrombus, and (vii) in-stent dissection. A total of 55 bifurcation lesions undergoing provisional stenting were analysed. At least one OCT complication was detectable in all cases. Across different bifurcation sites, significant differences in the occurrence of stent complications were observed. In particular, stent malapposition was more common at the proximal MV segment (P < 0.001), while tissue prolapse was more common at the distal MV segment (P < 0.001). CONCLUSION: In bifurcated interventions, OCT often detects vessel injuries/stent complications, which tend to have a specific geographical distribution. In particular, stent malapposition is more common at the proximal MV and tissue prolapse at the distal MV segment.

Selection of Medications to Prevent Stroke Among Individuals With Atrial Fibrillation : Update on Prevention of Stroke in Patients with AF.

OPINION STATEMENT: Vitamin K antagonists have been the only available orally active anticoagulants for decades. Although effective, their numerous limitations have driven the introduction of new oral anticoagulants (NOAs) that showed effectiveness at fixed doses without the need for routine coagulation monitoring. However, the safety and efficacy observed in controlled clinical trials may be hard to translate in clinical practice. Clinical conditions as well as drug interactions may considerably impact on patient outcomes. Moreover, the inability to monitor the pharmacological activity of NOAs and the absence of any antidote in the setting of bleeding or emergent invasive procedures may limit their use. Vitamin K antagonists will be still used in many circumstances, including patients with an optimal control of the INR, with mechanical heart valves, and other indications for which these new agents have not been investigated. Nevertheless, these new agents will reduce the burden of anticoagulation management at the patient as well as Health Care level.

Resolute zotarolimus-eluting stent to treat bifurcated lesions according to the provisional technique: a procedural performance comparison with sirolimus- and everolimus-eluting stents.

OBJECTIVES: Different drug-eluting stents (DES) may have different performance in bifurcation PCI. Thus, we compared the performance of a novel zotarolimus-eluting stent (ZRS) with that obtained using two other DES in bifurcation PCI. METHODS AND RESULTS: Consecutive patients with bifurcated lesions undergoing DES implantation were treated by a provisional approach with sirolimus-eluting stent (SES) or everolimus-eluting stent (EES) during a former period, and then by ZRS in a second period. The PCI procedural details were prospectively recorded and angiographic results were evaluated by a 3-dimensional quantitative coronary analysis software. Primary procedural end-point was "side-branch (SB) trouble" (occurrence, after MV stenting, of: SB TIMI flow<3 or need of specific wires for SB rewiring, or failure to re-wire/dilate the SB). Primary angiographic end-point was post-PCI minimal-lumen-diameter at SB-ostium. During the study, 225 patients were enrolled and treated by ZRS (n=75), by SES (n=75) or by EES (n=75). Among procedural characteristics, "SB trouble" occurred in 4% of patients treated by ZRS, a figure significantly lower compared to SES (16%, P=0.014) and non-significantly lower compared to EES (11%, P=0.12). At multivariable analysis, DES type, pre-PCI SB flow <3 and bifurcation complexity were the only predictors of "SB trouble". After the procedure, minimal-lumen-diameter at SB ostium was significantly larger with ZRS compared to SES (1.94 vs. 1.64 mm, P=0.008) and similar to that of EES. CONCLUSIONS: ZRS is associated to improved performance and SB angiographic results compared to SES. These results support the hypothesis that DES selection may influence the procedural course and the acute angiographic result of bifurcation PCI.

One-year outcomes of consecutive patients treated by Endeavor zotarolimus and Resolute zotarolimus stents: the impact of polymer coating in drug-eluting stent technology.

