Finding the missing many: improving Tuberculosis care in Kajiado county through active case finding and community approaches.

BACKGROUND: Tuberculosis related deaths remain a priority globally. Despite advancements in TB care, access to quality care remains inequitable to the disadvantage of those in rural and urban informal settlements. The Awareness, Traditions, and Innovation in combating Tuberculosis (ATI TB) project incorporated active case finding (ACF), use of GeneXpert technology and decentralized services to improve TB care in Kajiado County. This study sought to establish the impact of the project as well as implementation lessons learnt during its tenure in Kajiado County, Kenya. METHODS: This evaluation adopted a mixed-methods approach with retrospective cohort analysis for the quantitative data and qualitative data sought through key informant interviews with 28 purposively sampled respondents. The qualitative data was analyzed thematically using Taguette while quantitative data was analyzed using R Software yielding descriptive statistics and measures of association. RESULTS: While the males were a minority among the presumptive cases (623; 46%), they were the majority (59.3%) among the confirmed TB cases. 70% of the confirmed cases were aged between 15 and 44 years; with those aged between 25- and 34-years being majority (30% of the cases). Majority of the confirmed cases within the project were from rural Kajiado West (79; 66.9%). Though 61% of the presumptive cases were through ACF, only 7% of these tested positive. Conversely, 13% of the self-referrals tested positive. 53% (66) of the positive cases with valid data were self-referrals while ACF accounted for 47% (58) of the positives. CONCLUSION: Continued capacity development among health workers, sustained and targeted sensitization and screening among vulnerable groups, strategic collaborations, alongside increased budgetary prioritization of health and TB care by government and partners, and government investments in Social Determinants of Health can ensure gains in TB care are sustained.

Early detection of neurodevelopmental disorders in African children living in informal settlements in Nairobi.

BACKGROUND: Children in low-income and middle-income countries (LMICs) are at a substantially increased risk of delayed physical, emotional and sociocognitive outcomes, with consequential neurodevelopmental disorders. Evidence based, cost-effective and culturally appropriate screening tools are recommended for early identification of developmental disorders. METHODS: The present study aims to assess the feasibility of early screening for neurodevelopmental disorders in children living in informal settlements in Nairobi, Kenya (Korogocho). The selected tools (ie, the CDC checklist and the Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R)), widely used in high-income countries, are applied in two different populations: one from Kenya (LMIC) and one from Italy, to compare the different scores. RESULTS: Of 509 children screened, 8.6% were classified at-risk based on the results of the screening tools. Significant risk factors are history of low birth weight and Apgar score, presence of neurological disorders, malnutrition and/or rickets, younger age of the child and older age of the mother. Caesarean section delivery, first pregnancy and mothers' older age were common risk factors among the Kenyan and the Italian samples. The Italian sample had a significantly greater rate of missed milestones. CONCLUSIONS: Our data demonstrate the feasibility of using the CDC and M-CHAT-R tools in informal settlement dwellers. Further studies are needed to explore the opportunity for early diagnosis of developmental disorders in LMICs.

Burden of Pulmonary Rifampicin-Resistant Tuberculosis in Kajiado, Kenya: An Observational Study.

BACKGROUND: Rifampicin resistance (RR) is a major challenge in the clinical management of tuberculosis (TB), but data on its prevalence are still sparse in many countries. Our study aimed at estimating the prevalence of RR-TB in Kajiado County, Kenya. Secondary objectives were to estimate the incidence of pulmonary TB in adults and the rate of HIV-TB coinfection. METHODS: We conducted an observational study in the context of the ATI-TB Project, carried out in Kajiado. The project was based on an active-case-finding campaign implemented with the aid of village chiefs, traditional healers and community health volunteers. Diagnosis relied on Xpert MTB/RIF, including a mobile machine that could be used to cover areas where testing would otherwise be difficult. RESULTS: In sum, 3840 adults were screened for active TB during the campaign. RR cases among all TB diagnoses were 4.6%. The annual incidence of pulmonary TB among adults was 521 cases per 100,000 population. The rate of HIV coinfection was 22.2% among pulmonary TB diagnoses. CONCLUSION: The prevalence of RR-TB was four times that what could be inferred from official notifications in Kajiado, and higher than overall prevalence in Kenya. In addition, our estimate of incidence of pulmonary TB in adults in Kajiado significantly differed from cases notified in the same area. In contrast, the rate of HIV coinfection was in line with national and regional data. TB diagnostic capability must be strengthened in Kajiado to improve patients' management and public health interventions.

