Andrea Zuffi

Randomized comparison of 6- versus 24-month clopidogrel therapy after balancing anti-intimal hyperplasia stent potency in all-comer patients undergoing percutaneous coronary intervention: Design and rationale for the PROlonging Dual-antiplatelet treatment after Grading stent-induced Intimal hyperplasia study (PRODIGY)

BACKGROUND The optimal duration of clopidogrel therapy after coronary stenting is debated because of the scarcity of randomized controlled trials and inconsistencies arising from registry data. Although prolonged clopidogrel therapy after bare metal stenting is regarded as an effective secondary prevention measure, the safety profile of drug-eluting stents itself has been questioned in patients not receiving ≥ 12 months of dual-antiplatelet therapy. HYPOTHESIS Twenty-four months of clopidogrel therapy after coronary stenting reduces the composite of death, myocardial infarction, or stroke compared with 6 months of treatment. STUDY DESIGN PRODIGY is an unblinded, multicenter, 4-by-2 randomized trial. All-comer patients with indication to coronary stenting are randomly treated-balancing randomization-with bare metal stent (no active late loss inhibition), Endeavor Sprint zotarolimus-eluting stent (Medtronic, Santa Rosa, CA) (mild late loss inhibition), Taxus paclitaxel-eluting stent (Boston Scientific, Natick, MA) (moderate late loss inhibition), or Xience V everolimus-eluting stent (Abbott Vascular, Santa Clara, CA) (high late loss inhibition). At 30 days, patients in each stent group are randomly allocated to receive 24 or up to 6 months of clopidogrel therapy-primary end point randomization. With 1,700 individuals, this study will have >80% power to detect a 40% difference in the primary end point after sample size augmentation of 5% and a background event rate of 8%. SUMMARY The PRODIGY trial aims to assess whether 24 months of clopidogrel therapy improves cardiovascular outcomes after coronary intervention in a broad all-comer patient population receiving a balanced mixture of stents with various anti-intimal hyperplasia potency.

Pushing wrist access to the limit: homolateral right ulnar artery approach for primary percutaneous coronary intervention after right radial failure due to radial loop.

A 67‐year‐old man underwent primary percutaneous coronary intervention for acute anterior ST elevation myocardial infarction. The right radial artery was the access of choice. After easy cannulation, a 360‐degree loop was found at the elbow level. The brachial artery and a large ulnar artery were visible by injecting contrast through the radial loop. After an unsuccessful attempt to engage the loop, the operator switched entry site for the homolateral ulnar artery. Leaving the radial sheath in place, the cannulation of the ulnar artery was successful and uncomplicated. The operator could easily perform a successful intervention of the culprit vessel. An angiogram of the wrist, via the ulnar sheath showed the presence of a big interosseous artery with flow up to the hand and no flow in the radial and ulnar arteries distal to the sheaths. The ulnar and radial arteries were successfully sealed after a few hours, a valid pulsation was present on both arteries and no signs of ischemia were evident in the right hand the day after.

Swan‐Ganz‐induced pulmonary artery rupture: Management with stent graft implantation

Pulmonary artery catheterization is a useful tool for the diagnosis and management of lung or cardiac disease. This procedure is considered safe and associated with a low incidence of major complications. However, pulmonary artery rupture during right heart catheterization, albeit rare, remains a severe complication. Despite modern management with metal‐coil embolization, selective intubation and deployment of bronchial blocker, the mortality rate may be as high as 50%. In this case, we report a new approach to deal with a Swan‐Ganz‐induced pulmonary artery rupture based on stent graft implantation leading to successful sealing of the pulmonary perforation with final patency and normal antegrade blood flow in the pulmonary branch.

Management of two major complications in the cardiac catheterisation laboratory: the no-reflow phenomenon and coronary perforations

catheterisation laboratory: the no-reflow phenomenon and coronary perforations Olivier Muller1, MD PhD; Stephan Windecker2, MD; Thomas Cuisset3, MD; Jean Fajadet4, MD; Mark Mason5, MD; Andrea Zuffi6, MD; Alexander Doganov7, MD; Eric Eeckhout6, MD PhD 1. Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium; 2. Department of Cardiology, University Hospital Bern, Bern, Switzerland; 3. Department of Cardiology, University Hospital La Timone, Marseille, France; 4. Unite de Cardiologie Interventionnelle, Clinique Pasteur, Toulouse, France; 5. Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, United Kingdom; 6. Service de Cardiologie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; 7. National Heart Institute, Sofia, Bulgaria

First prospective multicenter experience with the 7 French Glidesheath slender for complex transradial coronary interventions

To assess the feasibility and safety of the 7 French (Fr) Glidesheath Slender for complex transradial (TR) percutaneous coronary interventions (PCI).

Left main dissection complicating blunt chest trauma: Case report and review of literature

Coronary artery injury after blunt chest trauma is rare, but can be life-threatening, resulting in severe myocardial ischaemia and acute myocardial infarction. We report a case of a 56-year-old male who presented a few days after a blunt chest trauma with crescendo unstable angina. Coronary angiography demonstrated left main coronary artery dissection that was fixed with stent implantation. After a blunt chest trauma symptoms and electrocardiographic findings of a coronary dissection can be nonspecific and confounded by the chest tenderness. In such cases careful evaluation to rule out traumatic coronary injuries is warranted and early intervention should not be delayed in the presence of clear evidence of myocardial ischemia.

Retrospective multicenter observational study of the interventional management of coronary disease in the very elderly: The NINETY

The aim of this observational, multicenter study was to describe the outcome of very elderly patients undergoing percutaneous coronary intervention (PCI).