BACKGROUND: Polymer-coating represents a key component of drug-eluting stent (DES) technology and its possible impact on vessel-wall healing is a matter of debate. The clinical impact of different polymer-coating may be assessed by comparing the outcome of patients treated by DES having the same stent platform and drug, and differing in the polymer. Thus, we compared the clinical outcome of patients treated by Endeavor Zotarolimus-eluting stent (E-ZES) and Resolute Zotarolimus-eluting stent (R-ZES) as they differ in the polymer-coating only. METHODS: At our Institution, E-ZES was available during a first period and then it was substituted by the R-ZES during a second period. Clinical, angiographic, and procedural data were prospectively collected. Clinical follow-up was prospectively obtained up to 1-year. Primary endpoint was the occurrence of major adverse cardiac events (MACE) at 12-month. RESULTS: A total of 467 patients undergoing percutaneous coronary intervention were enrolled: 233 patients treated with E-ZES and 234 with R-ZES. Patients treated by R-ZES had similar clinical characteristics and worse angiographic characteristics compared with those treated by E-ZES. At 12-month follow-up, MACE rate was significantly lower in the R-ZES group compared with E-ZES group (4.2% vs. 14.6%; P < 0.01). This difference was due to nonsignificantly lower rates of death and myocardial infarction and to significant lower rate of target-lesion-revascularization (R-ZES 3.4% vs. E-ZES 10.3%, P < 0.01). CONCLUSIONS: The results of this study suggest that the clinical outcome of patients treated by DES differing for the polymer coating only may be different. Polymer coating is a pivotal, probably underrated, component of DES technology which may influence the clinical performance of DES.

EuroSCORE predicts long-term mortality of unselected patients undergoing percutaneous coronary interventions.

BACKGROUND: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) is a simple risk model able to predict early and late mortality after cardiac surgery. Recent data suggest that this score may also predict early clinical outcome after percutaneous coronary intervention (PCI). Data regarding EuroSCORE usefulness to predict late outcome after PCI in unselected patients are lacking. METHODS: EuroSCORE was prospectively assessed in consecutive patients undergoing PCI during 18 months. The primary end-point was cardiac mortality during the follow-up after PCI. Total mortality was the secondary end-point. Kaplan-Meyer analyses were performed dividing the study population in three subgroups according to the additive EuroSCORE algorithm (low risk group: EuroSCORE 0-2; medium risk group: EuroSCORE 3-5; high-risk group: EuroSCORE ≥ 6). Receiver operating characteristics (ROC) curve and landmark analysis on cardiac mortality after 30 days were performed. RESULTS: The study population comprised 1170 patients undergoing PCI. Mean follow-up duration was 633 days (range: 365-1000 days). Cardiac mortality was 2%; 2.4%; 13.2% in patients with low, medium and high EuroSCORE respectively. Kaplan-Meyer survival curves for cardiac death differed significantly between EuroSCORE groups (p<0.0001). The area under the ROC curve for the prediction of cardiac death was 0.77. Similar results were obtained for total mortality. At landmark analysis starting 30 days after PCI, EuroSCORE groups were significantly associated with different survival in the long term (P=0.014). CONCLUSION: EuroSCORE risk model can be efficiently utilized to predict late mortality in consecutive, unselected, patients undergoing PCI.

Angiographic and clinical outcome of percutaneous coronary intervention for in-stent restenosis of bifurcated lesions.

AIMS: Restenosis and bifurcated lesions represent technically challenging lesions for percutaneous coronary interventions (PCI). Data regarding procedural and clinical outcome of re-PCI for restenosis of stented bifurcated lesions are lacking. Our aims were to evaluate angiographic and procedural results and one-year clinical outcome of PCI for restenosis of stented bifurcated lesions. METHODS AND RESULTS: Consecutive patients undergoing PCI for restenosis of one bifurcated lesion previously treated by stent implantation at our centre entered the study. The primary endpoint was angiographic and procedural success, defined as final residual stenosis ≤30% in the main vessel with TIMI 3 flow in both MV and side branch, and stenosis ≤50% in the SB without death, myocardial infarction or target vessel revascularisation during hospitalisation. The secondary endpoint was the incidence of major adverse cardiac events at one-year clinical follow-up. The study population included 64 patients treated by PCI on a single restenotic bifurcated lesion. Angiographic and procedural success was achieved in 61 cases (95.3%) whereas the three cases of failure were due to SB residual stenosis >50%. At one year, MACE rate was 18.7% (12/64) with rates of cardiac death, MI and TVR of 1.6% (1/64), 6.2% (4/64) and 18.7% (12/64), respectively. No cases of stent thrombosis occurred. Patients treated by a single drug-eluting stent (DES) on main vessel (MV) had a significant lower rate of MACE at one year as compared to patients treated with balloon only PCI or by double-stenting technique or with a BMS, irrespective of the strategy adopted: 4/37 (10.8%) vs. 8/27 (29.6%); p=0.04. CONCLUSIONS: PCI in restenotic bifurcated lesions can be a good treatment option with high rates of angiographic and procedural success and an acceptable rate of long-term MACE. The use of a single DES implantation may be a promising strategy as it is associated with lower rates of MACE in the long term.