Malnutrition, morbidity and infection in the informal settlements of Nairobi, Kenya: an epidemiological study.

BACKGROUND: Malnutrition constitutes one of the major public health challenges throughout the developing world. Urban poverty and malnutrition have been on the rise, with an increased rate of morbidity. We herein explore the relationship between infections and nutritional status and the related association with hygienic conditions as risk of infection in children residing in the slums of Nairobi. METHODS: Case-control study based on a secondary analysis of quantitative data collected from a cluster randomized trial carried out in two slums of Nairobi. The following information about resident children were selected: babies' anthropometric measurements, related life conditions, data on infant-feeding practices, food security, hygiene, immunization coverage and morbidity were collected and updated with structured questionnaires until 12 months of life. Prevalence of malnutrition was calculated, then both bivariate and multivariate analysis were used to explore the relationship between malnutrition and its determinants. RESULTS: The study involved a total of 1119 babies registered at birth (51.28% male and 48.03% female infants). Overall the prevalence of malnutrition was high, with 26.3% of the children being stunted, 6.3% wasted and 13.16% underweight. Prevalence of wasting was higher in the first months of life, while in older children more case of stunting and underweight were captured. Wasted infants were significantly associated with common childhood illnesses: with cough and rapid breathing as well as with diarrhea (p-value< 0.05). Stunting was associated with hygienic conditions (p-value< 0.05 in households that did not perform any water treatment and for children that had a toilet within the house compound), immunization program and low-birth-weight. Moreover, regression analysis showed that significant determinants of stunting were sex and feeding practices. Underweight was significantly associated with socio-demographic factors. CONCLUSIONS: In the specific environment where the study was conducted acute malnutrition is correlated with acute infections, while chronic malnutrition is more influenced by WASH conditions. Therefore, our findings suggest that one cannot separate infection and its risk factors as determinants of the whole malnutrition burden.

Prospective multicentre clinical performance evaluation of second and third generation zotarolimus-eluting stents to treat patients with bifurcated coronary lesions.

AIM: To assess the "real world" clinical outcome of patients with bifurcated lesions undergoing percutaneous coronary intervention with implantation of second and third generations of zotarolimus-eluting stent. METHODS AND RESULTS: Nine Italian centres participated in a prospective multicentre clinical project evaluating the outcome of patients receiving zotarolimus-eluting Resolute stent and Resolute Integrity stents. Patients with bifurcated lesions entered this evaluation. Clinical characteristics and angiographic and procedural details were prospectively recorded. Clinical outcome was prospectively assessed to evaluate the occurrence of major adverse cardiac events (MACE). A total of 577 patients were enrolled. The target lesion was distal left main in 11.1% and left anterior descending artery in 52.8%, and 30.3% of lesions were Medina 1,1,1. At a mean follow-up time of 27.0 ± 13.5 months, the survival free from MACE was 91.8%. Survival free from MACE was similar in patients grouped according to different bifurcated lesion complexity. On the contrary, patients receiving a single stent had better survival free from MACE as compared with those with double stent (P = 0.005). At multivariable analysis, double stenting (but not bifurcated lesion complexity) was found to be a significant predictor of MACE (hazard ratio, 2.52; 95% confidence interval, 1.28-4.94; P = 0.007). Of note, patients receiving the second stent as a bail-out had worse survival free from MACE compared with those who received it as a planned technique (P = 0.045). CONCLUSION: The treatment of patients with bifurcated lesions with second and third generation zotarolimus-eluting stents is associated with good long-term clinical outcomes. Clinical outcome seems to be independent of lesion complexity, but may be influenced by the stenting technique (single or double stenting as well as elective or bail-out double stenting). © 2015 Wiley Periodicals, Inc.

Radial approach for percutaneous coronary interventions on chronic total occlusions: technical issues and data review.

