Use of the Indigo CAT RX aspiration system during percutaneous coronary intervention.

BACKGROUND: The use of the Indigo CAT RX Aspiration System (Penumbra Inc.) during percutaneous coronary intervention has received limited study. METHODS: We retrospectively examined the clinical, angiographic, and procedural characteristics, outcomes, and follow-up of patients who underwent mechanical aspiration thrombectomy with the Indigo CAT RX system (Penumbra Inc.) at a large tertiary care hospital between January 2019 and April 2023. RESULTS: During the study period, 83 patients (85 lesions) underwent thrombectomy with the Indigo CAT RX. Mean patient age was 64.9 ± 14.48 years and 31.2% were women. The most common presentations were ST-segment elevation myocardial infarction (MI) (66.2%) and non-ST-segment elevation MI (26.5%). A final thrombolysis in MI flow grade of 3 and final myocardial blush grade of 3 were achieved in 76% and 46% of the cases, respectively. Technical success was achieved in 88.9% of the cases that included Indigo CAT RX treatment only, compared with 57.1% of the cases that also included manual aspiration. There were no device-related serious adverse events. At 30-day postprocedure, the incidence of major adverse cardiac events (composite of cardiovascular death, recurrent MI, cardiogenic shock, new or worsening New York Heart Association Class IV heart failure, stroke) was 8.5%: 1.3% stroke (postprocedure, in-hospital), 1.3% MI, 6.1% cardiac death, and 7.5% developed cardiogenic shock. CONCLUSIONS: Use of the Indigo CAT RX system is associated with high technical success and acceptable risk of complications, including stroke.

International survey of chronic total occlusion percutaneous coronary intervention operators.

BACKGROUND: Contemporary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) practice has received limited study. AIM: To examine the contemporary CTO PCI practice. METHODS: We performed an online, anonymous, international survey of CTO PCI operators. RESULTS: Five hundred forty-five CTO PCI operators and 190 interventional cardiology fellows with an interest in CTO PCI participated in this survey. Almost half were from the United States (41%), most (93%) were men, and the median h/week spent in the hospital was 58. Median annual case numbers were 205 (150-328) for PCIs and 20 (5-50) for CTO PCIs. Almost one-fifth (17%) entered CTO cases into registries, such as PROGRESS-CTO (55%) and EuroCTO (20%). More than one-third worked at academic institutions (39%), 31% trained dedicated CTO fellows, and 22% proctored CTO PCI. One-third (34%) had dedicated CTO PCI days. Most (51%) never discharged CTO patients the same day, while 17% discharged CTO patients the same day >50% of the time. After successful guidewire crossing, 38% used intravascular imaging >90% of the time. Most used CTO scores including J-CTO (81%), PROGRESS-CTO (35%), and PROGRESS-CTO complications scores (30%). Coronary artery perforation was encountered within the last month by 19%. On a scale of 0-10, the median comfort levels in treating coronary artery perforation were: covered stents 8.8 (7.0-10), coil embolization 5.0 (2.1-8.5), and fat embolization 3.7 (0.6-7.3). Most (51%) participants had a complication cart/kit and 25% conducted regular complication drills with catheterization laboratory staff. CONCLUSION: Contemporary CTO PCI practices vary widely. Further research on barriers to following the guiding principles of CTO PCI may improve patient outcomes.

Impact of proximal cap ambiguity on the procedural techniques and outcomes of chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS-CTO Registry.

