Sanjog Kalra

Outcomes With the Use of the Retrograde Approach for Coronary Chronic Total Occlusion Interventions in a Contemporary Multicenter US Registry

Background—We sought to examine the efficacy and safety of chronic total occlusion percutaneous coronary intervention using the retrograde approach. Methods and Results—We compared the outcomes of the retrograde versus antegrade-only approach to chronic total occlusion percutaneous coronary intervention among 1301 procedures performed at 11 experienced US centers between 2012 and 2015. The mean age was 65.5±10 years, and 84% of the patients were men with a high prevalence of diabetes mellitus (45%) and previous coronary artery bypass graft surgery (34%). Overall technical and procedural success rates were 90% and 89%, respectively, and in-hospital major adverse cardiovascular events occurred in 31 patients (2.4%). The retrograde approach was used in 539 cases (41%), either as the initial strategy (46%) or after a failed antegrade attempt (54%). When compared with antegrade-only cases, retrograde cases were significantly more complex, both clinically (previous coronary artery bypass graft surgery prevalence, 48% versus 24%; P<0.001) and angiographically (mean Japan-chronic total occlusion score, 3.1±1.0 versus 2.1±1.2; P<0.001) and had lower technical success (85% versus 94%; P<0.001) and higher major adverse cardiovascular events (4.3% versus 1.1%; P<0.001) rates. On multivariable analysis, the presence of suitable collaterals, no smoking, no previous coronary artery bypass graft surgery, and left anterior descending artery target vessel were independently associated with technical success using the retrograde approach. Conclusions—The retrograde approach is commonly used in contemporary chronic total occlusion percutaneous coronary intervention, especially among more challenging lesions and patients. Although associated with lower success and higher major adverse cardiovascular event rates in comparison to antegrade-only crossing, retrograde percutaneous coronary intervention remains critical for achieving overall high success rates.

Use of antegrade dissection re-entry in coronary chronic total occlusion percutaneous coronary intervention in a contemporary multicenter registry

BACKGROUND We assessed efficacy and safety of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using antegrade dissection re-entry (ADR). METHODS We examined outcomes of ADR among 1313 CTO PCIs performed at 11 US centers between 2012-2015. RESULTS 84.1% of patients were men. Prevalence of prior coronary artery bypass graft surgery was 34.3%. Overall technical and procedural success were 90.1% and 88.7%, respectively. In-hospital major adverse cardiovascular events (MACE) occurred in 31 patients (2.4%). ADR was used in 458 cases (34.9%), and was the first strategy in 169 cases (12.9%). ADR cases were angiographically more complex than non-ADR cases (mean J-CTO score: 2.8±1.2 vs. 2.4±1.2, p<0.001). ADR was performed using the CrossBoss catheter in 246 of 458 (53.7%) and the Stingray system in 251 ADR cases (54.8%). Compared with non-ADR cases, ADR cases had lower technical (86.9% vs. 91.8%, p=0.005) and procedural success (85.0% vs. 90.7%, p=0.002), but similar risk for MACE (2.9% vs. 2.2%, p=0.42). ADR was associated with longer procedure and fluoroscopy time, and higher patient air kerma dose and contrast volume (all p<0.001). After excluding retrograde cases, ADR and antegrade wire escalation (AWE) had similar technical success (92.7% vs. 94.2%, p=0.43), procedural success (91.8% vs. 94.1%, p=0.23), and MACE (2.1% vs. 0.6%, p=0.12). CONCLUSIONS ADR is used relatively frequently in contemporary CTO PCI, especially for challenging lesions and after failure of other strategies. ADR is associated with similar success rates and risk for complications as compared with AWE, and is important for achieving high procedural success.

