Journal of the Society for Cardiovascular Angiography & Interventions最新文献

Background

We aimed to develop a transcatheter aortic valve replacement (TAVR) sizing algorithm and implantation method to facilitate safe and effective TAVR without contrast use in patients with severe chronic kidney disease (CKD) who do not yet require renal replacement therapy. Patients with CKD are a challenging patient subset to treat using standard TAVR care pathways which most usually require the use of iodinated contrast media both during gated computed tomography (CT) angiography sizing, and valve deployment. Iodinated contrast exposure may worsen kidney function in a dose-dependent fashion, and may result in a need for renal replacement therapy. Therefore, a method to eliminate, or greatly lessen, contrast exposure during TAVR is highly desirable.

Methods

One hundred sixty patients who underwent standard CT angiography and TAVR implantation were used to develop (100 patients) and validate (60 patients) an algorithm to predict balloon-expandable valve size using measurements available from noncontrast CT. Model accuracy was measured using Pearson correlation between algorithm-predicted valve size and actual size used based on annular area. As proof of concept, we then report a case series of 35 consecutive patients who underwent TAVR evaluation and implantation with moderate sedation and no contrast between May 2021 and April 2024.

Results

The valve sizing algorithm incorporates sinus and sinotubular junction diameters, both available from a reformatted noncontrast, cardiac-gated CT. The algorithm demonstrated a strong correlation with the actual valve size used (development cohort R = 0.81, validation cohort R = 0.76). Thirty-five patients underwent “no-contrast TAVR” with noncontrast CT for valve sizing. Forty-eight percent were urgent inpatient TAVR. Technical procedural success, as defined by the VARC3 criteria, was 100%, with no patient deaths during the index procedure. Three patients had a mild paravalvular leak. No valve embolization or need for a second valve occurred. Four patients required a pacemaker.

Conclusions

We present a novel algorithm for TAVR evaluation and implantation without the use of iodinated contrast media in a high-risk patient subset with CKD.

Over most of the history of interventional cardiology, it has been tacitly assumed that once flow-limiting coronary disease had been documented, angiography was sufficient to plan percutaneous coronary intervention (PCI) and, subsequently, to decide if an optimal procedural result had been achieved. This view has been challenged by recent studies evaluating the results of PCI with fractional flow reserve and nonhyperemic pressure ratios. Evidence has accumulated showing that suboptimal functional PCI results occur frequently despite a good angiographic result and that they are associated with worse patient outcomes. In this article, we discuss how available coronary physiology tools, either guide wire or image-based, may address this problem by facilitating better procedural planning and PCI precision and optimization.

Background

Concern about fetus radiation dose and assumed health effects remains a barrier for women considering a career in invasive cardiology. However, there is a lack of real-world fetus exposure data that can be used to support career decisions. The purpose of this work was to measure radiation exposure to invasive cardiologists which would contribute to dose to the fetus during pregnancy.

Methods

Radiation exposure to 42 female and male interventional cardiologists and electrophysiologists was monitored during their clinical routine. Multivariate analysis was used to assess the influences of patient radiation exposure, radioprotective garment material thickness (0.25, 0.35, 0.5 mm Pb equivalent), and cardiologist sex, height, and clinical role on occupational radiation exposure to the abdomen.

Results

Exposure to the abdomen of invasive cardiologists increased proportional to patient exposure and decreased predictably with increasing radioprotective material thickness. The median abdomen exposure when covered with a 0.5 mm Pb equivalent radioprotective material over a 40-week period was 0.22 mGy (95th percentile, 0.8 mGy). Physician sex, height, and clinical role did not influence occupational exposure.

Conclusions

The use of a 0.5 mm Pb equivalent radioprotective garment covering the abdomen, combined with appropriate radiation safety practices, can ensure that fetus radiation dose is below both US and international limits. Assumed fetus risk due to very low occupational radiation exposure is likely inconsequential in light of other known pregnancy risks.

Coaxial trapping of guide extension catheters within a coronary artery allows for maximal support in delivering equipment; however, use of this technique within the left main coronary artery has been avoided due to concerns surrounding hemodynamic instability and vessel injury. We describe our initial experience with impromptu coaxial trapping of guide extension catheters within the left main coronary artery using the dual access rapid trap (DART) technique. Coaxial trapping of guide extension catheters within the left main coronary artery using DART enabled successful equipment delivery across balloon-uncrossable lesions. This case demonstrates that DART is a safe and effective method for equipment delivery across balloon-uncrossable lesions and may aid operators in safely solving complex cases.

Background

There are limited data on the mechanism of the Rotarex Rotational Excisional Atherectomy System in treating femoropopliteal arterial disease. The Rotarex iDissection study is a prospective, single center study evaluating the extent of excision and dissection in de novo and restenotic (not in-stent) lesions of the femoropopliteal arteries in symptomatic peripheral arterial disease patients.

Methods

Consecutive patients with symptomatic peripheral arterial disease were prospectively enrolled in the Rotarex iDissection study at a single US center after obtaining informed consent. The study was approved by a central ethics committee. Quantitative vascular angiography and intravascular ultrasound images were analyzed by an independent core laboratory. The Eagle Eye Platinum ST intravascular ultrasound (Phillips) was used to identify the depth (A, B, C for intima, media, and adventitia, respectively) and arc of dissections (1 and 2 for <180° and ≥180°, respectively) using the iDissection classification. Statistical significance was determined by a P value <.05.

Results

A total of 19 patients (20 procedures) were enrolled by 1 endovascular specialist. There were 57.9% men with mean age of 71.1 ± 9.6 years. Of the patients, 31.6% had diabetes mellitus, and 84.2% were current or past smokers. Thirty percent of treated vessels were chronic total occlusions. A total of 10 patients received stents (2 covered stents due to perforation, 6 due to National Heart, Lung, and Blood Institute Type C dissections, and 2 were primary stenting). Two distal embolizations occurred; one was attributed to the Rotarex, and both were treated with no adverse consequences. Angiographic baseline stenosis was 74.7% ± 25.6%; after Rotarex, 48.7% ± 14.8%; and after percutaneous transluminal angioplasty (PTA), 16.0% ± 6.2%. Baseline minimal lumen diameter was 1.0 ± 1.0 mm; after Rotarex, 2.4 ± 1.1 mm; and after PTA, 4.4 ± 1.0 mm. Angiographically, there was 1 type A dissection at baseline; 1 A, 1 B, and 2 C after Rotarex, and 3 A and 5 C after final adjunctive PTA. Intravascular ultrasound revealed a reference diameter of 6.2 ± 1.0 mm; 70% of patients had adventitial dissections. The mean arc of calcium was 221° ± 39.4° (moderate to severe calcium).

Conclusions

The Rotarex device is an effective atherectomy device in treating complex femoropopliteal arterial disease. A high frequency of adventitial dissections is seen with the Rotarex. The long-term outcomes of this finding need to be further studied.