BACKGROUND: Proximal cap ambiguity is a key parameter in the global chronic total occlusion (CTO) percutaneous coronary intervention (PCI) crossing algorithm. METHODS: We examined the baseline characteristics and procedural outcomes of 9718 CTO PCIs performed in 9498 patients at 41 US and non-US centers between 2012 and 2022. RESULTS: Proximal cap ambiguity was present in 35% of CTO lesions. Patients whose lesions had proximal cap ambiguity were more likely to have had prior coronary artery bypass graft surgery (37% vs. 24%; p < 0.001). Lesions with proximal cap ambiguity were more complex with higher J-CTO score (3.1 ± 1.0 vs. 2.0 ± 1.2; p < 0.001) and lower technical (79% vs. 90%; p < 0.001) and procedural (77% vs. 89%; p < 0.001) success rates compared with nonambiguous CTO lesions. The incidence of major adverse cardiovascular events (MACE) was higher in cases with proximal cap ambiguity (2.5% vs. 1.7%; p < 0.001). The retrograde approach was more commonly used among cases with ambiguous proximal cap (50% vs. 21%; p < 0.001) and was more likely to be the final successful crossing strategy (29% vs. 13%; p < 0.001). The antegrade dissection and re-entry (ADR) "move-the-cap" techniques were also more common among cases with proximal cap ambiguity. CONCLUSIONS: Proximal cap ambiguity in CTO lesions is associated with higher utilization of the retrograde approach and ADR, lower technical and procedural success rates, and higher incidence of in-hospital MACE.

Impact of lesion length on the outcomes of chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS-CTO registry.

BACKGROUND: The impact of occlusion length on the procedural techniques and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. METHODS: We examined the clinical and angiographic characteristics and procedural outcomes of 10,335 CTO PCIs at 42 US and non-US centers between 2012 and 2022. The cohort was divided into two groups based on lesion length (≥20 mm vs. <20 mm). RESULTS: Long lesions were present in 7208 (70%) patients. Comorbidities were more common in patients with long CTOs. Compared with short lesions, long lesions had higher J-CTO score (2.8 ± 1.1 vs. 1.3 ± 1; p < 0.001) and retrograde wiring was more often the initial (15.5% vs. 4.0%; p < 0.001) and successful (22.8% vs. 8.2%; p < 0.001) crossing strategy. Long lesions were more likely to require longer procedure (123 vs. 91 min; p < 0.001) and fluoroscopy (47.1 vs. 32.2 min; p < 0.001) time, larger contrast volume (218 vs. 200 mL; p < 0.001) and higher air kerma radiation dose (2.4 vs. 1.7 Gy; p < 0.001). After adjusting for potential confounders, long lesions were associated with lower technical success (odds ratio [OR]: 0.91 per 10 mm increase; 95% confidence interval [CI]: 0.88, 0.94) and higher major adverse cardiovascular events (MACE) (OR: 1.08 per 10 mm increase; 95% CI: 1.02, 1.15). CONCLUSIONS: CTO PCI of long occlusions is independently associated with lower rates of technical success and higher rates of in-hospital MACE.

Balloon-assisted subintimal entry (BASE) in chronic total occlusion percutaneous coronary interventions.

BACKGROUND: There is limited data on the use of the balloon-assisted subintimal entry (BASE) technique in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: We analyzed the baseline clinical and angiographic characteristics and outcomes of 155 CTO PCIs that utilized the BASE technique at 31 US and non-US centers between 2016 and 2023. RESULTS: The BASE technique was used in 155 (7.9%) of 1968 antegrade dissection and re-entry (ADR) cases performed during the study period. The mean age was 66 ± 10 years, 88.9% of the patients were men, and the prevalence of diabetes (44.6%), hypertension (90.5%), and dyslipidemia (88.7%) was high. Compared with 1813 ADR cases that did not use BASE, the target vessel of the BASE cases was more commonly the RCA and less commonly the LAD. Lesions requiring BASE had longer occlusion length (42 ± 23 vs. 37 ± 23 mm, p = 0.011), higher Japanese CTO (J-CTO) (3.4 ± 1.0 vs. 3.0 ± 1.1, p < 0.001) and PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention chronic total occlusion) (1.8 ± 1.0 vs. 1.5 ± 1.0, p = 0.008) scores, and were more likely to have proximal cap ambiguity, side branch at the proximal cap, blunt/no stump, moderate to severe calcification, and proximal tortuosity. Technical (71.6% vs. 75.5%, p = 0.334) and procedural success (71.6% vs. 72.8%, p = 0.821), as well as major adverse cardiac events (MACE) (1.3% vs. 4.1%, p = 0.124), were similar in ADR cases that used BASE and those that did not. CONCLUSIONS: The BASE technique is used in CTOs with longer occlusion length, higher J-CTO score, and more complex angiographic characteristics, and is associated with moderate success but also low MACE.