Prospective randomized comparison of sirolimus- or everolimus-eluting stent to treat bifurcated lesions by provisional approach.

OBJECTIVES: This study sought to compare the procedural performance and the acute angiographic result on side-branch ostium obtained using 2 different drug-eluting stents (DES) to treat patients with bifurcated coronary lesions. BACKGROUND: Drug-eluting stents are routinely used in percutaneous coronary interventions (PCI) of bifurcated coronary lesions. Different DES types have major technical differences that may influence the procedural and clinical performance in bifurcation PCI. METHODS: Consecutive patients with bifurcated lesions undergoing DES implantation using a systematic provisional-stenting strategy were randomized to sirolimus-eluting stent (SES) or everolimus-eluting stent (EES) before intervention. The procedural details for PCI were prospectively recorded to assess the occurrence of any trouble in the side-branch (SB) management (primary end point). Post-PCI angiographic result (primary end point: minimal lumen diameter at SB ostium) was evaluated offline by 3-dimensional reconstruction and quantitative coronary analysis. Clinical outcome was prospectively recorded up to 18 months to assess the occurrence of target bifurcation failure. RESULTS: A total of 150 patients were enrolled in the study (29% diabetics, 17% unprotected left main). The stent was successfully implanted according to randomization in all cases. Procedural performance was not significantly different between the 2 kinds of DES. Three-dimensional reconstruction and quantitative coronary analysis showed similar post-PCI results in the main vessel and better results in the SB with EES than with SES (minimal lumen diameter at SB ostium: 1.94 ± 0.72 mm vs. 1.64 ± 0.62 mm; p = 0.013). At 18 months, target bifurcation failure occurred in 7 (9.0%) of SES-treated patients versus 8 (10.7%) of EES patients (p = 0.57). CONCLUSIONS: In patients with bifurcated lesions treated by provisional stenting technique, EES compared with SES is associated with similar procedural performance and better 3-dimensional reconstruction and quantitative coronary analysis result in the SB. Both DES are associated with low rates of major adverse events and angiographic failure. (Sirolimus Versus Everolimus-Eluting Stent Randomized Assessment in Bifurcated Lesions and Clinical Significance of Residual Side-Branch Stenosis [SEA-SIDE]; NCT00697372).

Comparative assessment of mammalian target of rapamycin inhibitor-eluting stents in the treatment of coronary artery bifurcation lesions: the CASTOR-Bifurcation registry.

