Catheterization and Cardiovascular Interventions最新文献

Background: The effectiveness and safety of traditional versus dual lumen microcatheter (DLMC)-assisted parallel wiring in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study.

Aims: To compare traditional versus dual lumen microcatheter (DLMC)-assisted parallel wiring.

Methods: We compared the clinical and angiographic characteristics and outcomes of traditional versus DLMC-assisted parallel wiring after failed antegrade wiring (AW) in a large, multicenter CTO PCI registry.

Results: Among 1353 CTO PCIs with failed AW with a single wire, traditional parallel wiring (n = 1081) or DLMC-assisted parallel wiring (n = 272) were utilized at the operator's discretion. The baseline characteristics of patients were similar in both groups except for higher prevalence of diabetes mellitus, and lower prevalence of hypertension, prior heart failure, prior MI and cerebrovascular disease in DLMC patients. Lesions in the DLMC group were more likely to have proximal cap ambiguity, side branch at the proximal cap, blunt/no stump, moderate/severe calcification, and had higher J-CTO score (2.6 ± 1.0 vs. 2.1 ± 1.3, p < 0.001). Technical (87.1% vs. 74.3%, p < 0.001) and procedural (83.8% vs. 75.5%, p = 0.001) success and the incidence of in-hospital major cardiac adverse events (MACE) (4.8% vs. 2.0%, p = 0.020) were higher in the DLMC group. In propensity score matching analysis, DLMC-assisted wiring was associated with higher technical success (odds ratio [OR] 2.17, 95% confidence interval [CI] 1.33-3.54, p = 0.002) and no significant difference in MACE (OR 2.00, 95% CI 0.89-4.50, p = 0.093).

Conclusions: In lesions that could not be crossed with AW, DLMC-assisted parallel wiring was associated with a higher likelihood of technical success, without an increased risk of MACE, compared with traditional parallel wiring.

Background: Previous studies using high-risk criteria to select patients for mechanical circulatory support (MCS) during percutaneous coronary intervention (PCI) have not consistently shown a benefit in reducing adverse outcomes. Identifying correlates for intra-procedural hemodynamic instability (HI) may improve patient selection for MCS.

Methods: Consecutive, hemodynamically stable patients undergoing non-emergent PCI between 2018 and 2022 were reviewed. High-risk patients, defined by left ventricular ejection fraction ≤ 35% with unprotected left main intervention or LVEF ≤ 35% with 3-vessel disease, were compared to the non-high-risk patients. The primary outcome was HI during PCI, a composite outcome defined by the occurrence of death, cardiac arrest, emergent MCS, or the need for sustained vasopressor support.

Results: A total of 278 high-risk patients were compared to 2854 non-high-risk patients. The high-risk group was older with more comorbidities and poorer left ventricular ejection fraction (24.7% vs. 51.5%). The occurrence of HI was overall low but occurred more frequently in high-risk patients (4.3% vs. 2.2%, p = 0.025), mostly driven by sustained vasopressor need (75% vs. 66%, p = 0.023). Post-procedural adverse clinical events were more common in the high-risk group, including death (4.7% vs. 0.7%, p < 0.001). A predictive model for intraprocedural HI included: ejection fraction ≤ 25%, left main intervention, and atherectomy (AUC = 0.703), while 3-vessel disease, age and other clinical comorbidities were not strongly associated with HI.

Conclusion: The rate of HI during contemporary, non-emergent PCI is very low. While Traditional high-risk PCI criteria are associated with HI, prediction may be improved by including only very low EF, left main intervention and atherectomy. Further studies are needed to evaluate whether utilizing risk factors for HI could be a more effective strategy for selecting patients of MCS during PCI.

Background: Previous studies have shown comparable outcomes between first-generation high-dose drug-coated balloon (HD-DCB) and second-generation low-dose drug-coated balloon (LD-DCB) for femoropopliteal artery disease. However, data about the clinical performances of these DCBs for longer lesions in real-world clinical settings are limited.

