Journal of Invasive Cardiology最新文献

With the increasing utilization of endovascular mechanical circulatory support devices, such as the Impella CP (Abiomed), there is a need for standardized guidelines for its safe removal. Development of the Perclose post-closure technique was facilitated by the introduction of a new Impella repositioning sheath in 2019, which enabled re-access to the sidearm and stylet, rewiring of the access artery, and Impella sheath removal. Our retrospective single-center study included all patients undergoing Perclose post-closure technique for vascular access closure after Impella removal between 2018 and 2024. Forty-six patients, with a mean age of 63.8 years, predominantly male (82.6%), were included in the analysis. Indications for Impella placement included complex percutaneous coronary intervention (34.8%) and cardiogenic shock (CS) (heart failure-CS: 32.6%, myocardial infarction-CS: 21.7%). Clinically relevant complications were encountered in less than 5% of cases. No instances of covered stent placement, fasciotomy, amputation, or access site infections were reported. Our study underscores the safety of the Perclose post-closure technique following Impella removal in a diverse cohort of patients, with an overall clinically significant complication rate of less than 5%. The Perclose post-closure technique is a reliable and well-tolerated method for vascular access closure in patients undergoing Impella support.

Objectives: Transcoronary ablation of septal hypertrophy (TASH) and surgical myectomy are the recommended treatment options for patients with hypertrophic obstructive cardiomyopathy refractory (HOCM) when conventional drug treatment is not sufficient. We describe the application of radiofrequency (RF) energy via coronary guidewires in an animal model for selective occlusion of coronary side branches that mimics the principle of TASH.

Methods: Transcoronary guidewire ablation of coronary vessels was performed in 5 adult pigs under general anaesthesia in an animal cathlab after successful bench testing of the ablation settings. After assessing transcoronary pacing parameters, RF energy was delivered via coronary guidewires insulated by coating or by a monorail balloon and positioned in different coronary side branches. Occlusion or patency of the specific coronary side branch was documented by coronary angiography after RF delivery.

Results: After the transcoronary RF ablation, the intended occlusion of the coronary vessel (thrombolysis in myocardial infarction [TIMI]-0 or TIMI-1 flow) could be verified by angiography in 82% of the septal branches attempted and 79% of the epicardial branches. The mean ablation duration was 10.3 seconds at 20-W power with an initial impedance of 176 ± 31 Ώ. No unintended occlusion of the main vessels occurred in any case.

Conclusions: RF ablation via coronary guidewires is a feasible method for inducing an acute occlusion of coronary vessels and may change the interventional therapy of HOCM if the current limitations of this technique are overcome.

Clot-in-transit (CIT) is associated with high mortality, and optimal treatment strategies remain uncertain. This study compares the efficacy of catheter-based thrombectomy (CBT) with other treatments for CIT, including anticoagulation, systemic thrombolytic (ST) therapy, and surgical thrombectomy. We conducted a retrospective analysis of patients with CIT documented on echocardiography between January 2020 and May 2024, managed with urgent upfront CBT. We compared the all-cause mortality rates of the CBT cohort to performance goal rates for anticoagulation, systemic thrombolysis (ST), and surgical thrombectomy from a published meta-analysis. Our cohort included 26 patients who underwent CBT (mean age 59.3 ± 17.9 years, 42.3% women, 57.7% Black). Compared to 463 patients from the meta-analysis receiving alternative treatments, the CBT group's short-term mortality was significantly lower (7.7% vs 32.4% for anticoagulation, 13.8% for ST, and 23.2% for surgical thrombectomy). CBT demonstrated noninferiority to anticoagulation (P < .001), ST (P = .031) and surgical thrombectomy (P < .001), and was superior to anticoagulation (P = .0056) and surgical thrombectomy (P = .036). This study suggests CBT is a promising treatment for CIT. Further prospective studies are warranted to validate these findings.

Background: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can be performed using an antegrade-only (AO) approach or a retrograde approach (RA). Whether an RA carries a higher risk of complications needs further investigation.

Methods: The Canadian CTO PCI (CCTOP) was a multicenter, prospective, investigator-initiated cohort study conducted at 6 experienced centers across Canada between March 2014 and October 2019. Patients who underwent an RA were compared to AO patients. The primary endpoint was in-hospital major adverse cardiac events (MACE), defined as death, any post-PCI cardiac enzyme elevation, urgent revascularization, and tamponade. A multivariable analysis was performed to control for potential confounders.

Results: A total of 1033 patients were included in the study, and an RA was used in 48.4% of the cases. The RA was associated with higher lesions complexity (J-CTO score 2.7 ± 1.1 vs 2.3 ± 1.1, P < .001) and lower technical success (81.2% vs 91.5%, P < .001). The risk of in-hospital MACE was higher with the RA (10.2% vs 4.7%, P < .001), and all deaths occurred in the RA group (0.8% vs 0%, P = .038). In the multivariable model, the RA remained associated with an increased risk of MACE (OR, 2.25; 95% CI, 1.26 to 4.02).

