Occlusion patterns, strategies and procedural outcomes of percutaneous coronary intervention for in-stent chronic total occlusion.

BACKGROUND: In-stent chronic total occlusion (CTO) presents various occlusion patterns, which complicate percutaneous coronary intervention (PCI). AIMS: The aim of the study was to investigate the initial outcome and strategy of PCI for in-stent CTO according to the angiographic occlusion patterns. METHODS: This study assessed 791 in-stent CTOs from the Japanese CTO-PCI Expert Registry from 2015 to 2018. They were divided into four patterns: pattern A (n=419), CTO within the stent segment; pattern B (n=196), CTO beyond the distal edge; pattern C (n=85), CTO beyond the proximal edge; and pattern D (n=69) CTO beyond both the proximal and distal edges. RESULTS: There were significant differences in the technical success rates (96.2%, 86.2%, 92.9%, and 75.4% for patterns A-D, respectively; p<0.001), guidewire crossing times (22 [interquartile range: 10-46], 52 [24-102], 40 [20-78], and 86 [45-127] min, respectively; p<0.001), and the rates of antegrade approach alone (90.9%, 61.2%, 67.1%, and 31.9%, respectively; p<0.001). CONCLUSIONS: PCI for CTO within the stent segment was associated with excellent initial outcomes with the antegrade approach. However, PCI for CTO beyond both the proximal and distal edges was associated with the poorest outcomes, even with the bidirectional approach.

Assessment of reattempted percutaneous coronary intervention strategy for chronic total occlusion after prior failed procedures: Analysis of the Japanese CTO-PCI Expert Registry.

OBJECTIVES: We aimed to investigate strategies for reattempted percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs) by highly skilled operators after a failed attempt. BACKGROUND: Development of complex techniques and algorithms has been standardized for CTO-PCI. However, there is no appropriate strategy for CTO-PCI after a failed procedure. METHOD: From 2014 to 2016, the Japanese CTO-PCI Expert Registry included 4,053 consecutive CTO-PCIs (mean age: 66.8 ± 10.9 years; male: 85.6%; Japanese CTO [J-CTO] score: 1.92 ± 1.15). Initial outcomes and strategies for reattempted CTO-PCIs were evaluated and compared with first-attempt CTO-PCIs. RESULTS: Reattempt CTO-PCIs were performed in 820 (20.2%) lesions. The mean J-CTO score of reattempt CTO-PCIs was higher than that of first-attempt CTO-PCIs (2.86 ± 1.03 vs. 1.68 ± 1.05, p < .001). The technical success rate of reattempt CTO-PCIs was lower than that of first-attempt CTO-PCIs (86.7% vs. 90.8%, p < .001). Regarding successful CTO-PCIs, the strategies comprised antegrade alone (reattempt: 36.1%, first attempt: 63.8%), bidirectional approach (reattempt: 54.4%, first attempt: 30.3%), and antegrade approach following a failed bidirectional approach (reattempt: 9.4%, first attempt: 5.4%). Parallel wire technique, intravascular ultrasound guide crossing, and bidirectional approach technique were frequently performed in reattempt CTO-PCIs. Reattempt CTO-PCIs showed higher rates of myocardial infarction (2.1% vs. 0.9%, p < .001) and coronary perforation (6.9% vs. 4.2%, p = .002) than first-attempt CTO-PCIs. CONCLUSIONS: The technical success rate of reattempt CTO-PCIs is lower than that of first-attempt CTO-PCIs. However, using more complex strategies, the success rate of reattempt CTO-PCI can be improved by highly skilled operators.

A Novel Wiring Technique to Insert a Retrograde Guidewire Directly Into the Antegrade Guiding Catheter at the Ascending Aorta for Retrograde Percutaneous Recanalization of an Ostial Coronary Total Occlusion.

In recent years, the use of a retrograde approach has become a common practice in the treatment of chronic total occlusion (CTO) of the coronary ostium and artery with an anomalous origin. Use of this approach has increased the chances of a successful percutaneous coronary intervention (PCI). However, the approach requires capturing the retrograde guidewire within the aorta, which can often pose a problem. Therefore, we developed a technique in which the retrograde guidewire is passed through the CTO and inserted directly into the antegrade guiding catheter in the ascending aorta. This technique enabled the successful treatment of the ostial CTO of the right coronary artery using retrograde PCI.

Retrograde percutaneous recanalization of chronic total occlusion of the left anterior descending artery through an extremely tortuous right ventricular branch.

We report a case of chronic total occlusion (CTO) of the left anterior descending artery, which was treated by percutaneous coronary intervention using a retrograde approach via an extremely tortuous right ventricular branch of the right coronary artery. New concept guidewires and a channel dilator were advanced by delicate manipulation into the distal site of the CTO and a successful percutaneous recanalization was performed. These new concept guidewires may facilitate the retrograde approach for CTOs via tortuous collateral channels.

Effect of changes in left ventricular diastolic function during exercise on exercise tolerance assessed by exercise-stress tissue Doppler echocardiography.

