Aristotelis Papayannis

Retrograde Coronary Chronic Total Occlusion Revascularization: Procedural and In-Hospital Outcomes From a Multicenter Registry in the United States

OBJECTIVES This study sought to examine the contemporary outcomes of retrograde chronic total occlusion (CTO) interventions among 3 experienced U.S. centers. BACKGROUND The retrograde approach, pioneered and developed in Japan, has revolutionized the treatment of coronary CTO, yet limited information exists on procedural efficacy, safety, and reproducibility of outcomes in other settings. METHODS Between 2006 and 2011, 462 consecutive retrograde CTO interventions were performed at 3 U.S. institutions. Patient characteristics, procedural outcomes, and in-hospital clinical events were ascertained. RESULTS Mean patient age was 65 ± 9.7 years, 84% were men, and 50% had prior coronary artery bypass surgery. The CTO target vessel was the right coronary artery (66%), circumflex (18%), left anterior descending artery (15.5%), and left main artery or bypass graft (0.5%). The retrograde approach was used as the primary method in 46% of cases and after failed antegrade recanalization in 54%. Retrograde collateral vessels were septal (68%), epicardial (24%), and bypass grafts (8%). Technical and procedural success was 81.4% (n = 376) and 79.4% (n = 367), respectively. The mean contrast volume and fluoroscopy time were 345 ± 177 ml and 61 ± 40 min, respectively. A major complication occurred in 12 patients (2.6%). In multivariable analysis, years since initiation of retrograde CTO percutaneous coronary intervention (PCI) at each center, female sex, and ejection fraction ≥40% were associated with higher technical success. CONCLUSIONS Among selected U.S. programs, retrograde CTO PCI is often performed in patients with prior coronary bypass graft surgery and is associated with favorably high success and low complication rates.

Subintimal Dissection/Reentry Strategies in Coronary Chronic Total Occlusion Interventions

Subintimal dissection/reentry techniques are increasingly being used for crossing coronary chronic total occlusions both antegradely (using a knucle wire or the Bridgepoint system) or retrogradely (using the controlled antegrade and retrograde tracking and dissection, and reverse controlled antegrade and retrograde tracking and dissection technique). Subintimal dissection/reentry techniques can increase procedural success rates, but their subsequent clinical outcomes are poorly studied, and they appear to be associated with high rates of in-stent restenosis and repeat target lesion revascularization. In the present review, we describe in detail the chronic total occlusions subintimal dissection/reentry techniques, clarify the related terminology and summarize the published studies in this area and the current gaps of knowledge.

Periprocedural Myocardial Injury in Chronic Total Occlusion Percutaneous Interventions: a Systematic Cardiac Biomarker Evaluation Study

OBJECTIVES This study sought to evaluate the incidence, correlates, and clinical implications of periprocedural myocardial injury (PMI) during percutaneous coronary intervention (PCI) of chronic total occlusions (CTO). BACKGROUND The risk of PMI during CTO PCI may be underestimated because systematic cardiac biomarker measurement was not performed in published studies. METHODS We retrospectively examined PMI among 325 consecutive CTO PCI performed at our institution between 2005 and 2012. Creatine kinase-myocardial band fraction and troponin were measured before PCI and 8 to 12 h and 18 to 24 h after PCI in all patients. PMI was defined as creatine kinase-myocardial band increase ≥ 3 x the upper limit of normal. Major adverse cardiac events during mid-term follow-up were evaluated. RESULTS Mean age was 64 ± 8 years. The retrograde approach was used in 26.8% of all procedures. The technical and procedural success was 77.8% and 76.6%, respectively. PMI occurred in 28 patients (8.6%, 95% confidence intervals: 5.8% to 12.2%), with symptomatic ischemia in 7 of those patients. The incidence of PMI was higher in patients treated with the retrograde than the antegrade approach (13.8% vs. 6.7%, p = 0.04). During a median follow-up of 2.3 years, compared with patients without PMI, those with PMI had a higher incidence of major adverse cardiac events (hazard ratio [HR]: 2.25, p = 0.006). Patients with only asymptomatic PMI also had a higher incidence of major adverse cardiac events on follow-up (HR: 2.26, p = 0.013). CONCLUSIONS Systematic measurement of cardiac biomarkers post-CTO PCI demonstrates that PMI occurs in 8.6% of patients, is more common with the retrograde approach, and is associated with worse subsequent clinical outcomes during mid-term follow-up.

Transfemoral use of the guideLiner catheter in complex coronary and bypass graft interventions

The GuideLiner catheter (Vascular Solutions, Minneapolis, MN) is a novel, rapid exchange catheter that allows deep vessel intubation. We describe 21 patients in whom the GuideLiner catheter [7 French (F) in 76% and 6F in 24%] was used to facilitate equipment delivery (n = 14) or vessel engagement (n = 7). Pressure dampening after GuideLiner catheter insertion was observed in 12 patients (57%). The procedure was successfully completed in 19 patients (90%) and one patient developed acute vessel closure, likely due to dissection. The GuideLiner catheter can facilitate complex coronary interventions but should be used with caution to minimize the risk for vessel injury.

Relation between the presence and extent of coronary lipid core plaques detected by near-infrared spectroscopy with postpercutaneous coronary intervention myocardial infarction.