Impact of preprocedural anemia on in-hospital and follow-up outcomes of chronic total occlusion percutaneous coronary intervention.

BACKGROUND: The impact of preprocedural anemia on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. METHODS: We examined the clinical and angiographic characteristics and procedural outcomes of 8633 CTO PCIs performed at 39 US and non-US centers between 2012 and 2023. Anemia was defined as a hemoglobin level of <13 g/dL in men and <12 g/dL in women. RESULTS: Anemia was present in 1652 (19%) patients undergoing CTO PCI. Anemic patients had a higher incidence of comorbidities, such as diabetes mellitus, hypertension, dyslipidemia, heart failure, cerebrovascular disease, and peripheral arterial disease. CTOs in anemic patients were more likely to have complex angiographic characteristics, including smaller diameter, longer length, moderate to severe calcification, and moderate to severe proximal tortuosity. Anemic patients required longer procedure (119 vs. 107 min; p < 0.001) and fluoroscopy (45 vs. 40 min; p < 0.001) times but received similar contrast volumes. Technical success was similar between the two groups. In-hospital major adverse cardiac events (MACE) rates were higher in patients with anemia; however, this association was no longer significant after adjusting for confounding factors. Baseline anemia was independently associated with follow-up MACE (adjusted hazard ratio [HR]: 1.63; 95% confidence interval [CI]: 1.07-2.49; p = 0.023) and all-cause mortality (adjusted HR: 3.03; 95% CI: 1.41-6.49; p = 0.004). CONCLUSIONS: Preprocedural anemia is associated with more comorbidities, higher lesion complexity, longer procedure times, and higher follow-up MACE and mortality after CTO PCI.

Aortocoronary dissection during percutaneous coronary interventions for chronic total occlusion: Insights from the PROGRESS-CTO registry.

BACKGROUND: Aortocoronary dissection is a potentially serious complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: We examined the incidence, mechanisms, treatment, and outcomes of aortocoronary dissection among 12,117 CTO PCIs performed between 2012 and 2022 in a large multicenter CTO PCI registry. RESULTS: The incidence of aortocoronary dissection was 0.2% (n = 27). Most aortocoronary dissections occurred in the right coronary artery (96.3%, n = 26). The baseline clinical characteristics of patients with and without aortocoronary dissection were similar, except for dyslipidemia, which was less common in patients with aortocoronary dissection (70.4% vs. 86.0%; p = 0.019). The retrograde approach was used more commonly among cases complicated by aortocoronary dissection (59.3% vs. 31.0%; p = 0.002). Technical (74.1% vs. 86.6%; p = 0.049) and procedural (70.4% vs. 85.2%; p = 0.031) success rates were lower among aortocoronary dissection cases, with a similar incidence of in-hospital major adverse cardiovascular events (3.7% vs. 2.0%; p = 0.541). Of the 27 patients with aortocoronary dissection, 19 (70.4%) were treated with ostial stenting and 8 (29.6%) were treated conservatively without subsequent adverse clinical outcomes. No patients required emergency surgery. Follow-up was available for 22 patients (81.5%): during a mean follow up of 767 (±562) days, the incidence of in-stent restenosis was 11.1% (n = 3). CONCLUSIONS: Aortocoronary dissection occurred in 0.2% of CTO PCIs performed by experienced operators, was associated with lower technical and procedural success, and was treated most commonly with ostial stenting. None of the patients required emergency cardiac surgery.

Same day discharge versus overnight observation following chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS-CTO registry.