OBJECTIVE: To overview the scientific data and the technical details regarding percutaneous coronary interventions (PCI) on chronic total occlusions (CTO) by radial approach. BACKGROUND: Trans-femoral approach is commonly regarded as the standard for PCI on CTO. METHODS: A systematic search in Medline and in the main international websites was realized. Key data were extracted and analyzed using standard meta-analytic techniques. Bench test assessment of compatibility between different combinations of interventional devices (required for CTO recanalization techniques) and the following guiding catheters was performed: 5 Fr, Sheathless 6.5 Fr, 6 Fr, Sheathless 7.5 Fr and 8 Fr. RESULTS: No prospective randomized study was found, whereas 13 observational studies on 3,501 CTOs treated by radial approach were identified. Overall, the crossover to femoral access rate ranged between 0 and 5.8%. Access site complications were noted in <1% of cases and in-hospital major adverse events were reported in 0-3.8% of patients. PCI success was significantly influenced by the learning curve: In the five studies comparing the success rates between a first and a later period of practice, a significant improvement was observed (OR, 95% CI: 0.30, 0.39-0.51; P < 0.001). The technical details relevant to approach a CTO by transradial access are discussed, and the original results of bench tests provide details regarding the compatibility of various CTO recanalization techniques with specific guiding catheter sizes. CONCLUSIONS: The transradial access represents a promising alternative to trans-femoral access to treat patients undergoing CTO PCI in high-volume transradial centres. The presented data may be useful to plan transradial PCI attempts on CTO lesions.

Radial versus femoral approach comparison in percutaneous coronary intervention with intraaortic balloon pump support: the RADIAL PUMP UP registry.

BACKGROUND: The role of intraaortic balloon pump (IABP) during percutaneous coronary intervention (PCI) in high-risk acute patients remains debated. Device-related complications and the more complex patient management could explain such lack of clinical benefit. We aimed to assess the impact of transradial versus transfemoral access for PCI requiring IABP support on vascular complications and clinical outcome. METHODS: We retrospectively analyzed 321 consecutive patients receiving IABP support during transfemoral (n = 209) or transradial (n = 112) PCI. Thirty-day net adverse clinical events (NACEs) (composite of postprocedural bleeding, cardiac death, myocardial infarction, target lesion revascularization, and stroke) were the primary end point, with access-related bleeding and hospital stay as secondary end points. RESULTS: Cardiogenic shock and hemodynamic instability were the most common indications for IABP support. Cumulative 30-day NACE rate was 50.2%, whereas an access site-related bleeding occurred in 14.3%. Patients undergoing transfemoral PCI had a higher unadjusted rate of NACEs when compared with the transradial group (57.4% vs 36.6%, P < .01), mainly due more access-related bleedings (18.7% vs 6.3%, P < .01). Such increased risk of NACEs was confirmed after propensity score adjustment (hazard ratio 0.57 [0.4-0.9], P = .007), whereas hospital stay appeared comparable in the 2 groups. CONCLUSIONS: In this observational registry, high-risk patients undergoing PCI and requiring IABP support appeared to have fewer NACEs if transradial access was used instead of transfemoral, mainly due to fewer access-related bleedings. Given the inherent limitations of this retrospective work, including the inability to adjust for unknown confounders, further controlled studies are warranted to confirm or refute these findings.

Open-label, randomized, placebo-controlled evaluation of intracoronary adenosine or nitroprusside after thrombus aspiration during primary percutaneous coronary intervention for the prevention of microvascular obstruction in acute myocardial infarction: the REOPEN-AMI study (Intracoronary Nitroprusside Versus Adenosine in Acute Myocardial Infarction).