Methods: In this multicenter, retrospective study, the clinical performances of the HD-DCB (IN.PACT, Medtronic, MN, USA) and the LD-DCB (Ranger, Boston, MA, USA) were assessed in cases of femoropopliteal artery disease with lesion length ≥ 150 mm. From the database, 288 lesions in 288 patients were assigned to the HD-DCB group, and 88 lesions in 88 patients were assigned to the LD-DCB group. Propensity score-matching analysis was performed to adjust for baseline patient and lesion characteristics. The primary outcome was the 2-year primary patency rate of the two types of DCBs.

Results: Propensity score matching was used to extract 76 pairs with no significant intergroup differences in baseline patient and lesion characteristics. The average lesion length was 257.5 and 255.7 mm in the HD and LD-DCB groups, respectively. The 2-year primary patency rates between the HD and LD-DCB groups were comparable (68.5% vs. 60.4%; p = 0.33). There were also no significant differences in clinically driven target lesion revascularization, acute limb ischemia, major amputation, or overall survival between the two types of DCBs.

Conclusion: The clinical outcomes between the HD and LD-DCBs did not significantly differ in real-world populations with severely complex lesions.

The management of a chronic total occlusion (CTO) of a coronary artery has been a conundrum in interventional cardiology, as revascularization has not been proven to provide a mortality benefit. However, there are subgroups of patients with a CTO that have high levels of ischemia on myocardial perfusion imaging and high circulating levels of high sensitivity troponin-I (hsTn-I) and N terminal pro-brain natriuretic peptide (NT pro-BNP) that are at a particularly high-risk for adverse cardiovascular events. These high-risk subgroups of patients with a CTO may have not been well represented in prior clinical trials, and may gain a mortality benefit from revascularization of the CTO. Conversely, patients with low levels of ischemia and these biomarkers are at lower risk and may not gain a mortality benefit from revascularization of their CTO. It is important for future randomized controlled trials to investigate the efficacy of CTO PCI in patients with elevated biomarkers and high ischemic burden on myocardial perfusion imaging to determine if patients at high-risk gain a mortality benefit from revascularization.

Background: The potential for coronary artery compression (CC) during transcatheter pulmonary valve replacement (TPVR) using self-expanding valves (SEV) is not fully understood, yet anecdotal reports suggest that this risk exists.

Aims and methods: We performed a retrospective cohort study of patients evaluated for SEV-TPVR to evaluate the relationship between the right ventricular outflow tract (RVOT) and coronary arteries (CA). CT-derived segmentations of the RVOT and CA were created using machine learning. A 2D map of the distance between the RVOT surface and CA, in systole and diastole, was created. In the subset of patients with post-procedural CTA, the distance before and after TPVR was measured.

Results: Forty-two individuals underwent screening for SEV-TPVR, of which 83% (n = 35) had SEV implanted (Harmony = 24; Alterra = 11). Median age was 22.9 years (range 12-60) and 76% had tetralogy of Fallot (TOF). There was no significant change in the distance between the RVOT and LCA between diastole and systole (p = 0.31), yet the RVOT area nearest to the LCA displaced proximally by 11 mm (IQR: 5.6-19.9) in systole. In 8 patients with pre- and post-TPVR CTA, no statistically significant differences were observed in the RVOT-to-LCA relation after intervention. The distance to the LCA was smaller in pulmonary stenosis/atresia patients than those with TOF (median distance 1.2 and 2.1 mm, respectively; p = 0.185).

Conclusion: The RVOT area in closest proximity to LCA is dynamic and should be considered when planning TPVR. Special attention should be given to patients with a diagnosis of pulmonary stenosis/atresia.

Introduction: There is no single best treatment for arteriovenous vascular access thrombosis, with comparable patency rates for both surgical and endovascular treatment. This study aims to evaluate the results of endovascular thrombectomy in our center and analyze the patency rates in different groups.

Material and methods: We retrospectively selected patients referred to our vascular access treatment unit due to arteriovenous access thrombosis from June 2017 to February 2022. All patients were submitted to endovascular manual thromboaspiration. Patient demographic data, comorbidities and clinical data were collected from medical records for further analysis.