Drug-eluting stents (DES) have revolutionized the treatment of coronary bifurcation lesions. Among different DES types, sirolimus-eluting stents (SES) showed better outcomes than paclitaxel-eluting stents. Because novel sirolimus analogues have been implemented in DES, a prospective observational comparison was undertaken to compare major mammalian target of rapamycin inhibitor-eluting stents in the treatment of bifurcation lesions according to the provisional T-stenting and small protrusion (TAP) technique. Overall, 187 patients (165 men, 65 ± 10 years) were enrolled in the study: 80 patients received a SES, whereas zotarolimus-eluting stents (ZES) were implanted in 53 patients and everolimus-eluting stents (EvES) in 62 patients. Primary end-point of the study was the 12-month incidence of target bifurcation failure (TBF) defined as occurrence of cardiovascular death, nonfatal myocardial infarction (MI), and target vessel revascularization (TVR) or angiographic documentation of > 50% restenosis on the main vessel or TIMI flow < 3 on the side branch. Groups were homogeneous according to main clinical and angiographic characteristics. Overall, 17 (9.1%) patients had TBF: 4 (2.1%) patients had nonfatal non-ST-segment elevation MI, 9 (4.8%) patients underwent TVR, and 6 (3.2%) patients had an angiographic restenosis. The rate of TBF was statistically different among the three groups (7.9% in SES group, 18% in ZES group, and 3.3% in EvES group, P = 0.024). Previous MI was associated with a worse outcome (P = 0.025), whereas final kissing balloon was associated with a better outcome (P = 0.045). In conclusion, in this prospective registry, significant differences between DES were found in the outcome of patients treated for coronary bifurcation lesions according to provisional TAP technique. Thus, prospective randomized trials in this field are needed.

Thrombus aspiration without additional ballooning or stenting to treat selected patients with ST-elevation myocardial infarction.

BACKGROUND: The use of thrombus aspiration during percutaneous coronary intervention (PCI) is recommended in patients with ST-elevation myocardial infarction (STEMI) undergoing mechanical revascularization. When thrombus aspiration is adopted, the standard technique includes, after mechanical thrombus extraction, angioplasty and/or stent implantation to eliminate residual stenosis. To date, no data are available concerning the use of thrombectomy alone without additional ballooning or stenting. METHODS AND RESULTS: We report the angiographic and clinical outcome of a series of selected STEMI patients undergoing mechanical reperfusion by thrombus aspiration without additional ballooning or stenting. Four patients out of 316 consecutive STEMI patients were managed by thrombus aspiration alone (1.3%). All patients had angiographic documentation of an occlusive large intracoronary thrombus in the infarct-related artery before intervention and complete restoration of coronary flow in the absence of critical coronary stenosis after thrombus aspiration. Three of these patients had a clinical contraindication to dual antiplatelet therapy, thus suggesting that to avoid stent implantation would be advisable. Angiographic reevaluation was performed before discharge in 3 patients confirming persistent patency of the infarct-related artery (in 1 case the residual stenosis was judged to require intravascular ultrasound evaluation and subsequent elective PCI with stent implantation). The thirty-day clinical course was uneventful in all patients. CONCLUSIONS: In selected patients with STEMI undergoing mechanical reperfusion, thrombus aspiration without additional ballooning or stenting may be successfully performed. Further studies are needed to assess the clinical relevance of this novel approach.

Provisional TAP-stenting strategy to treat bifurcated lesions with drug-eluting stents: one-year clinical results of a prospective registry.

OBJECTIVE: To assess the clinical outcome of unselected patients undergoing drug-eluting stent (DES) implantation on bifurcated lesions using a "provisional T And small Protrusion (TAP)" stenting strategy. METHODS: Consecutive patients undergoing DES implantation on one major bifurcation lesion were treated by main-vessel (MV) stenting, followed (if needed) by side-branch (SB) rewiring (with a "pullback" technique) and kissing balloon. SB stenting was performed according to the TAP-technique in selected cases. The endpoint of the study was a 12-month incidence of major adverse cardiac events (MACE) defined as cardiac death, myocardial infarction (MI), stent thrombosis and target vessel revascularization (TVR). RESULTS: The study population included 266 patients (9% unprotected left main). Only 19 patients (7.1%) (with more complex angiographic features) received stents in both the MV and SB using the TAP-technique. Overall, 22 (8.2%) patients had MACE at 1 year. Observed, non-hierarchical MACE were: 1 (0.4%) cardiac death, 11 (4.1%) MI, 2 probable stent thromboses and 12 (4.5%) TVRs. Postprocedural troponin T increase and adverse events up to 12 months were similar between patients treated by MV stenting only or double stenting. CONCLUSIONS: In unselected patients undergoing DES implantation on bifurcated lesions, a provisional TAP-stenting strategy (with a low rate of SB stenting) appears to be safe and effective.