BACKGROUND: Same day discharge (SDD) following chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. METHODS: We evaluated the clinical, angiographic, and procedural characteristics of patients discharged the same day versus those kept for overnight observation in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO, NCT02061436). RESULTS: Of the 7181 patients who underwent CTO PCI, 943 (13%) had SDD. The SDD rate increased from 3% in 2015 to 21% in 2022. Patients with SDD were less likely to have a history of heart failure (21% vs. 26%, p = 0.005), chronic lung disease (10% vs. 15%, p = 0.001), or anemia (12% vs. 19%, p < 0.001). Technical success (87% vs. 88%, p = 0.289) was similar, but in-hospital major adverse cardiovascular events (0.0% vs. 0.4%, p = 0.041) were lower in SDD. In multivariable logistic regression analysis, prior myocardial infarction odds ratio (OR): 0.71 (95% confidence interval [CI]: 0.59-0.87, p = 0.001), chronic lung disease OR: 0.64 (95% CI: 0.47-0.88, p = 0.006), and increasing procedure time OR: 0.93 (95% CI: 0.91-0.95, p < 0.001, per 10-min increase) were associated with overnight observation, while radial-only access OR: 2.45 (95% CI: 2.03-2.96, p < 0.001) had the strongest association with SDD. In the SDD, 2 (0.4%) of 514 patients were readmitted, due to retroperitoneal bleeding (n = 1) and ischemic stroke (n = 1). CONCLUSION: The overall frequency of SDD after CTO PCI was 13% and has been increasing over time. SDD is feasible in select patients following CTO PCI, and radial-only access had the strongest association with SDD.

Incidence, mechanisms, treatment, and outcomes of donor vessel injury during percutaneous coronary interventions for chronic total occlusion.

BACKGROUND: Donor vessel injury is a potentially life-threatening complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). AIMS: Our goal was to examine the incidence, mechanisms, treatment, and outcomes of patients with donor vessel injury in a large multicenter CTO PCI registry. METHODS: We analyzed the baseline clinical and angiographic characteristics, and procedural outcomes of 12,349 CTO PCIs performed between 2012 and 2022 at 44 centers. RESULTS: The incidence of donor vessel injury was 0.35% (n = 43). The baseline clinical characteristics of patients with and without donor vessel injury were similar. Cases complicated by donor vessel injury were more complex with higher Japanese CTO score (2.9 ± 1.1 vs. 2.4 ± 1.3; p = 0.004) and lower procedural success rate (69.8% vs. 85.2%; p = 0.004). The retrograde approach was used more commonly in donor vessel injury cases (68.9% vs. 30.9%; p < 0.001). Most (53.5%) donor vessel injuries were guide catheter-induced, whereas 20.9% were due to donor vessel thrombosis. Of the 43 patients with donor vessel injury, 36 (83.7%) were treated with stenting and seven (16.3%) received a left ventricular assist device. The incidence of major adverse cardiovascular events (MACEs) was significantly higher in cases with donor vessel injury (23.3% vs. 2.0%; p < 0.001). Of the 43 patients with donor vessel injury, five patients (11.6%) experienced acute myocardial infarction and four patients (9.3%) died. CONCLUSIONS: Donor vessel injury, occurred in 0.35% of CTO PCIs performed by experienced operators, was mainly due to guide catheter-induced dissection or thrombosis and was associated with lower procedural success and higher MACE.

External validation of the PROGRESS-CTO perforation risk score: Individual patient data pooled analysis of three registries.