We aimed to examine whether an association exists between the presence and extent of coronary lipid core plaques (LCPs) detected by near-infrared spectroscopy (NIRS) performed before percutaneous coronary intervention (PCI) with postprocedural myocardial infarction (MI). NIRS was performed in the native coronary arteries of 30 patients before PCI. Angular extent of LCP, lesion segment lipid core burden index, and block chemogram were evaluated. Cardiac biomarkers were measured before and 16 to 24 hours after PCI to determine occurrence of postprocedural MI. Mean number of 2-mm yellow blocks within the stented lesion was 1.4 ± 2.1 and mean lesion lipid core burden index was 110.3 ± 99. Using a definition of creatine kinase-MB >1 time upper limit of normal (ULN), >2 times ULN, and >3 times ULN, MI after PCI occurred in 23%, 13%, and 10% of patients, respectively. Compared to patients who did not have MI after PCI, those who did had similar clinical characteristics but received more stents and had more blocks within the stented lesion. Creatine kinase-MB increase >3 times ULN was observed in 27% of patients with ≥1 yellow block versus in none of the patients without a yellow block within the stented lesion (p = 0.02). In conclusion, PCI of LCP-positive lesions as assessed by NIRS is associated with increased risk for MI after PCI. NIRS may allow lesion-specific risk stratification before PCI and optimization of PCI strategies for myocardial injury risk minimization.

Embolic protection device utilization during stenting of native coronary artery lesions with large lipid core plaques as detected by near-infrared spectroscopy†

Stenting of large lipid core plaques (LCPs), as assessed by near‐infrared spectroscopy (NIRS), has been associated with periprocedural myocardial infarction (MI), possibly due to distal embolization.

Effect of a Real-Time Radiation Monitoring Device on Operator Radiation Exposure During Cardiac Catheterization The Radiation Reduction During Cardiac Catheterization Using Real-Time Monitoring Study

Background—The Radiation Reduction During Cardiac Catheterization Using Real-Time Monitoring study sought to examine the effect of a radiation detection device that provides real-time operator dose reporting through auditory feedback (Bleeper Sv; Vertec Scientific Ltd; Berkshire, UK) on patient dose and operator exposure during cardiac catheterization. Methods and Results—Between January 2012 and May 2014, 505 patients undergoing coronary angiography, percutaneous coronary intervention, or both were randomized to use (n=253) or no use (n=252) of the Bleeper Sv radiation monitor. Operator radiation exposure was measured in both groups using a second, silent radiation exposure monitoring device. Mean patient age was 65±8 years, most patients (99%) were men, and 30% had prior coronary artery bypass graft surgery. Baseline clinical characteristics were similar in the 2 study groups. Radial access was used in 18% and chronic total occlusion percutaneous coronary intervention constituted 7% of the total procedures. Median procedure time was 17 (12–27) minutes for diagnostic angiography, 42 (28–70) minutes for percutaneous coronary intervention, and 27 (14–51) minutes in the overall study population, with similar distribution between the study groups. First (9 [4–17] versus 14 [7–25] &mgr;Sv; P<0.001) and second (5 [2–10] versus 7 [4–14] &mgr;Sv; P<0.001) operator radiation exposure was significantly lower in the Bleeper Sv group. Use of the device did not result in a significant reduction in patient radiation dose. The effect of the Bleeper Sv device on operator radiation exposure was consistent among various study subgroups. Conclusions—Use of a real-time radiation monitoring device that provides auditory feedback can significantly reduce operator radiation exposure during cardiac catheterization. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01510353.

Use of the Crossboss catheter in coronary chronic total occlusion due to in-stent restenosis.

We describe treatment of six chronic total occlusions due to in‐stent restenosis with the CrossBoss catheter (BridgePoint Medical, Minneapolis, Minnesota). The CrossBoss catheter allowed successful CTO crossing in 5 of 6 lesions (83%): in 50% the catheter entered the distal true lumen, whereas in 33% a wire was required for distal true lumen crossing. No complications were observed. Use of the CrossBoss catheter can facilitate treatment of coronary chronic total occlusions due to in‐stent restenosis.

Optical coherence tomography evaluation of drug-eluting stents: A systematic review

We performed a systematic review of studies reporting stent strut coverage and malapposition post implantation of different drug‐eluting stent (DES), as assessed by optical coherence tomography (OCT).

Association of coronary lipid core plaque with intrastent thrombus formation: A Near-Infrared Spectroscopy and Optical Coherence Tomography Study

Background: Optical coherence tomography (OCT) and near‐infrared spectroscopy (NIRS) allow assessment of the anatomy (OCT) and composition (NIRS) of coronary lesions. We sought to examine the association between pre‐stenting lipid core plaque (LCP), as assessed by NIRS and post‐stenting thrombus formation, as assessed by OCT. Methods: We reviewed the angiograms of nine patients who underwent coronary stenting in association with NIRS and OCT imaging. A large LCP by NIRS was defined as at least three 2‐mm yellow blocks on the NIRS block chemogram with >200° angular extent. Intracoronary thrombus was defined as a mass of medium reflectivity protruding into the vessel lumen, discontinuous from the surface of the vessel wall. Results: Mean age was 67 ± 7 years, and all patients were men, presenting with stable angina (56%), unstable angina (11%), or acute myocardial infarction (33%). The mean vessel lipid core burden index (LCBI) was 120 ± 45, and the mean highest 6‐mm LCBI was 386 ± 190. Three patients had a large LCP and two of them (66%) developed intrastent thrombus after stent implantation compared to none of six patients without large LCPs (0%, P = 0.02). The thrombus resolved after intracoronary glycoprotein IIb/IIIa administration and balloon postdilation. Postprocedural myocardial infarction occurred in 33% versus 17% of patients with and without large LCP, respectively (P = 0.57). Conclusion: Stenting of large LCPs may be associated with intrastent thrombus formation, suggesting that more intensive anticoagulant and/or antiplatelet therapy may be beneficial in such lesions.