Catheter-directed therapy for acute pulmonary embolism: results of a multicenter national registry.

INTRODUCTION AND OBJECTIVES: Catheter-directed therapy (CDT) for acute pulmonary embolism (PE) is an emerging therapy that combines heterogeneous techniques. The aim of the study was to provide a nationwide contemporary snapshot of clinical practice and CDT-related outcomes. METHODS: This Investigator-initiated multicenter registry aimed to include consecutive patients with intermediate-high risk (IHR) or high-risk (HR), acute PE eligible for CDT. The primary outcome of the study was in-hospital all-cause death. RESULTS: A total of 253 patients were included, of whom 93 (36.8%) had HR-PE, and 160 (63.2%) had IHR-PE with a mean age of 62.3±15.1 years. Local thrombolysis was performed in 70.8% and aspiration thrombectomy in 51.8%, with 23.3% of patients receiving both. However, aspiration thrombectomy was favored in the HR-PE cohort (80.6% vs 35%; P<.001). Only 51 patients (20.2%) underwent CDT with specific PE devices. The success rate for CDT was 90.9% (98.1% of IHR-PE patients vs 78.5% of HR-PE patients, P<.001). In-hospital mortality was 15.5%, and was highly concentrated in the HR-PE patients (37.6%) and significantly lower in IHR-PE patients (2.5%), P<.001. Long-term (24-month) mortality was 40.2% in HR-PE patients vs 8.2% in IHR-PE patients (P<.001). CONCLUSIONS: Despite the high success rate for CDT, in-hospital mortality in HR-PE is still high (37.6%) compared with very low IHR-PE mortality (2.5%).

Bioactive or Drug-Eluting Stents in 75 Years or Older Patients: The BIODES-75 Registry.

BACKGROUND: TiNO-coated BAS have demonstrated competitive outcomes compared to drug-eluting stents (DES). These devices allow short antiplatelet regimens and may be a good option for the growing elderly population undergoing percutaneous coronary intervention (PCI). METHODS: Multicenter observational trial in routine clinical practice. A propensity-score matched analysis compared a prospective cohort of patients ≥ 75 years undergoing PCI with BAS, with a contemporary and retrospective cohort treated with last-generation DES. The co-primary endpoints of the study were the Target-Lesion-Failure (Cardiac death, non-fatal myocardial infarction, or target lesion revascularization) and Major Adverse Cardiovascular Events (total death, non-fatal myocardial infarction, stroke, or new revascularization) at 1 year. RESULTS: Whole population included 1000 patients, and 326 patients in each group were matched for analysis. No differences in primary endpoints were found: TLF 10.4% vs. 11% (HR 0.96 (Confidence Interval 95%, 0.36-1.7; p = 0.87)) and MACE 16.3% vs. 17.2% (HR 0.98 (Confidence Interval 95%; 0.3-1.5, p = 0.93)). Patients treated with BAS received shorter antiplatelets regimens (dual antiplatelet therapy at 1 year, 25.7% vs. 70.6%, p = 0.0001), and they presented lower incidence of bleeding (3.7% vs. 11.7%, HR 0.3 (IC 95% 0.16-0.6, p = 0.001)). CONCLUSION: In this real-life registry of patients ≥ 75 years, BAS were similar to the latest-generation DES in terms of efficacy and reduced the duration of the antithrombotic therapy, lowering bleeding events.

Intravascular ultrasound-guided drug-coated balloon venoplasty for in-stent restenosis in pulmonary veins stenosis: a case report.

BACKGROUND: Pulmonary veins stenosis (PVS) after atrial fibrillation radiofrequency ablation is an uncommon complication. When it occurs, percutaneous treatment is the preferred approach. There is a lack of standardized procedures, and when stenting restenosis is relatively common. CASE SUMMARY: We present a young patient with recurrence of PVS after first percutaneous treatment. The recurrence of haemoptysis and dyspnoea after treatment in PVS allowed the diagnosis of significant stenosis again in our patient. In the Heart Team, we opted for a new percutaneous treatment, using intravascular ultrasound (IVUS) to optimize the final result. DISCUSSION: Nowadays, percutaneous approach is preferred and among percutaneous treatments for PVS, stenting has shown better results than balloon angioplasty (BA). Despite this, experience in in-stent restenosis is limited, and there is a lack of adequate and specific material for its approach. In this case, we present the possible role of the IVUS and the drug-coated BA in this entity.

Correction to: Double chimney stent technique in bilateral sequential coronary occlusion during corevalve valve-in-valve procedure.

This corrects the article DOI: 10.23736/S0026-4725.19.05064-3.

The Feasibility and Safety of Ambulatory Percutaneous Coronary Interventions in Complex Lesions.