Glycoprotein IIB/IIIA inhibitor to reduce postpercutaneous coronary intervention myonecrosis and improve coronary flow in diabetics: the 'OPTIMIZE-IT' pilot randomized study.

BACKGROUND: Subgroup analyses of trials enrolling acute coronary syndrome patients suggest that inhibition of glycoprotein IIb/IIIa can improve the outcome of diabetic patients undergoing percutaneous coronary interventions (PCIs), possibly by improving microvascular perfusion. However, the efficacy of small-molecule IIb/IIIa receptor inhibitors to improve microvascular perfusion in stable diabetic patients undergoing elective PCI has not been specifically investigated. METHODS: We randomized consecutive stable diabetic patients, undergoing elective PCI, to tirofiban or placebo groups along with double antiplatelet therapy. High-dose bolus (25 microg/kg per 3 min) of tirofiban was administered immediately before PCI followed by 8 h continuous infusion (0.15 microg/kg per min). Postprocedural myonecrosis was assessed prospectively by measurement of cardiac troponin T (cTnT) at 6 and 24 h after PCI. The primary end-points were post-PCI coronary flow estimated by corrected thrombolysis in myocardial infarction frame count and post-PCI myocardial infarction. Platelet aggregation was measured by platelet function analyser-100 values. RESULTS: Forty-six patients entered the study (22 randomized to placebo and 24 randomized to tirofiban). The study drug was associated with a significant increase of platelet function analyser-100 values that peaked immediately after PCI and was maintained at 6 h (pre-PCI: 131 +/- 65 s; post-PCI: 222 +/- 49 s; after 6 h: 219 +/- 55 s).Post-PCI corrected thrombolysis in myocardial infarction frame count was similar in tirofiban and in placebo groups (10.2 +/- 3.6 vs. 12.0 +/- 7.6, P = 0.30, respectively). The prevalence of raised cTnT levels was similar in the two groups (25 vs. 30%, P = 0.56, respectively). At multivariate analysis, direct stenting (associated with reduced myonecrosis) and postdilatation (associated with increased myonecrosis) predicted cTnT elevation. CONCLUSION: A high-dose bolus of tirofiban in stable diabetic patients undergoing elective PCI, along with double antiplatelet therapy, was associated with a significant further inhibition of platelet aggregation which, however, did not translate in a lower incidence of post-PCI distal embolization.

Urgent PCI in patients with stent thrombosis: an observational single-center study comparing thrombus aspiration and standard PCI.

OBJECTIVES: Stent thrombosis (ST) is a recognized complication of percutaneous coronary interventions (PCI). Due to the high thrombus burden present in ST, the use of thrombus aspiration (TA) may enhance the angiographic results by limiting distal embolization. METHODS: Consecutive patients undergoing urgent PCI due to ST were studied, consisting of two groups according to the type of intervention (standard PCI [SP] or TA). TIMI flow, corrected TIMI frame count (cTFC), myocardial blush grade (MBG), thrombus score (TS), Yip's adverse thrombus burden features, occurrence of angiographically evident distal embolization (DE) were evaluated offline. In-hospital outcomes were also recorded. RESULTS: Twenty-eight patients entered the study. Baseline clinical and angiographic features were similar between patients treated by SP (n = 12) and those treated by TA (n = 16). After PCI, a trend in favor of TA as compared to SP was observed for post-PCI TIMI 3 flow rate (67% vs. 89%; p = 0.10), final cTFC (31 +/- 35 vs. 17 +/- 21; p = 0.10) and MBG 2-3 rate (40% vs. 67%; p = 0.12). Accordingly, the rate of adverse angiographic outcome (post-PCI TIMI 0-1 flow and/or DE) was significantly lower in the TA as compared to SP: 5% (1 out of 18) vs. 33% (5 out of 15) respectively (p = 0.04). Throughout hospitalization, major adverse events occurred in 6% of TA patients vs. 33% of SP patients (p = 0.08). CONCLUSIONS: TA in patients with ST is safe and is associated with better angiographic outcomes compared to standard PCI. Larger studies are warranted to confirm these early observations.