OBJECTIVES: This study sought to assess whether intracoronary adenosine or nitroprusside following thrombus aspiration (TA) is superior to TA alone for the prevention of microvascular obstruction (MVO) in ST-segment elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI). BACKGROUND: MVO, due to its multifactorial pathogenesis, still occurs after TA in a sizeable portion of patients. METHODS: We performed a placebo-controlled, randomized, open-label, blind-examination, multicenter trial. A total of 240 STEMI patients with Thrombolysis In Myocardial Infarction (TIMI) flow grade 0/1 were randomly allocated 1:1:1 to receive adenosine (n = 80), nitroprusside (n = 80), or saline (n = 80) given distal to the occluded site after TA. The primary endpoint was the incidence of ST-segment resolution (STR) >70% on surface electrocardiogram at 90 min after PCI. Secondary endpoints were angiographic MVO incidence (TIMI flow grade ≤2 or 3 with a myocardial blush grade <2) and major adverse cardiac event (MACE) rate at 30 days as a composite of cardiac death, myocardial infarction, target lesion revascularization, and heart failure requiring hospitalization. RESULTS: STR >70% occurred in in 71% of adenosine-treated patients, in 54% of nitroprusside-treated patients, and in 51% of saline-treated patients (p = 0.009 and p = 0.75, respectively, vs. saline). Angiographic MVO occurred in 18% of adenosine-treated patients, in 24% of nitroprusside-treated patients, and in 30% of saline-treated patients (p = 0.06 and p = 0.37, respectively, vs. saline). MACE occurred in 10%, 14%, and 20% of patients, respectively (p = 0.08 and p = 0.29 vs. saline). CONCLUSIONS: In STEMI patients treated by PCI and TA, the additional intracoronary administration of adenosine, but not that of nitroprusside, results in a significant improvement of MVO, as assessed by STR.

Angiographic and clinical outcome of percutaneous coronary intervention for in-stent restenosis of bifurcated lesions.

AIMS: Restenosis and bifurcated lesions represent technically challenging lesions for percutaneous coronary interventions (PCI). Data regarding procedural and clinical outcome of re-PCI for restenosis of stented bifurcated lesions are lacking. Our aims were to evaluate angiographic and procedural results and one-year clinical outcome of PCI for restenosis of stented bifurcated lesions. METHODS AND RESULTS: Consecutive patients undergoing PCI for restenosis of one bifurcated lesion previously treated by stent implantation at our centre entered the study. The primary endpoint was angiographic and procedural success, defined as final residual stenosis ≤30% in the main vessel with TIMI 3 flow in both MV and side branch, and stenosis ≤50% in the SB without death, myocardial infarction or target vessel revascularisation during hospitalisation. The secondary endpoint was the incidence of major adverse cardiac events at one-year clinical follow-up. The study population included 64 patients treated by PCI on a single restenotic bifurcated lesion. Angiographic and procedural success was achieved in 61 cases (95.3%) whereas the three cases of failure were due to SB residual stenosis >50%. At one year, MACE rate was 18.7% (12/64) with rates of cardiac death, MI and TVR of 1.6% (1/64), 6.2% (4/64) and 18.7% (12/64), respectively. No cases of stent thrombosis occurred. Patients treated by a single drug-eluting stent (DES) on main vessel (MV) had a significant lower rate of MACE at one year as compared to patients treated with balloon only PCI or by double-stenting technique or with a BMS, irrespective of the strategy adopted: 4/37 (10.8%) vs. 8/27 (29.6%); p=0.04. CONCLUSIONS: PCI in restenotic bifurcated lesions can be a good treatment option with high rates of angiographic and procedural success and an acceptable rate of long-term MACE. The use of a single DES implantation may be a promising strategy as it is associated with lower rates of MACE in the long term.

Intracoronary use of GP IIb/IIIa inhibitors in percutaneous coronary interventions.

The glycoprotein (GP) IIb/IIIa receptor is critical to the process of platelet aggregation and thrombus formation as it serves as the final common pathway for platelet aggregation. For this reason, the development of GP IIb/IIIa inhibitors that block fibrinogen binding to the receptor has become an attractive strategy for antiplatelet therapy with an expected strong and specific effect. Presently, there are three commercially available GP IIb/IIIa inhibitors: abciximab, eptifibatide and tirofiban. All three drugs are commonly administered intravenously, and large-scale clinical trials have demonstrated a clear clinical benefit and good safety profile in patients at high risk, especially those undergoing percutaneous coronary interventions (PCI). Recently, several studies tested the intracoronary (IC) route for GP IIb/IIIa inhibitors in order to verify its safety and its possible superiority as compared to the intravenous (IV) route. The majority of the studies testing the IC route were conducted using abciximab and in patients with STEMI with better results in terms of myocardial reperfusion and infarct size and also promising results in terms of clinical outcome. On the IC administration of eptifibatide and tirofiban only some, even if promising, data are available. Larger and randomized studies are warranted to confirm the superiority of the IC route of administration of the GP IIb/IIIa inhibitors to the IV one in patients with coronary artery disease undergoing PCI.