BACKGROUND: Coronary artery perforation is one of the most feared and common complications of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: To assess the usefulness of the recently developed PROGRESS-CTO (NCT02061436) perforation risk score in independent cohorts. Individual patient-level data pooled analysis of three registries was performed. RESULTS: Of the 4566 patients who underwent CTO PCI at 25 centers, 196 (4.2%) had coronary artery perforation. Patients with perforations were older (69 ± 10 vs. 65 ± 10, p < 0.001), more likely to be women (19% vs. 13%, p = 0.009), more likely to have a history of prior coronary artery bypass graft (34% vs. 20%, p < 0.001), and unfavorable angiographic characteristics such as blunt stump (62% vs. 48%, p < 0.001), proximal cap ambiguity (52% vs. 34%, p < 0.001), and moderate-severe calcification (60% vs. 49%, p = 0.002). Technical success was lower in patients with perforations (73% vs. 88%, p < 0.001). The area under the receiver operating characteristic curve of the PROGRESS-CTO perforation risk model was 0.76 (95% confidence interval [CI], 0.72-0.79), with good calibration (Hosmer-Lemeshow p = 0.97). We found that the CTO PCI perforation risk increased with higher PROGRESS-CTO perforation scores: 0.3% (score 0), 2.3% (score 1), 3.1% (score 2), 5.5% (score 3), 7.5% (score 4), 14.6% (score 5). CONCLUSION: Given the good discriminative performance, calibration, and the ease of calculation, the PROGRESS-CTO perforation score may facilitate assessment of the risk of perforation in patients undergoing CTO PCI.

An algorithmic approach to balloon undilatable coronary lesions.

Balloon undilatable lesions are lesions that have been successfully crossed by both a guidewire and a balloon but cannot be expanded despite multiple high-pressure balloon inflations. Balloon undilatable lesions can be de novo or in-stent. We describe a systematic, algorithmic approach to treat both de novo and in-stent balloon undilatable lesions using various techniques, such as high-pressure balloon inflation, plaque modification balloons, intravascular lithotripsy, very high-pressure balloon inflation, coronary atherectomy, laser coronary angioplasty, and extraplaque lesion crossing. Knowledge of the various techniques can increase the efficiency, success and safety of the procedure.

Radial access for chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS-CTO registry.

Use of radial access for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been increasing. We examined the clinical characteristics and procedural outcomes of patients who underwent CTO PCI with radial versus femoral access in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO, NCT02061436). Of 10,954 patients who underwent CTO PCI at 55 centers in 7 countries between 2012 and 2022, 2578 (24%) had a radial only approach. Patients who underwent radial only access were younger (63 ± 10 vs. 65 ± 10, years, p &lt; 0.001), more likely to be men (84% vs. 81%, p = 0.001), and had significantly lower prevalence of comorbidities compared with the femoral access group including diabetes mellitus (39% vs. 45%, p &lt; 0.001) and coronary artery bypass graft surgery (57% vs. 64%, p &lt; 0.001). In addition, radial only cases had lower angiographic complexity with lower J-CTO and PROGRESS-CTO scores. After adjusting for potential confounders, radial only access was associated with lower risk of access site complications (odds ratio [OR]: 0.45, 95% confidence interval [CI]: 0.22-0.91), similar technical success (OR: 0.87, 95% CI: 0.74-1.04) and major adverse cardiovascular events (MACE) (OR: 0.65, 95% CI: 0.40-1.07), compared with the femoral access group. Radial only access was used in 24% of CTO PCIs and was associated with lower access site complications, and similar technical success and MACE as compared with the femoral access group.

Gender differences in chronic total occlusion percutaneous coronary interventions: Insights from the PROGRESS-CTO registry.

BACKGROUND: There are limited data describing gender differences in patients undergoing chronic total occlusion (CTO) percutaneous coronary interventions (PCI). METHODS: We compared baseline clinical and angiographic characteristics and procedural outcomes between men and women among 9457 CTO PCIs performed at 38 centers between 2012 and 2022. RESULTS: A total of 7687 (81%) men and 1770 (19%) women were treated. Women were older, more likely to have comorbidities such as diabetes, hypertension and peripheral arterial disease, and had higher left ventricular ejection fraction. The most common CTO target vessel was the right coronary artery for both men (53%) and women (52%), although the left anterior descending artery was more frequently the target vessel among women (31% vs. 25%; p < 0.001). The J-CTO score (2.4 ± 1.3 vs. 2.2 ± 1.2; p < 0.001) as well as the PROGRESS-CTO score (1.3 ± 1.0 vs. 1.1 ± 1.0; p < 0.001) were higher among men. In female patients, antegrade wiring was more frequently the initial crossing strategy (87.6% vs. 82.4%; p < 0.001) and was more successful in crossing the target lesion (62.7% vs. 54.0%; p < 0.001) compared with men. Interventions in men required longer procedure time and fluoroscopy time, as well as higher air kerma radiation dose and contrast volume when compared to women. Technical (89% vs. 86%; p < 0.001) and procedural (87% vs. 84%; p = 0.003) success rates were higher among women. In-hospital major adverse cardiovascular events (MACE) were also higher in women (2.9% vs. 1.8%; p < 0.001). CONCLUSIONS: Women undergoing CTO PCI had higher technical and procedural success rates, but also higher in-hospital MACE compared with men.