Comparison of the transradial and transfemoral approaches for coronary angiographic evaluation in patients with internal mammary artery grafts.

OBJECTIVE: Transradial access for coronary angiography may offer some advantages in comparison with conventional transfemoral access in specific subgroups of patients. Therefore, the aim of this study was to compare the transradial and transfemoral approaches in patients with previous coronary artery bypass graft (CABG) surgery using the left internal mammary artery (IMA). METHODS: The time to left IMA cannulation, the time needed for left IMA evaluation, and total procedure time were compared in 60 patients previously submitted to CABG surgery using the left IMA. The homolateral radial access was attempted in 20 consecutive patients (TR group), whereas the transfemoral approach was undertaken in 40 patients (2: 1, TF group), matched for age, sex and number of grafts. RESULTS: In the TR group, the time to left IMA cannulation and the time needed for left IMA evaluation were 39% and 46%, respectively, lower than those in the TF group (P = 0.01 and P = 0.001, respectively), whereas total procedure time was similar. In the subgroup of patients with less than three saphenous vein grafts (n = 36), the time to left IMA cannulation, the time needed for left IMA evaluation as well as total procedure time were significantly reduced (P = 0.01, P = 0.001 and P = 0.004, respectively). The rate of ad-hoc coronary angioplasty procedures was unaffected by the access site (20% in the TR group and 27% in the TF group, P = 0.53). CONCLUSIONS: The present study shows that the homolateral transradial approach facilitates left IMA evaluation in patients with previous CABG surgery undergoing coronary angiography, in particular in patients with a lower number of coronary artery bypass conduits, in the absence of an excess of periprocedural complications.

Feasibility of sequential thrombus aspiration and filter distal protection in the management of very high thrombus burden lesions.

BACKGROUND: A series of thrombectomy and distal filter devices have been developed to limit distal embolization during percutaneous coronary interventions (PCI). OBJECTIVE: To evaluate the feasibility of the combined use of thrombus-aspirating catheters and distal filter devices in patients at high risk of no-reflow. METHODS: Thrombus aspiration (TA) and distal filter protection (DFP) were sequentially used in a series of patients undergoing urgent PCI within 48 hours of acute myocardial infarction (MI). Inclusion criteria were: (1) occlusion of the infarct-related artery; (2) at least 2 out of the 6 Yip's classification features of high thrombus burden. Coronary angiograms were evaluated off-line to assess thrombus score, coronary flow and distal embolization in different phases of the procedure. RESULTS: TA followed by DFP prior to balloon dilatation or stent implantation was successfully performed in 20 patients with acute MI due to occlusion of de novo lesions (80%) or in-stent thrombosis (20%) located in a native coronary artery (90%) or a saphenous vein graft (10%). TA was associated with a significant acute reduction of TS and improvement of coronary flow (TIMI grade from 0.7 +/- 0.8 to 1.6 +/- 1.1; p = 0.004 and CTFC from 83 +/- 29 to 52 +/- 36; p = 0.006). This facilitated the deployment of DFP, which did not induce significant flow modification (TIMI grade: 2.3 +/- 0.9 pre-DFP placement vs. 2.2 +/- 1.0 post-DFP placement; p = 0.20; CTFC: 32 +/- 28 pre-DFP placement vs. 35 +/- 28 post-DFP placement; p = 0.47). Post-PCI angiography revealed a 90% TIMI 3 flow rate and 47% MBG 3 rate with only 1 case of angiographically evident distal embolization. CONCLUSIONS: Sequential use of TA and DFP may be successfully used during PCI in patients at very high risk of distal embolization. However, the possible benefits of such an approach should be weighted with the increased complexity of the procedure. Further evaluations of the clinical efficacy of this approach are needed.