Vishal G. Patel

Angiographic Success and Procedural Complications in Patients Undergoing Percutaneous Coronary Chronic Total Occlusion Interventions : A Weighted Meta-Analysis of 18,061 Patients From 65 Studies

OBJECTIVES This study sought to perform a weighted meta-analysis of the complication risk during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BACKGROUND The safety profile of CTO PCI has received limited study. METHODS We conducted a meta-analysis of 65 studies published between 2000 and 2011 reporting procedural complications of CTO PCI. Data on the frequency of death, emergent coronary artery bypass graft surgery, stroke, myocardial infarction, perforation, tamponade, stent thrombosis, major vascular or bleeding events, contrast nephropathy, and radiation skin injury were collected. RESULTS A total of 65 studies with 18,061 patients and 18,941 target CTO vessels were included. Pooled estimates of outcomes were as follows: angiographic success 77% (95% confidence interval [CI]: 74.3% to 79.6%); death 0.2% (95% CI: 0.1% to 0.3%); emergent coronary artery bypass graft surgery 0.1% (95% CI: 0.0% to 0.2%); stroke <0.01% (95% CI: 0.0% to 0.1%); myocardial infarction 2.5% (95% CI: 1.9% to 3.0%); Q-wave myocardial infarction 0.2% (95% CI: 0.1% to 0.3%); coronary perforation 2.9% (95% CI: 2.2% to 3.6%); tamponade 0.3% (95% CI: 0.2% to 0.5%); and contrast nephropathy 3.8% (95% CI: 2.4% to 5.3%). Compared with successful procedures, unsuccessful procedures had higher rates of death (0.42% vs. 1.54%, p < 0.0001), perforation (3.65% vs. 10.70%, p < 0.0001), and tamponade (0% vs. 1.65%, p < 0.0001). Among 886 lesions treated with the retrograde approach, success rate was 79.8% with no deaths and low rates of emergent coronary artery bypass graft surgery (0.17%) and tamponade (1.2%). CONCLUSIONS CTO PCI carries low risk for procedural complications despite high success rates.

Procedural Outcomes of Revascularization of Chronic Total Occlusion of Native Coronary Arteries (from a Multicenter United States Registry)

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) is a rapidly evolving area of interventional cardiology. We sought to examine the immediate procedural and in-hospital clinical outcomes of native coronary artery CTO PCI from a multicenter United States (US) registry. We retrospectively examined the procedural outcomes of 1,361 consecutive native coronary artery CTO PCIs performed at 3 US institutions from January 2006 to November 2011. Mean age was 65 ± 11 years, 85% of patients were men, 40% had diabetes, 37% had previous coronary artery bypass graft surgery, and 42% had previous PCI. The CTO target vessel was the right coronary artery (55%), circumflex (23%), left anterior descending artery (21%), and left main or bypass graft (1%). The retrograde approach was used in 34% of all procedures. The technical and procedural success rates were 85.5% and 84.2%, respectively. The mean procedural time, fluoroscopy time, and contrast utilization were 113 ± 61 minutes, 42 ± 29 minutes, and 294 ± 158 ml, respectively. In multivariate analysis, female gender, no previous coronary artery bypass surgery, and years since initiation of CTO PCI at each center were independent predictors of procedural success. Major complications occurred in 24 patients (1.8%). In conclusion, among selected US-based institutions with experienced operators, native coronary artery CTO PCI can be performed with high success and low major complication rates.

Prevalence and management of coronary chronic total occlusions in a tertiary veterans affairs hospital

We sought to determine the contemporary prevalence and management of coronary chronic total occlusions (CTO) in a veteran population.

Medical Management After Coronary Stent Implantation: A Review

IMPORTANCE Percutaneous coronary intervention (PCI) with stents is currently the most commonly performed coronary revascularization procedure; hence, optimizing post-PCI outcomes is important for all physicians treating such patients. OBJECTIVE To review the contemporary literature on optimal medical therapy after PCI. EVIDENCE REVIEW We performed a comprehensive search of the PubMed and Cochrane Library databases for manuscripts on medical therapy after PCI, published between 2000 and February 2013. Bibliographies of the retrieved studies were searched by hand for other relevant studies. Priority was given to data from large randomized controlled trials, systematic reviews, and meta-analyses. Of the 6852 publications retrieved, 91 were included. FINDINGS Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor (eg, ticlopidine, clopidogrel, prasugrel, ticagrelor) reduces the risk of stent thrombosis and subsequent cardiovascular events post-PCI (number needed to treat, 33-53) and is the current standard of care. Aspirin should be continued indefinitely and low dose (75-100 mg daily) is preferred over higher doses. A P2Y12 inhibitor should be administered for 12 months after PCI, unless the patient is at high risk for bleeding; however, ongoing studies are assessing the value of shorter or longer duration of P2Y12 inhibitor administration. In patients with acute coronary syndromes, prasugrel and ticagrelor further reduce cardiovascular ischemic events compared with clopidogrel but are associated with higher bleeding risk. If possible, noncardiac surgery should be delayed until 12 months after coronary stenting. Patients receiving coronary stents who require warfarin are at high risk for bleeding if they also receive dual antiplatelet therapy. Omission of aspirin may be advantageous in such patients. Routine platelet function or genetic testing is currently not recommended to tailor antiplatelet therapy after PCI. CONCLUSIONS AND RELEVANCE Dual antiplatelet therapy remains the cornerstone of medical therapy after PCI. Continuous advances in pharmacotherapy can further enhance our capacity to improve outcomes in this high-risk patient group.