Identifying opportunities to advance health equity in interventional cardiology: Structural heart disease.

Health care practices are influenced by variety of factors. These factors that include social determinants, race and ethnicity, and gender not only affect access to health care but can also affect quality of care and patient outcomes. These are a source of health care disparities. This article acknowledges that these disparities exist in getting optimal care in structural heart disease, reviews the literature and proposes steps that can help reduce these disparities on personal and committee levels.

Antegrade dissection and re-entry versus parallel wiring in chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS-CTO registry.

BACKGROUND: The comparative efficacy and safety of parallel wiring versus antegrade dissection and re-entry (ADR) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is controversial. METHODS: We compared the clinical and angiographic characteristics and outcomes of parallel wiring versus ADR after failed antegrade wiring in a large, multicenter CTO PCI registry. RESULTS: A total of 1725 CTO PCI procedures with failed antegrade wiring with a single wire were approached with parallel wiring (692) or ADR (1033) at the discretion of the operator. ADR patients were older (65 ± 10 vs. 62 ± 10, years, p < 0.001) and had higher prevalence of comorbidities, such as diabetes mellitus (43% vs. 32%, p < 0.001), prior coronary artery bypass graft surgery (31% vs. 19%, p < 0.001), and lower left ventricular ejection fraction (50 ± 14 vs. 53 ± 11%, p < 0.001). The ADR group had higher J-CTO (2.8 ± 1.1 vs. 2.1 ± 1.3, p < 0.001) and PROGRESS-CTO (1.6 ± 1.1 vs. 1.2 ± 1.0, p < 0.001) scores. Equipment use including guidewires, balloons, and microcatheters was higher, and the procedures lasted longer in the ADR group. Technical success (78% vs. 75%, p = 0.046) and major adverse cardiovascular events (composite of all-cause mortality, stroke, acute myocardial infarction, emergency surgery or re-PCI, and pericardiocentesis) (3.7% vs. 1.9%, p = 0.029) were higher in the ADR group, with similar procedural success (75% vs. 73%, p = 0.166). CONCLUSION: In lesions that could not be crossed with antegrade wiring, ADR was associated with higher technical but not procedural success, and also higher MACE compared with parallel wiring.

Outcomes and challenges of the provisional stenting technique: Insights from the PROGRESS-BIFURCATION registry.

BACKGROUND: Provisional stenting is the most commonly used coronary bifurcation stenting strategy. METHODS: We examined the clinical and angiographic characteristics, challenges encountered, and procedural outcomes with the provisional bifurcation stenting strategy in the Prospective Global Registry of Percutaneous Coronary Intervention (PCI) in Bifurcation Lesions (PROGRESS-BIFURCATION, NCT05100992). RESULTS: Provisional stenting was used in 334 of 430 bifurcation interventions (78%). Technical success was lower (95% vs. 100%, p = 0.017) in provisional, but procedural success (90% vs. 95%, p = 0.095) and incidence of in-hospital major adverse cardiovascular events were similar (5% vs. 5%, p = 0.945) compared with two-stent strategies. Provisional was less often preferred in left main/left anterior descending involvement (47% vs. 73%, p < 0.001). Provisional stenting cases had smaller side branch (SB) diameter (2.4 ± 0.5 vs. 2.7 ± 0.6 mm, p < 0.001), shorter SB lesion length (5 [3-8] vs. 10 [5-10] mm, p < 0.001), less SB diameter stenosis (46 ± 35 vs. 81 ± 20%, p < 0.001), and were less likely to be Medina 1,1,1 (34% vs. 73%, p < 0.001). PCI challenges were less common (30% vs. 58%, p < 0.001) with provisional stenting: (1) rewiring difficulty (43%) that was overcome with use of a different wire (74%) or microcatheter (46%); (2) inability to deliver a stent (22%) or balloon (9%) that was overcome with use of a smaller balloon (88%), rewiring (25%), or increased support/microcatheter (25%). CONCLUSIONS: Provisional bifurcation stenting was more often performed in distal lesions with less SB involvement and had lower technical success, but similar procedural success and complications compared with two-stent strategies.