Endovascular carotid interventions

Introduction This article in the EuroIntervention Tools & Techniques series provides the “how-to-do” plus “tips & tricks” for carotid artery stenting (CAS). The complete, unabridged e-version with dynamic images can be viewed at www.eurointervention.org. The following is a summary and highlights the key approach that underpins a safe practice and the way to obtain good results. Endovascular carotid intervention was developed due to a need to provide a less-invasive and less-traumatic revascularisation strategy for patients considered high-risk for open surgery. The currents of rapid advancement in endovascular technologies and techniques over the last 10 years has resulted in the evolution of CAS to a refined procedure with great potential to be applied to routine carotid revascularisation practice. The benchmark for perioperative stroke or death for carotid revascularisation is the limit of 6% for symptomatic and 3% for asymptomatic patients.

Transradial access without preliminary Allen test--letter of comment on Rhyne et al.

We have read with interest the case reported by Rhyne et al. on critical hand ischemia following transradial coronary intervention [1]. However, we explicitly challenge their conclusion that traditional or pletismography form of Allen test should be mandatory before transradial or transulnar access. First, their case, as emphasized in his accompanying editorial by Shigeru Saito [2], is the only case ever reported in the literature, thus showing that this complication is exceedingly rare despite the thousands of cases performed every month of transradial procedures worldwide. Thus, unexperienced or experienced radialists should bear in mind this possible risk, but be also aware that they are unlikely to face it ever in their clinical practice. Second, several operators with extensive radial experience [3], including us, routinely perform transradial procedures without any form of Allen test (either traditional or pletismography) with outstanding safety outcomes, even in unselected patients or those with ST-elevation myocardial infarction. Yet, none of us is aware of any other reported or unpublished case of hand ischemia due to radial or ulnar occlusion, confirming the very low frequency of hand ischemia following radial access. Third, while we acknowledge the reality of such risk of hand ischemia, despite being extremely rare, the issue of critical ischemia due to vessel occlusion actually applies to any arterial access, such as brachial, axillary, femoral, popliteal, or tibial [4]. In fact, given the presence of a rich collateral system and the presence of interosseous branches in several patients, even concomitant radial and ulnar occlusion can be possibly tolerated. Conversely, occlusion of brachial, axillary, or femoral vessels is much more likely to be limb or lifethreatening, given the muscular mass served by these vessels. Indeed, we have performed a number of cases in which both radial and ulnar arteries of the same wrist were subsequently or concomitantly accessed during the same procedure, without performing any kind of Allen test before the procedure, and yet we did not find any clinical evidence of hand ischemia or ensuing complication (Fig. 1), thus suggesting that even placing two arterial sheaths in the same wrist can be safely done in selected cases and by skilled operators. Fourth, we completely agree with the authors’ suggestion of careful occlusion compression which should indeed be performed with the minimal compression able to block the bleeding but not causing complete vessel flow occlusion. Indeed, many authors have outlined that prolonged occlusive compression often leads to late radial artery occlusion. This can be significantly reduced by the utilization of radial wrist pads containing prothrombotic substances such as caolin which can favor rapid bleeding reduction, decreasing at the same

Interosseous artery collaterals and their support to ulno-palmar arch: A case report and a review of the literature

Article history: Received 3 June 2015 Accepted 20 June 2015 Available online 27 June 2015 (Glidesheath, Terumo, Somerset, NJ) instead of a brachial access to perform coronary angiography. We also performed a right forearm arteriography (Fig. 1), which demonstrated an efficient collateralization from interosseous anterior branch to distal radial artery. The access site was managed with verapamil 5 mg and heparin 5000 UI. The coronary angiography showed a sub-occlusive restenosis of the RCA treated with a DES. At the end of the procedure, the 6 French ulnar sheath was A 65 year-old woman, with known hypertension, dyslipidemia, and positive family history of coronary artery disease and conservatively treated for an aorto-iliac occlusive disease, was admitted in September 2014 in our institution with angina (CCS 2) and a positive non-invasive test suggests myocardial ischemia in the inferior wall of the left ventricle. Diagnostic suspicion of a right coronary artery (RCA) restenosis indicated an invasive coronary artery assessment. Patient clinical history starts 7 months before with an acute anterior non-ST-segment Elevation Myocardial Infarction. Coronary angiography, performed through a right trans-radial access (TRA) evidenced a sub-occlusive mid-LAD stenosis and a significant stenosis on the RCA. The patient was successfully treated by a PCI on the proximal left anterior descending (LAD)with drug eluting stent (DES) implantation. After a short and uneventful hospitalization, she was discharged. One month later, the patient was readmitted to undergo a stage procedure on the RCA due to ventricular inferior wall ischemia evidence. Arterial pulse evaluation showed a probably iatrogenic right radial arterial occlusion (RAO). Therefore, in the context of the aorto-iliac occlusive disease, a left TRA was chosen. Coronary angiography confirmed the good result of the LAD stenting and the RCA stenosis was treated with PCI and Bare Metal Stent (BMS) implantation. The procedure was uneventful and the patient was discharged the following day. Prior to coronary artery angiography, during September 2014 hospitalization, pulse examination was performed with a bilateral radial artery occlusion evidence. Despite a highly abnormal reverse modified Allen test which would have contraindicated a wrist access, the pulseoxymetry evaluation (right thumb) recorded a C pattern [1] suggesting the presence of an efficient blood flow to ulno-palmar arch. We then