Mother–Daughter–Granddaughter Double GuideLiner Technique for Delivering Stents Past Multiple Extreme Angulations

Failure to deliver stents and balloons past tortuous, calcific lesions because of inadequate support has long plagued interventional cardiologists. The mother–daughter technique using a GuideLiner Catheter (Vascular Solutions, Inc, Minneapolis, MN) is now commonly used to address these situations.1,2 Despite the improved support provided by the GuideLiner catheter, occasions arise in which a single GuideLiner is not adequate to facilitate the delivery of stents or balloons to target lesions. This is especially problematic when attempting percutaneous coronary intervention (PCI) on the retrograde limb of a bypassed coronary through a long saphenous vein graft (SVG). The double bend of the anastomosis into the retrograde coronary artery combined with the antegrade turn of the target branch is often uncrossable even with modern balloon and stent technology. We describe 2 cases of the mother–daughter–granddaughter double GuideLiner technique using a 6 Fr GuideLiner inside an 8 Fr GuideLiner to perform highly challenging PCI. Seventy-two-year-old man with a history of remote coronary artery bypass grafting with left internal mammary artery to left anterior descending and SVG to the first obtuse marginal (OM1) bypass, who later required left main, left anterior descending, and proximal left circumflex (LCX) complex bifurcation stenting, presented to his cardiologist with severe refractory chest pain. Subsequent angiography demonstrated that the left main, proximal LCX, and left anterior descending stents were totally occluded. The angiogram also showed a patent SVG to the OM1, with slow retrograde flow into a nearly occluded LCX and second obtuse marginal artery (OM2; Figure 2A and Data Supplement Movie I). ### Description of the Procedure for Case 1 Given the complexity of the turns required to gain access to the LCX, the mother–daughter–granddaughter double GuideLiner approach was used. The mother–daughter–granddaughter system was …

Trends, etiologies, and predictors of 90-day readmission after percutaneous ventricular assist device implantation: A national population-based cohort study

Percutaneous ventricular assist devices (pVADs) are indicated to provide hemodynamic support in high‐risk percutaneous interventions and cardiogenic shock. However, there is a paucity of published data regarding the etiologies and predictors of 90‐day readmissions following pVAD use. We studied the data from the US Nationwide Readmissions Database (NRD) for the years 2013 and 2014. Patients with a primary discharge diagnosis of pVAD use were collected by searching the database for International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9‐CM) procedural code 37.68 (Impella and TandemHeart devices). Amongst this group, we examined 90‐day readmission rates. Comorbidities as identified by “CM_” variables provided by the NRD were also extracted. The Charlson Comorbidity Index was calculated using appropriate ICD‐9‐CM codes, as a secondary diagnosis. A 2‐level hierarchical logistic regression model was then used to identify predictors of 90‐day readmission following pVAD use. Records from 7074 patients requiring pVAD support during hospitalization showed that 1562 (22%) patients were readmitted within 90 days. Acute decompensated heart failure (22.6%) and acute coronary syndromes (11.2%) were the most common etiologies and heart failure (odds ratio [OR]: 1.39, 95% confidence interval [CI]: 1.17–1.67), chronic obstructive pulmonary disease (OR: 1.26, 95% CI: 1.07–1.49), peripheral vascular disease (OR: 1.305, 95% CI: 1.09–1.56), and discharge into short‐ or long‐term facility (OR: 1.28, 95% CI: 1.08–1.51) were independently associated with an increased risk of 90‐day readmission following pVAD use. This study identifies important etiologies and predictors of short‐term readmission in this high‐risk patient group that can be used for risk stratification, optimizing discharge, and healthcare transition decisions.

OUTCOMES WITH USE OF THE RETROGRADE APPROACH FOR CORONARY CHRONIC TOTAL OCCLUSION INTERVENTIONS IN A CONTEMPORARY MULTICENTER US REGISTRY

We sought to examine the efficacy and safety of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using the retrograde approach. We compared the outcomes of the retrograde vs. antegrade only approach to CTO PCI among 1,301 procedures performed at 11 US centers between 2012 and

TCT-133 Use of a Micro-axial Percutaneous Left Ventricular Assist Device (pLVAD) for Patients with Cardiogenic Shock

The mortality of patients with cardiogenic shock (CS) remains unacceptably high. Impella® (Abiomed, Danvers, MA), a micro-axial percutaneous left ventricular assist device (pLVAD), has been used for hemodynamic support in CS. Its optimal use in severe CS is of interest. We retrospectively reviewed