Vascular complications and access crossover in 10,676 transradial percutaneous coronary procedures.

BACKGROUND: Randomized trials have shown that transradial approach, compared with transfemoral, reduces vascular complications (VCs) of coronary procedures in selected patients. Yet, radial approach is associated to a variety of access-site VC as well as to a higher failure rate compared with femoral access. METHODS: At our institution, from May 2005 to May 2010, we prospectively assessed the occurrence and outcome of VC in consecutive patients undergoing transradial percutaneous coronary procedures performed by trained radial operators. The need of access crossover to complete the procedure was also prospectively investigated. Vascular complications were classified as "radial related" or "nonradial related" (in the case of access crossover). Vascular complications were also classified "major" if requiring surgery and/or blood transfusions or causing hemoglobin drop >3 g/dL. RESULTS: Ten thousand six hundred seventy-six procedures were performed using a right radial (87.5%), left radial (12.4%), or ulnar (0.1%) artery as primary access. A total of 53 VCs (0.5%) were observed: 44 (83%) radial related and 9 (17%) nonradial related. Major VCs occurred in 16 patients only (0.2%) and were radial related in 10 (62.5%) and nonradial related in 6 (37.5%) patients. Vascular complications rate was stable during the study and independent of operator's experience. Access crossover rate was 4.9%, differed according to the operator radial experience and significantly decreased over time. CONCLUSIONS: The present study, conducted in a center with high volume of radial procedures, shows that transradial approach is associated with a very low rate of VC, which is stable over time. On the contrary, access crossover rate decreased over time and differed according to operator (radial) experience.

Procedural and clinical evaluation of the novel zotarolimus-eluting resolute stent in patients with unselected bifurcated coronary stenosis treated by provisional approach: a multicenter registry.

AIMS: As data on the use of the latest-generation drugeluting stents (DES) in bifurcation interventions are lacking, we realized a multicenter registry to assess the procedural and clinical results obtained in patients with unselected bifurcated lesions treated with the novel zotarolimus-eluting Resolute stent (ZRS). METHODS AND RESULTS: Three Italian centers participated in the study. Consecutive patients with significant stenosis of bifurcated lesions undergoing DES implantation were treated with ZRS. The recommended technique was the "provisional TAP approach" [main-vessel (MV) stent implantation eventually followed by kissing balloon and sidebranch (SB) stenting according to TAP technique]. Clinical characteristics, procedural details and clinical follow-up data were prospectively recorded. Procedural success was defined as post-percutaneous coronary intervention visual stenosis > 20% on MV and TIMI 3 flow on both MV and SB. Primary endpoint was major adverse coronary events (cardiac death, myocardial infarction and target vessel revascularization) at 9-month follow up. A total of 180 patients were enrolled. The target lesion was located in the distal left main in 16% and in the left anterior descending artery in 52%. All but 3 cases were treated according to the provisional TAP approach (kissing balloon rate, 69%; overall SB stenting rate, 10.6%). Procedural success was obtained in 98.3% (3 failures due to final SB TIMI flow < 3). At 9-month follow up, the survival free from MACE was 97.8% (1 cardiac death and 3 repeat revascularizations). CONCLUSION: The use of the latest-generation ZRS in unselected bifurcated lesions treated by a provisional approach is associated with excellent procedural results and with promising clinical outcomes.

Comparison of immediate vs early invasive strategy in patients with first acute non-ST-elevation myocardial infarction.