Cardiac function during exercise is assumed to be important in determining exercise tolerance. The aims of this study were to evaluate changes in left ventricular diastolic function (LVDF) during exercise and its effect on exercise tolerance assessed by a noninvasive method, exercise-stress tissue Doppler echocardiography. Twenty-six men with sinus rhythm (controls, hypertension, and cardiomyopathy) underwent cardiopulmonary exercise testing. To assess LVDF during exercise, exercise-stress Doppler echocardiography was performed with a constant workload at rest, and at 50%, 100%, and 120% of anaerobic threshold (AT). Doppler variables related to LVDF increased significantly as the workload increased (P < 0.05). Resting E'correlated significantly with AT (r = 0.424, P = 0.0308) and peak VO(2) (r = 0.471, P = 0.0152). However, the difference in E'between rest and 120% AT (DeltaE') was closely correlated with AT (r = 0.744, P < 0.0001) and peak VO(2) (r = 0.748, P < 0.0001). Moreover, DeltaE'was correlated independently with AT (P = 0.0321) and peak VO(2) (P = 0.0192) by multiple regression analysis. These results suggest that the ability to increase LVDF during exercise is an important factor in determining exercise tolerance.

Simultaneous right and left coronary occlusion caused by an extensive dissection to the coronary sinus of Valsalva during percutaneous intervention in right coronary artery.

We report a case of simultaneous right and left coronary occlusion during percutaneous coronary intervention in the right coronary artery. An aortocoronary dissection induced by the forceful manipulation extended from the right to left sinus of Valsalva and occluded the ostia of both coronary arteries. The patient suffered cardiogenic shock and ventricular fibrillation. However, after successful rapid stenting to right and left coronary arteries, safe discharge was possible.

Effects of antiplatelet agents on subacute thrombosis and restenosis after successful coronary stenting: a randomized comparison of ticlopidine and cilostazol.

BACKGROUND: A prospective randomized study compared the preventive effects of ticlopidine plus aspirin therapy versus cilostazol plus aspirin therapy on subacute thrombosis (SAT) and restenosis after coronary stenting. METHODS AND RESULTS: After successful stenting of 327 coronary lesions in 282 consecutive patients, the patients were randomized to receive ticlopidine (200 mg/day) or cilostazol (200 mg/day). Aspirin (81 mg/day) was administered concomitantly in both groups. SAT occurred in 1 patient in the ticlopidine group (0.7%) and in 8 patients in the cilostazol group (5.6%, p=0.037). Based on follow-up angiography, restenosis occurred in 30 patients (23.3%) in the ticlopidine group and 35 patients (26.9%) in the cilostazol group (NS). The late loss was significantly smaller in the cilostazol group than the ticlopidine group (1.08+/-0.95 mm vs 0.78+/-0.93 mm, respectively, p=0.037). No significant differences between the 2 groups were observed with respect to the rates of total death, non-fatal cardiovascular events, or bleeding complications. CONCLUSION: The ticlopidine group showed significantly less SAT after stenting compared with the cilostazol group. After 6 months of treatment, the inhibition of neointimal proliferation was greater in the cilostazol group than in the ticlopidine group, but the prevention of restenosis was not confirmed.

Usefulness of insulin resistance measured by homeostasis model assessment in predicting restenosis after coronary stent placement in nondiabetic patients.

The homeostasis model assessment enabled us to evaluate insulin resistance easily and accurately in the clinical setting. The restenosis rate of coronary stenting was significantly higher among patients with high values for the homeostasis model assessment. Our findings suggest that insulin resistance measured by the homeostasis model assessment predicts restenosis after coronary stent placement in nondiabetic patients.

[Comparison of clinical and angiographic outcomes between S670 and NIR stents].

OBJECTIVES: This study evaluated the long-term outcomes of successfully implanted S670 and NIR stents. METHODS: Stents were successfully implanted in 143 patients (148 lesions) aged 65 +/- 9 years from January 1999 to April 2001. Sixty-eight lesions were treated with S670 stents and 80 with NIR stents. Quantitative coronary angiography was performed before, immediately after and 6 months after implantation. An angiographic classification of in-stent restenosis was developed according to the geographic distribution of intimal hyperplasia in reference to the implanted stent. Furthermore, the relationships between stent diameter and length and restenosis rate were estimated. RESULTS: Type B2/C lesions were significantly more common in patients with S 670 (77.3%) stents compared with NIR (43.6%). Stent length was longer and diameter was smaller in patients with S 670 stents compared with those with NIR stents. Acute-gain was similar in the two groups, but late-loss was significantly greater in patients with S 670 stents compared with those with NIR stents. Restenosis rate and target lesion revascularization rate were similar in the two groups. The diffuse type of restenosis lesion was frequently found in S 670 stents. The stent diameter, but not stent length, influenced the restenosis rate in S 670 stents. Both stent length and diameter influenced the restenosis rate in NIR stents. CONCLUSIONS: Late-loss was larger and in-stent restenosis of diffuse type was significantly greater in S 670 stents compared with NIR stents. However, stent length was significantly longer and type B2/C lesions were significantly greater in S 670 stents compared with NIR stents. There was no difference in restenosis rate and target lesion revascularization rate. In addition, restenosis rate was not influenced by stent length in S 670 stents, so S 670 stents may be useful for complex lesions.