Angiographic success and procedural complications in patients undergoing retrograde percutaneous coronary chronic total occlusion interventions: A weighted meta-analysis of 3482 patients from 26 studies

BACKGROUND The efficacy and safety profile of retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We sought to perform a weighted meta-analysis of the success and complication rates of retrograde CTO PCI. METHODS We conducted a meta-analysis of 26 studies published between 2006 and April 2013 reporting in-hospital outcomes of retrograde CTO PCI. Data on procedural success, frequency of death, emergent coronary artery bypass graft surgery (CABG), stroke, myocardial infarction (MI), perforation, tamponade, stent thrombosis, major vascular or bleeding events, contrast nephropathy, and radiation skin injury were collected. RESULTS A total of 26 studies with 3482 patients and 3493 target CTO lesions were included. Primary retrograde CTO PCI was attempted in 52.4%. Pooled estimates of outcomes were as follows: procedural success 83.3% [95% confidence interval (CI): 79.0% to 87.7%]; death 0.7% (95% CI: 0.5% to 1.2%); urgent CABG 0.7% (95% CI: 0.4% to 1.2%); tamponade 1.4% (95% CI: 1.0% to 2.2%); collateral perforation 6.9% (95% CI: 4.6% to 10.4%); coronary perforation 4.3% (95% CI: 1.2% to 15.4%); donor vessel dissection 2% (95% CI: 0.9% to 4.5%); stroke 0.5% (95% CI: 0.2% to 1.0%); MI 3.1% (95% CI: 0.2% to 5.0%); Q wave MI 0.6% (95% CI: 0.4% to 1.1%); vascular access complications 2% (95% CI: 0.9% to 4.5%); contrast nephropathy 1.8% (95% CI: 0.8% to 3.7%); and wire fracture and equipment entrapment 1.2% (95% CI: 0.6% to 2.5%). CONCLUSIONS Retrograde CTO PCI is associated with high procedural success rate and acceptable risk for procedural complications.

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.

Outcomes of preoperative bridging therapy for patients undergoing surgery after coronary stent implantation: A weighted meta‐analysis of 280 patients from eight studies

Preoperative bridging with a glycoprotein IIb/IIIa inhibitor is often performed in patients with prior coronary stents undergoing surgery who require antiplatelet therapy discontinuation, but its safety and efficacy have received limited study. We performed a weighted meta‐analysis of the outcomes in patients with coronary stents undergoing bridging with glycoprotein IIb/IIIa inhibitors prior to surgery.

Surrogate and clinical outcomes following ischemic postconditioning during primary percutaneous coronary intervention of ST‐Segment elevation myocardial infarction: A meta‐analysis of 15 randomized trials

To conduct a meta‐analysis on surrogate and clinical outcomes with myocardial ischemic postconditioning (IPoC) following revascularization with primary percutaneous intervention (PPCI) for ST‐segment myocardial infarction (STEMI) compared with PPCI alone.

Meta-analysis of stroke after transradial versus transfemoral artery catheterization

BACKGROUND Transradial (TR) catheterization is gaining popularity due to its association with lower bleeding and access site complications, improved patient comfort, and lower costs compared to transfemoral (TF) catheterization; however, there is concern that TR catheterization may be associated with an increased risk of neurological complications. New randomized data has emerged since the publication of the last meta-analysis evaluating the risk of stroke between TR and TF catheterization in 2009. METHODS We conducted a meta-analysis of randomized studies published until 2013 reporting risk of stroke in TR vs. TF catheterization. RESULTS Data from 11,273 patients in 13 studies were collated. The majority of patients were men, and 8987 (79.7%) were enrolled in acute coronary syndrome trials. Very few patients had a history of prior coronary artery bypass grafting, and approximately 2/3 of patients underwent percutaneous coronary intervention. Stroke occurred in 25 of 5659 patients in the TR group, vs. 24 of 5614 patients in the TF group. There was no difference in stroke rates between the TR and TF groups (risk difference 0.00%, 95% confidence interval -0.29%-0.25%, p=0.88). CONCLUSIONS TR catheterization is not associated with a significant increase in stroke compared to TF catheterization.

Amplatzer vascular plug IV for occlusion of pulmonary arteriovenous malformations in a patient with cryptogenic stroke

Paradoxical embolism resulting in cryptogenic stroke has received much attention recently, with the primary focus on patent foramen ovale (PFO). However, it is essential to be vigilant in the search for other causes of paradoxical embolic events, such as pulmonary arteriovenous malformations (PAVM). We describe successful closure of pulmonary AVM with a St Jude Medical (Plymouth, MN) Amplatzer™ vascular plug IV. The newer AVP-IV devices can be used for successful embolization of tortuous pulmonary AVM in remote locations where use of other traditional devices may be technically challenging.