BACKGROUND: The safety and feasibility of ambulatory PCI has been demonstrated in selected patients with "simple" lesions, but it is not well known whether it could be applied in more "complex" scenarios. METHODS: Main objective is to assess the feasibility and safety of ambulatory complex PCI. Prospective multicentre registry of 1047 consecutive patients planned for ambulatory trans-radial PCI. Outcomes in patients with "complex angioplasty" (CA group: 313 (30%)) were analysed and compared with those of "simple angioplasty" (SA group: 734, 70%). The feasibility (% of patients finally discharged) and safety (MACE at 24 h and at 1 month) were compared between groups. We also analyse admissions, visits to the emergency department and minor vascular complications. RESULTS: Feasibility was higher for SA (80.6% vs. 63.6%, OR 1.89, 95% CI 1.52-2.35, p < 0.001). Ambulatory PCI was very safe in both groups. In CA no MACE occurred at 24 h (vs. 0.17% SA) or 30 days (vs. 0.68% in SA). There were also no differences in re-admissions, visits to the emergency department or minor vascular complications (there was a non-significant tendency to higher rate of radial occlusion at 1 month in the CA group, 5.5% vs. 2.7%, p: 0.07). CONCLUSIONS: The feasibility of ambulatory PCI in selected patients with complex lesions is lower than in simple lesions, however when it is possible, it is as safe as in selected patients with simple lesions.

Safety of transradial diagnostic cardiac catheterization in patients under oral anticoagulant therapy.

BACKGROUND: Cardiac catheterization in anticoagulated patients is usually performed after the anticoagulation has been withdrawn, at least in the previous 48h, and sometimes bridging therapy with heparin is used. METHODS: A prospective observational study including 489 patients undergoing transradial catheterization was conducted. A total of 140 patients were under acenocoumarol (group A) and they were compared with the remainder (group B) for complications after the procedure (bleeding and vascular access complications). RESULTS: Patients in group A were older (74±12 years vs. 68±17 years, p<0.01) and the main indication for anticoagulation was atrial fibrillation (58.6%). No complications occurred during the procedures. There were no acute bleedings just after the bandage removal. During the first 24h, only 3 (2.1%) radial occlusions in group A and 2 (0.6%) in group B (p=0.14) were recorded. Hematomas between 5 and 10cm appeared in 5% of the group A vs. 4.6% in group B. During the 1-month follow-up period, one more radial occlusion in each group was recorded and there were 4 (1.1%) additional mild hematomas in group B and none in group A (p=0.48). CONCLUSIONS: Performing a transradial diagnostic cardiac catheterization without removal of the oral chronic anticoagulation appears safe in patients under acenocumarol therapy.

Safety and Feasibility of Outpatient Percutaneous Coronary Intervention in Selected Patients: A Spanish Multicenter Registry.

INTRODUCTION AND OBJECTIVES: The exponential increase in coronary interventions plus the generalization of the radial approach represent the ideal scenario for starting outpatient angioplasty programs with the aim of reducing the costs while maintaining safety. This article reports data from a multicenter Spanish registry on fully ambulatory transradial angioplasty in selected patients for the first time. METHODS: Prospective registry of elective outpatient transradial-ulnar angioplasty in patients with stable coronary disease. Patients were discharged the same day and were followed up at 24hours and 30 days. Safety and feasibility were analyzed. RESULTS: Of the 723 patients included (76% male; age, 66.6±10.5 years), 533 (73.7%) were finally discharged after 4 to 12hours of surveillance. Among the remaining 190 (26.7%) patients, the most common reason for hospitalization was clinical instability after the procedure (60.5%). Independent predictors of admission were a history of peripheral artery disease, a higher baseline creatinine level, ad hoc performance of the procedure, and multivessel disease. At 24hours, there was 1 major adverse event in 1 patient (0.19%), who required hospitalization for major bleeding not related to vascular access. At 30 days, there were 3 major adverse events (0.56%): 1 subacute stent thrombosis, 1 revascularization of a vessel other than the treated vessel, and 1 minor stroke. Eight patients (1.5%) required admission at 30 days. CONCLUSIONS: The application of an outpatient transradial-ulnar angioplasty program with discharge after 4 to 12 hours' surveillance is safe and feasible in well-selected patients.

Early aspirin desensitization in unstable patients with acute coronary syndrome: Short and long-term efficacy and safety.

BACKGROUND: Aspirin hypersensitivity is not a rare condition among patients with acute coronary syndrome. However, despite the publication of several successful desensitization protocols, the procedure is not as widespread as expected. We present a cohort of patients with acute coronary syndrome undergoing aspirin desensitization to evaluate its short- and long-term efficacy and safety and to reinforce data from previous studies. METHODS: Of 1306 patients admitted to our Coronary Care Unit between February 2011 and February 2013, 24 (1.8%) had a history of aspirin hypersensitivity. All 24 patients underwent an eight-dose aspirin desensitization protocol (0.1, 0.3, 1, 3, 10, 25, 50 and 100 mg of aspirin given by mouth every 15 minutes) after premedication with antihistamines and corticosteroids or antileucotrienes. Previously prescribed ß blockers and angiotensin-converting enzyme inhibitors were not discontinued. All patients were desensitized within 72 hours of admission. Those requiring urgent catheterization (five patients with ST segment elevation myocardial infarction) were desensitized within 12 hours of catheterization and the remainder before catheterization. RESULTS: All patients were successfully desensitized and only one presented with an urticarial reaction. The five patients with ST segment elevation myocardial infarction were treated with abciximab until desensitization was complete. All but one patient underwent catheterization and 20 underwent percutaneous coronary intervention, most (66%) with the implantation of a bare metal stent. At follow-up (a minimum of 6-24 months), only two patients had discontinued aspirin, both due to gastrointestinal bleeding, and no hypersensitivy reaction had occurred. CONCLUSIONS: Aspirin desensitization is effective and safe in unstable patients with acute coronary syndrome in both the short and long term.