Dimitri Karmpaliotis

Transradial approach for coronary chronic total occlusion interventions: Insights from a contemporary multicenter registry

To examine the impact of transradial access on the procedural outcomes of chronic total occlusion (CTO) percutaneous coronary interventions (PCI).

Diagnosis and Management of Cardiovascular Disease in Advanced and End‐Stage Renal Disease

Chronic kidney disease (CKD) affects 13% of the US population.[1][1] Although a significant proportion of these patients progress to end‐stage renal disease (ESRD) requiring renal replacement therapy (RRT)[2][2] or renal transplantation, cardiovascular disease remains the most common cause of

Optical coherence tomography-guided percutaneous coronary intervention in pre-terminal chronic kidney disease with no radio-contrast administration

A 67-year-old man with advanced chronic kidney disease (CKD) (creatinine = 4.5 mg/dL, eGFR = 13 mL/min/1.73 m2) not requiring haemodialysis presented with progressive angina. Diagnostic angiography with ultra-low radio-contrast volume (12 mL, contrast volume/eGFR ratio <1) revealed significant stenosis in the left anterior descending (LAD) artery ( Panel A ). The lesion was haemodynamically significant (fractional flow reserve: 0.77). Post-angiography, the …

Impact of Saphenous Vein Graft Radiographic Markers on Clinical Events and Angiographic Parameters

BACKGROUNDnUse of saphenous vein graft (SVG) radiographic markers has been associated with shorter cardiac catheterization procedure times and reduced contrast agent volume for postoperative coronary artery bypass graft (CABG) catheterizations. Use of such markers is varied and often operator-dependent, as the effect of SVG markers has not been fully evaluated. The goal of the present analysis was to evaluate the association of SVG markers with clinical outcomes and graft patency.nnnMETHODSnData were drawn from the Project of Ex-vivo Vein Graft Engineering via Transfection (PREVENT) IV trial of patients undergoing CABG at 107 hospitals across the United States. Repeat angiography was performed within 12 to 18 months after CABG. The SVG markers were used at the discretion of the surgeon and were identified on the follow-up angiogram as any device used to mark the ostium, regardless of shape.nnnRESULTSnThe SVG markers were present in 51.2% of evaluable patients (910 of 1,778) and 52.3% of SVGs (2,228 of 4,240). Among patients with totally occluded SVGs (n = 911), visual identification of the SVG was obtained more frequently in those with an SVG marker (90.7% vs 72.1%, p < 0.001). The SVG stenosis 70% or greater at follow-up did not differ by use of markers (25.8% with marker vs 24.4% without marker, p = not significant). These findings were also consistent in ostial lesions (n = 942). Long-term death or myocardial infarction (MI) was similar by use of marker. The perioperative CABG MI was higher in patients with SVG markers (10.1% vs 5.5%, odds ratio adjusted 1.86, p = 0.021).nnnCONCLUSIONSnSaphenous vein graft radiographic markers were associated with higher rates of direct visualization of totally occluded SVGs without an adverse effect on graft patency or long-term clinical outcomes, but the association of SVG markers with increased perioperative CABG MI warrants further examination.

Utility of near-infrared spectroscopy for detection of thin-cap neoatherosclerosis.

Aims Near-infrared spectroscopy (NIRS) has been employed to assess the composition of the atherosclerotic plaques in native coronary arteries. However, little is known about the detection of neoatherosclerosis by NIRS in in-stent restenosis (ISR). The aim of the study was to assess the relationship between the distribution of lipid determined by NIRS and morphology of ISR on optical coherence tomography (OCT). Methods and results We performed both NIRS and OCT in 39 drug-eluting stents with ISR. Values of lipid-core burden index (LCBI) derived by NIRS were compared with the OCT-derived thickness of the fibrous cap covering neoatherosclerotic lesions. A total of 22 (49%) in-stent neointimas were identified as lipid rich by both NIRS and OCT. There was good agreement between OCT and NIRS in identifying lipid within in-stent neointima (kappa = 0.60, 95% CI: 0.34–0.86). OCT identified thin-cap neoatheromas (TCNA) (<65 µm) in 12 stents (23%). The minimal cap thickness of in-stent neoatherosclerotic plaque measured by OCT correlated with the maxLCBI4mm (maximal LCBI per 4 mm) within the stent (r = −0.77, P< 0.01). Moreover, maxLCBI4mm was able to accurately predict TCNA with a cut-off value of >144. Conclusion NIRS correlates with OCT identification of lipids in stented vessels and is able to predict the presence of thin fibrous cap neoatheroma.