Results: Out of the 96 patients selected, 45 (47%) had AV grafts and 51 (53%) had AV fistulas. The mean age was 74 (±15) years and 54% were males. The overall success rate of interventions was 85.4% (n = 82), while the reintervention rate stood at 59.8% (n = 49). AV grafts exhibited superior secondary patency compared to AV fistulas (92.4% vs. 78.0% and 85.3% vs. 74.1% at 6 and 12 months, respectively; p = 0.047). Forearm fistulas demonstrated enhanced primary patency (72.7% vs. 41.5% and 58.2% vs. 23.1% at 6 and 12 months, respectively; p = 0.017), better assisted primary patency (81.8% vs. 55.8% and 81.8% vs. 42.0% at 6 and 12 months, respectively; p = 0.025), and a lower reintervention rate (27.3% vs. 63.3%; p = 0.040) compared to upper arm fistulas.

Conclusions: Endovascular manual thromboaspiration seems to be an alternative technique for salvaging thrombosed vascular accesses. Forearm fistulas had the best assisted primary patency, which consolidates the rationale of giving primacy to its construction over other options.

Background: Incidence and prognostic of unstable angina after high-sensitivity troponin assesment is controversial.

Aims: This study evaluated prognostic of a contemporary population of patients with UA defined using high sensitive T troponin (T hs-cTn) measurements and with significant coronary artery disease (CAD).

Methods: Consecutive patients admitted in 2 French university centres with UA defined as clinical ischemic symptoms and T hs-cTn dosages undetectable (< 5 ng/L), non-elevated (> 14 ng/L) or mildly elevated (14-50 ng/L) were included. The primary end-point included major events at 1-year follow-up.

Results: Among 1752 patients admitted for ACS between December 2021 and February 2023, 210 (12.0%) have UA and significant CAD. Mean age was 66 ± 12 years, with predominantly men (n = 143; 68.1%). Patients had undetectable (n = 4), non-elevated (n = 80) or mildly elevated and stable T hs-cTn (n = 126). History of CAD was found in 98 patients (46.6%). Percutaneous intervention was required in main patients (n = 186; 88.6%). Adverse non-fatal in-hospital event occurred in one patient. The primary outcome was achieved in 55 patients (26.2%; CI 95% [20.2-32.1]) mainly related to new ACS (n = 34, 16.2%). The level of troponin at admission (p = 0.639) was not associated with the primary outcome. In multivariate analysis, multiple risk factors (OR 1.93, [1.01-3.69], p = 0.0194), history of CAD (3.09; CI [1.63; 5.87], p = 0.0005), and tritroncular disease (OR 2.66; CI [1.24; 5.69], p = 0.0118) were significantly associated with major events at 1-year.

Conclusion: Contemporary incidence of UA with significant CAD is low with few in-hospital events, but with a 1-year incidence of cardiac events high (26%), mainly related to new ACS. Improving secondary prevention may be crucial for these patients. (ID: NCT06378333).

Background: Paclitaxel (PCB) and sirolimus-coated balloons (SCB) are major therapeutic options for coronary artery disease, but there is no direct head-to-head histological comparison of their effects during the percutaneous coronary intervention (PCI).

Aims: We aimed to investigate the vascular and downstream effects and drug pharmacokinetics in a porcine coronary model treated with MagicTouch-SCB (MT-SCB), Selution-SRL-SCB (SEL-SCB), Agent PCB, and plain old balloon angioplasty (POBA).

Methods: Twenty-eight coronary arteries from 10 pigs were treated with one of three drug-coated balloons (DCBs) (n = 7 for each) or POBA (n = 7) with 28 days follow-up. In six pigs, histological assessment was performed for the arterial response with semi-quantified scoring. In four pigs, sirolimus and paclitaxel concentrations were measured in the coronary artery and downstream myocardium. All 10 animals were histologically assessed for downstream effects on the myocardium for distal emboli and tissue injury.