Predictors of success in primary retrograde strategy in chronic total occlusion percutaneous coronary intervention: insights from the PROGRESS-chronic total occlusion registry.

BACKGROUND: An upfront (primary) retrograde strategy is often used in complex chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: We examined the clinical, angiographic characteristics, and procedural outcomes of CTO PCIs that were approached with a primary retrograde strategy in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO, NCT02061436). RESULTS: Of 10,286 CTO PCIs performed between 2012 and 2022, a primary retrograde strategy was used in 1329 (13%) with an initial technical success of 66%, and a final success of 83%. Patients who underwent successful versus unsuccessful primary retrograde cases had similar characteristics: age (65 ± 10 vs. 65 ± 9, years, p = 0.203), men (83% vs. 87%, p = 0.066), prior PCI (71% vs. 71%, p = 0.809), and prior coronary artery bypass graft surgery (52% vs. 53%, p = 0.682). The PROGRESS-CTO score (1.3 ± 0.9 vs. 1.6 ± 0.9, p < 0.001), air kerma radiation (3.9 ± 2.8 vs. 3.4 ± 2.6, gray, p = 0.013), and contrast use (294 ± 148 ml vs. 248 ± 128, ml, p < 0.001) were higher in the unsuccessful group, whereas the presence of interventional collaterals (95% vs. 72%, p < 0.001) and Werner collateral connection grade 2 (43% vs. 31%, p < 0.001) were higher in the successful group. On multivariable logistic regression analysis, the only variable associated with a successful primary retrograde strategy was the presence of interventional collaterals: odds ratio: 6.52 (95% confidence intervals; 3.5-12.1, p < 0.001). CONCLUSION: Presence of interventional collaterals is independently associated with higher success rates with a primary retrograde strategy in CTO PCI.

Amiodarone Use Prior to Cardiac Transplant Impacts Early Post-Transplant Survival.

PURPOSE: It remains unclear if use of amiodarone pre-cardiac transplantation impacts early post-transplant survival. METHODS: We selected all patients undergoing heart transplant from 2004 to 2006 with available information using the United Network for Organ Sharing database (n = 4057). Multivariable Cox models compared the risk of death within 30 days post-transplant in patients who were taking amiodarone at the time of transplant listing (n = 1227) to those who were not (n = 2830). RESULTS: Mean age was 52 (± 12) years, and 23% were women. Patients who died within 30 days (n = 168) were older; had higher panel reactive antibody levels, higher bilirubin levels, and higher prevalence of prior cardiac surgery; were often at status 1B; and had higher use of amiodarone at listing compared to those who survived (5.3% versus 3.6%; p = 0.02). Cause of death was unknown in 49% and was reported as graft failure in 43% of cases. In multivariable Cox models, patients on amiodarone at the time of listing had 1.56-fold higher risk of post-transplant death within 30 days (95% confidence intervals 1.08-2.27) compared to patients who were not on amiodarone at listing (C-statistic 0.70). CONCLUSION: In conclusion, patients who reported taking amiodarone at the time of listing for transplant had a higher risk of death within 30 days post-transplant.