Performance of J-CTO and PROGRESS CTO Scores in Predicting Angiographic Success and Long-term Outcomes of Percutaneous Coronary Interventions for Chronic Total Occlusions

Patient selection for and predicting clinical outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) remain challenging. We hypothesized that both J-CTO (Multicenter Chronic Total Occlusion Registry of Japan) and PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) scores will predict not only angiographic success but also long-term clinical outcomes of the patients who underwent PCI of CTO. Of 325 CTO PCIs performed at 2 Emory University hospitals from January 2012 to August 2015, 249 patients with complete baseline clinical, angiographic and follow-up data, were included in this analysis. Major adverse cardiovascular events (MACEs) consisted of a composite of death, myocardial infarction, and target vessel revascularization. Mean age was 63u2009±u200911 years old and mean follow-up was 19.8u2009±u200913.1 months. Angiographic success rates increased from 74.5% in 2012 to 85.7% in 2015. Greater J-CTO and PROGRESS CTO scores were not only associated with lower likelihood of angiographic success but also higher rates of long-term MACE. Compared with the scores of 0 to 2, J-CTO and PROGRESS CTO scores of ≥3 were associated with higher MACE. Multivariable analysis demonstrated that PROGRESS CTO scores of ≥3, male sex, and peripheral vascular disease were independent predictors of MACE. In conclusion, J-CTO and PROGRESS CTO scores are useful in predicting procedural success. In addition, the PROGRESS CTO score, and to a lesser degree J-CTO score, have predictive value for long-term outcomes in patients who underwent CTO PCI.

Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention in Patients With Diabetes: Insights From the OPEN CTO Registry

OBJECTIVESnFew studies have evaluated the relationship of diabetes with technical success and periprocedural complications, and no studies have compared patient-reported health status after chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in patients with and without diabetes.nnnBACKGROUNDnCTOs are more common in patients with diabetes, yet CTO PCI is less often attempted in patients with diabetes than in patients without. The association between diabetes and health status after CTO PCI is unknown.nnnMETHODSnIn the 12-center OPEN-CTO PCI registry (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion Registry), patients with and without diabetes were assessed for technical success, periprocedural complications, and health status over 1 year following CTO PCI using the Seattle Angina Questionnaire and the Rose Dyspnea Scale. Hierarchical modified Poisson regression was used to examine the independent association between diabetes and technical success, and hierarchical multivariable linear regression was used to assess the association between diabetes and follow-up health status.nnnRESULTSnDiabetes was common (41.2%) and associated with a lower crude rate of technical success (83.5% vs. 88.1%; pxa0= 0.04). After adjustment, there was no significant difference between diabetic and nondiabetic patients (relative risk:xa00.96, 95% confidence interval: 0.91 to 1.01). There were no significant differences in complication rates between patients with and without diabetes. Angina burden, quality of life, and overall health status scores were similar betweenxa0diabetic and nondiabetic patients over 1xa0year.nnnCONCLUSIONSnAlthough technical success was lower in patients with diabetes, this reflected lower success amongxa0patients with prior bypass surgery, without any significant difference in success rate after adjusting for prior bypassxa0andxa0disease complexity. CTO PCI complication rates are similar in diabetic and nondiabetic patients, andxa0symptomxa0improvement following CTO PCI is robust and of a similar magnitude regardless of diabetes status.

Zero-contrast percutaneous coronary intervention on calcified lesions facilitated by rotational atherectomy: Atherectomy-assisted Zero Contrast PCI

Percutaneous coronary intervention (PCI) in patients with advanced chronic kidney disease (CKD) is challenging due to frequent presence of complex calcified lesions and the very high risk of contrast‐induced nephropathy (CIN). We report a strategy of “zero contrast” PCI, guided by intravascular imaging and physiology, performed in three patients with advanced CKD in whom severe calcification necessitated rotational atherectomy (RA) to facilitate and optimize PCI. This approach resulted in safe and successful PCI while preserving renal function.

Impact of subintimal plaque modification procedures on health status after unsuccessful chronic total occlusion angioplasty

We sought to determine the impact of subintimal plaque modification (SPM) on early health status following unsuccessful chronic total occlusion (CTO) PCI.

Association of Stress Test Risk Classification With Health Status After Chronic Total Occlusion Angioplasty (from the Outcomes, Patient Health Status and Efficiency in Chronic Total Occlusion Hybrid Procedures [OPEN-CTO] Study)

Stress testing is endorsed by the American College of Cardiology/American Heart Association Appropriate Use Criteria to identify appropriate candidates for Chronic Total Occlusion (CTO) Percutaneous Coronary Intervention (PCI). However, the relation between stress test risk classification and health status after CTO PCI is not known. We studied 449 patients in the 12-center OPEN CTO registry who underwent stress testing before successful CTO PCI, comparing outcomes of patients with low-risk (LR) versus intermediate to high-risk (IHR) findings. Health status was assessed using the Seattle Angina Questionnaire Angina Frequency (SAQ AF), Quality of Life (SAQ QoL), and Summary Scores (SAQ SS). Stress tests were LR in 40 (8.9%) and IHR in 409 (91.1%) patients. There were greater improvements on the SAQ AF (LR vs IHR 14.2u2009±u20092.7 vs 23.3u2009±u20091.3 points, pu2009<0.001) and SAQ SS (LR vs IHR 20.8u2009±u20092.3 vs 25.4u2009±u20091.1 points, pu2009=u20090.03) in patients with IHR findings, but there was no difference between groups on the SAQ QoL domain (LR vs IHR 24.8u2009±u20093.4 vs 27.3u2009±u20091.6 points, pu2009=u20090.42). We observed large health status improvements after CTO PCI in both the LR and IHR groups, with the greatest reduction in angina among those with IHR stress tests. Although patients with higher risk studies may experience greater reduction in angina symptoms, on average, patients with LR stress tests also experienced large improvements in symptoms after CTO PCI, suggesting patients with refractory symptoms should be considered appropriate candidates for CTO PCI regardless of stress test findings.