Results: All DCBs showed minimal neointimal formation, but the MT-SCB and SEL-SCB showed less medial SMC loss compared to the PCB. In the histology section-based analysis of downstream myocardium, PCB showed evidence of myocyte necrosis/scarring in 21% of sections, whereas there was no evidence in the other groups (p < 0.01). POBA had the lowest downstream emboli (6%), followed by MT-SCB (15%), SEL-SCB (25%), and PCB (36%) (p = 0.02). In the pharmacokinetic analysis, paclitaxel showed higher concentration after PCB treatment compared to sirolimus after both two SCBs treatment in coronary and downstream myocardium.

Conclusion: MT-SCB and SEL-SCB demonstrated less arterial injury, less downstream effect, and lower drug concentration compared to PCB during PCI.

Background: Diabetes mellitus (DM) is a well-known risk factor for cardiovascular diseases, including coronary artery diseases (CAD). Complex percutaneous coronary intervention (PCI) such as PCI for bifurcation lesions often yields poor outcomes, especially in DM patients.

Aims: The effect of DM on cardiovascular outcomes in bifurcation PCI was investigated in this retrospective, multicenter, observational, real-world registry of 2648 patients with coronary bifurcation lesions undergoing PCI with contemporary drug-eluting stents (DES).

Methods: The primary outcome was target lesion failure (TLF), defined as a composite of cardiac death, target vessel myocardial infarction and target lesion revascularization. The adjusted outcomes were compared using 1:1 propensity score (PS) matching.

Results: Overall, DM patients were more likely to be older, female, and have hypertension or chronic kidney disease. After PS matching, the cumulative incidence of the primary outcome remained higher in the DM group (7.9% vs. 5.5%, log-rank p = 0.033). In multivariable analysis, DM (HR, 1.57; 95% CI, 1.02-2.43; p = 0.040), chronic kidney disease (HR, 2.62; 95% CI, 1.27-5.38; p = 0.008), low left ventricular ejection fraction (HR, 1.92; 95% CI, 1.10-3.35; p = 0.022) and the two-stent technique (HR, 2.18; 95% CI, 1.17-4.05; p = 0.013) were independent predictors of TLF. For patients with intravascular ultrasound-guided PCI, TLF rates were similar between DM and non-DM groups (9.1% vs. 7.3%, log-rank p = 0.347).

Conclusion: For patients with coronary bifurcation lesions undergoing contemporary PCI, 5-year TLF rates were worse in DM patients. Careful planning and usage of imaging devices may help ameliorate outcomes for DM patients.

Background: Intravascular lithotripsy (IVL) is increasingly used to treat coronary artery calcification (CAC). This study aimed to identify clinical and procedural factors associated with IVL treatment success.

Methods: This retrospective analysis included 454 patients (73 ± 9 years, 75% male) treated with IVL from the multicenter BENELUX-IVL registry (May 2019 to February 2024). Treatment success was defined as achieving residual coronary diameter stenosis < 30% and luminal gain, assessed by quantitative coronary analysis (QCA). Linear and binary logistic regression analyses were performed to identify factors associated with these outcomes.

Results: The mean luminal gain was 1.9 ± 0.9 mm, and residual diameter stenosis < 30% was achieved in 354 (90%) lesions. Stenting after IVL for therapy completion (p < 0.001), intracoronary imaging (ICI) guidance (p = 0.024) and chronic total occlusions (CTOs; p < 0.001) were associated with increased luminal gain, while bifurcation lesions (p = 0.029) were associated with decreased luminal gain. Long (> 20 mm) lesions (p = 0.034) and post-IVL stenting for therapy completion (p = 0.041) were associated with a residual diameter stenosis < 30%, while aorto-ostial lesions (p = 0.014) were negatively associated with this outcome. Technical IVL parameters such as inflation pressure and number of pulses delivered were not significantly associated with treatment success.

Conclusion: Stenting after IVL for therapy completion, ICI guidance and CTOs were associated with increased luminal gain, while bifurcation lesions were linked to decreased luminal gain. Long lesions and post-IVL stenting for therapy completion were associated with residual diameter stenosis < 30%, while the presence of aorto-ostial lesions was negatively associated with this outcome. Technical IVL-related procedural factors did not significantly impact treatment success.