BACKGROUND: The best timing for coronary angiography (immediate vs early) in patients with acute non-ST-elevation myocardial infarction (NSTEMI) is controversial. HYPOTHESIS: Evaluate in NSTEMI patients the effects of an immediate compared to an early invasive strategy on microvascular damage, myocardial perfusion, and infarct size. METHODS: We randomized 54 consecutive patients with first episode of NSTEMI: 27 patients (22 males, age 58.8 ± 9.4 years, group A) underwent immediate (≤6 hours) percutaneous coronary intervention (PCI) with a double bolus of eptifibatide, and 27 patients (24 males, age 59.7 ± 9.8 years, P = 0.72, group B) underwent early (7-72 hours) PCI with upstream eptifibatide. Microvascular damage was evaluated at predischarge by myocardial contrast echocardiography, and the contrast defect length was calculated. RESULTS: There were no significant differences in pre-PCI myocardial blush grade (MBG) (41% MBG 0 or 1 in group A vs 37% MBG 0 or 1 in group B, P = 0.78), in post-PCI MBG (7.4% MBG 0 or 1 in both groups, P = 1.00), and in contrast defect length (4.5% in group A vs 2.8% in group B, P = 0.56). However, group A showed a significant reduction in creatine kinase myocardial band isoenzyme peak (26 ± 26 ng/mL in group A vs 69 ± 79 ng/mL in group B, P = 0.01) and in troponin T peak (0.84 ± 1.2 ng/mL in group A vs 1.8 ± 2.1 ng/mL in group B, P = 0.048). CONCLUSIONS: In patients with NSTEMI treated with eptifibatide, immediate PCI is associated with less increase in myonecrosis markers compared with PCI within 72 hours. There were no significant differences in myocardial perfusion between the 2 strategies.

Thrombus aspiration in ST elevation myocardial infarction: comparative efficacy in patients treated early and late after onset of symptoms.

BACKGROUND: Restoration of myocardial perfusion is the goal of percutaneous coronary intervention (PCI) in patients with ST elevation myocardial infarction. A major predictor of no-reflow is the increasing time to treatment (TTT). Thrombus aspiration (TA) is reported to improve myocardial reperfusion as compared with standard PCI (SP). OBJECTIVE: To investigate the influence of TTT on TA efficacy. DESIGN: Pooled analysis of individual patients' data of three prospective randomised trials comparing TA and SP. PATIENTS: A total of 299 patients (150 in TA group and 149 in SP group) entered the study. The study population was divided into three subgroups according to the TTT: < or = 3 h (short TTT subgroup), >3 h to < or = 6 h (intermediate TTT subgroup), >6 h to < or = 12 h (long TTT subgroup). MAIN OUTCOME MEASURES: The goal of the study was the comparison of optimal myocardial reperfusion, defined as the combination of myocardial blush grade 2 or 3 at post-PCI angiography and ST resolution more than 70% at post-PCI ECG, between SP and TA according to TTT. RESULTS: In the SP group, increasing TTT was associated with a decreased rate of optimal reperfusion (27.4% vs 17.9% vs 10%, p for trend=0.06), whereas in the TA group the same trend was not seen (40.9% vs 33.8% vs 50%, p for trend=0.93). In a multivariate logistic regression model, a significant interaction (p=0.04) between time to treatment and thrombus aspiration was observed. CONCLUSIONS: TA limits the adverse effects of TTT prolongation on myocardial reperfusion.

Comparison by meta-analysis of eptifibatide and tirofiban to abciximab in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention.

Adjunctive therapy with abciximab during primary percutaneous coronary intervention (PPCI) in patients with ST-elevation myocardial infarction (STEMI) determines a better short-term outcome compared to placebo. Tirofiban and eptifibatide represent a valid option with lower cost, but these have been less studied. The aim of the present study was to combine all randomized trials and registries to demonstrate the noninferiority of tirofiban and eptifibatide compared to abciximab in patients with STEMI treated with PPCI. We identified 6 randomized trials and 4 registries. Overall, 4,653 received small molecules and 2,696 abciximab, and the rate of combined death and nonfatal reinfarction did not differ (4.6% vs 4.5%, odds ratio 0.99, 95% confidence interval [CI] 0.78 to 1.27, p = 0.95) up to 30 days of follow-up, with an absolute difference of 0.1% (95% CI -1.06 to 0.8). Because the noninferiority limit was set at +1.5%, and because the upper point estimate (0.8%) of the 95% CI did not cross the prespecified limit, the noninferiority of the small molecules was documented. In-hospital major bleeding was also similar (8.8% vs 6.1%, odds ratio 0.92, 95% CI 0.75 to 1.13, p = 0.43). Sensitivity analysis comparing randomized trials to registries and tirofiban or eptifibatide to abciximab did not show any significant differences. In conclusion, our results documented noninferiority of "small molecules" compared to abciximab and, therefore, support their alternative use as adjunctive therapy during PPCI for patients with STEMI.