Conclusions: Our experience confirms that the RA is associated with an independent increased risk of in-hospital MACE when compared with an AO approach.

Objectives: Outcomes of balloon pulmonary angioplasty (BPA) using intravascular ultrasound (IVUS) with a rounded tip to cross a total occlusion lesion in chronic thromboembolic pulmonary hypertension without passing a conventional guidewire remain unclear. Even in initially unsuccessful cases of total occlusion lesions, improved blood flow may be observed in the postprocedural phase as a result of breaking the thrombosis cap surface. The aim of the study was to verify the initial success of BPA with a new technique using IVUS for total occlusion lesions and to evaluate peripheral blood flow in the postprocedural phase in initially unsuccessful cases.

Methods: Initial success rate and associated factors were evaluated in 50 total occlusion lesions by attempted IVUS passage using a new technique without a preceding guidewire from August 2016 to February 2024. Peripheral blood flow improvement in the postprocedural phase among initially unsuccessful cases was investigated via subsequent angiographic examination or during follow-up.

Results: The success rate was 54%, and the sole determinant of success was the angle of the lesion. Peripheral perfusion improved in 15 of 23 initially unsuccessful cases in the postprocedural phase. Even in the unsuccessful cases, significant improvement in peripheral perfusion occurred in the postprocedural phase in the patients undergoing dilatation with the balloon advanced partway into the total occlusion lesion to confirm intravascular location of the balloon (P = .0257).

Conclusions: BPA treatment of total occlusion lesions may improve perfusion in the postprocedural phase even following an initially unsuccessful treatment. Maximizing use of IVUS may provide an adjunctive role in BPA of total occlusion lesions.

Radial artery occlusion (RAO), a complication of transradial access, has an incidence of 4.0% to 9.1% in patients with advanced chronic kidney disease (CKD) and may preclude its use creation of arteriovenous fistula. Distal transradial access (dTRA) has lower rates of RAO compared with TRA, but prior studies excluded patients with advanced CKD. This was a single center study of patients with advanced CKD who underwent coronary procedures with dTRA from January 1, 2019 to May 12, 2022 who were retrospectively evaluated for radial artery patency in follow-up with reverse Barbeau testing or repeat access of the artery. Of 71 patients, 66% were on hemodialysis and the remainder had CKD 3 to 5. Access was ultrasound-guided, and all received adequate spasmolytic therapy and patent hemostasis. Proximal radial arteries were patent in 100% of the patients at follow-up. Our data suggest that dTRA is safe for patients with advanced CKD and preserves radial artery patency.

In complex chronic total occlusion (CTO) percutaneous coronary interventions (PCI), a retrograde crossing strategy is often necessary. Recently, the Japanese retrograde (JR) CTO score was developed using a simple 4-item tool. This score showed a good performance in predicting guidewire crossing failure in patients undergoing primary retrograde CTO PCI. We evaluated the JR-CTO score’s performance in patients treated at 44 centers between 2013 and 2024 as part of the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO). In an independent cohort, although the JR-CTO score showed an association with crossing and technical failure, its predictive ability for both outcomes was modest.

Background: The impact of peripheral artery disease (PAD) on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is not well studied.

Methods: We analyzed the association of PAD with CTO-PCI outcomes using data from the PROGRESS-CTO registry of procedures performed at 47 centers between 2012 and 2023.

Results: The prevalence of PAD among 12 961 patients who underwent CTO PCI during the study period was 13.9% (1802). PAD patients were older, more likely to be current smokers, and had higher rates of dyslipidemia, diabetes, cerebrovascular disease, hypertension, prior myocardial infarction, PCI, and coronary artery bypass graft surgery. Their PROGRESS-CTO (1.35 vs 1.22; P < .001) and J-CTO (2.63 vs 2.33; P < .001) scores were higher, lesion length was longer, and angiographic characteristics were more complex. Their access site was more likely to be bifemoral (33.6% vs 30.9%; P = .024) compared with patients with no PAD. Technical (82.9% vs 87.7%; P < .001) and procedural (80.5% vs 86.6%; P < .001) success rates were lower in patients with PAD, while the incidence of major adverse cardiovascular events (MACE) was higher (3.1% vs 1.8%; P < .001), with higher mortality (0.8% vs 0.4%; P = .034), acute myocardial infarction rate (0.9% vs 0.4%; P = .010), and perforations rate (6.6% vs 4.5%; P < .001). In multivariable analysis, PAD was associated with higher MACE (odds ratio [OR]: 1.53; 95% CI, 1.01-2.26; P = .038) and lower technical success (OR: 0.82; 95% CI, 0.69-0.99; P = .039).

Conclusions: PAD patients undergoing CTO PCI have higher comorbidity burden, more complex CTOs, higher MACE, and lower technical success.