How to solve difficult side branch access?

Safe guidewire placement in the main vessel (MV) and in the side branch (SB) does represent the key point for successful percutaneous coronary interventions (PCI) in bifurcated lesions. During bifurcation PCI, SB wiring is systematically performed as a first step and is often repeated ("rewiring") during the procedure in order to treat the SB after MV stenting. Wiring and rewiring are crucial phases of bifurcation PCI which require, in the most complex cases, specific operator experience. In the present paper, the classic SB wiring techniques necessary for routine bifurcation interventions (antegrade and pullback wiring technique) as well as "advanced" wiring techniques ("reverse wire" technique, Venture-facilitate wiring, MV balloon predilation or debulking) are described. Moreover, the rewiring technique is discussed in detail, with particular attention on the tips and tricks which may facilitate the achievement of optimal result with provisional stenting (pullback rewiring) and help manage bail out situations like acute SB flow impairment after MV stenting.

How to manage difficult anatomic conditions affecting transradial approach coronary procedures?

The adoption of transradial approach for percutaneous coronary diagnostic and interventional procedures is known to reduce access-site complications. However, anatomic variants of brachial-radial axis, axillary-subclavian-anonymous axis and aortic arch may obstacle successful completion of transradial procedures. In the present paper, we discuss how to diagnose and manage the possible obstacles occurring at the different steps of transradial diagnostic and interventional procedures.

A new operative classification of both anatomic vascular variants and physiopathologic conditions affecting transradial cardiovascular procedures.

Transradial approach is known to reduce access-site complications of coronary procedures. However, the diffusion of transradial approach in the interventional cardiology community is limited by its higher failure rate compared to transfemoral. Transradial approach failures are mainly caused by a series of anatomic variants which may be encountered in the upper limb arteries. Such anatomic variants have been variously classified based on postmortem studies or systematic angiographic studies. We propose a simplified "operative" classification of anatomic vascular variants and physiopathologic conditions of the arterial axis, from radial to aortic root, possibly affecting transradial cardiovascular procedures.

Clinical impact of thrombectomy in acute ST-elevation myocardial infarction: an individual patient-data pooled analysis of 11 trials.

AIMS: Thrombectomy in patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) is associated to better myocardial reperfusion. However, no single trial was adequately powered to asses the impact of thrombectomy on long-term clinical outcome and to identify patients at higher benefit. Thus, we sought to assess these issues in a collaborative individual patient-data pooled analysis of randomized studies (study acronym: ATTEMPT, number of registration: NCT00766740). METHODS AND RESULTS: Individual data of 2686 patients enrolled in 11 trials entered the pooled analysis. Primary endpoint of the study was all-cause mortality. Major adverse cardiac events (MACE) were considered as the occurrence of all-cause death and/or target lesion/vessel revascularization and/or myocardial infarction (MI). Subgroups analysis was planned according to type of thrombectomy device (manual or non-manual), diabetic status, IIb/IIIa-inhibitor therapy, ischaemic time, infarct-related artery, pre-PCI TIMI flow. Clinical follow-up was available in 2674 (99.6%) patients at a median of 365 days. Kaplan-Meier analysis showed that allocation to thrombectomy was associated with significantly lower all-cause mortality (P = 0.049). Thrombectomy was also associated with significantly reduced MACE (P = 0.011) and death + MI rate during the follow-up (P = 0.015). Subgroups analysis showed that thrombectomy is associated to improved survival in patients treated with IIb/IIIa-inhibitors (P = 0.045) and that the survival benefit is confined to patients treated in manual thrombectomy trials (P = 0.011). CONCLUSION: The present large pooled analysis of randomized trials suggests that thrombectomy (in particular manual thrombectomy) significantly improves the clinical outcome in patients with STEMI undergoing mechanical reperfusion and that its effect may be additional to that of IIb/IIIa-inhibitors.