Neurointerventional tools and techniques for coronary thrombus removal. A case-based review.

Due to the negative results of randomized aspiration thrombectomy studies, its role in myocardial infarction has been limited to high thrombus burden and/or failed vessel recanalization, with little technological advancement over the last years. In contrast, there has been rapid progress in mechanical thrombectomy in stroke, which is understandable as most ischemic cerebrovascular accidents have an embolic etiology.We present three transradial procedures wherein neurointerventional catheters were used as a first-line device for en bloc removal of large clots lodged distally in tortuous coronary anatomy. First-pass reperfusion was achieved in all the cases, without dissection, distal embolization, or the no reflow phenomenon. Learning objective: In the case of large clots, where coronary aspiration devices fail, neurointerventional catheters may be considered as a rescue strategy. They provide large aspiration lumen and excellent trackability with atraumatic design. Many other neurointerventional techniques can be easily adopted into the coronary armamentarium, possibly increasing the safety and efficacy of thrombus aspiration.

Forewarned Is Forearmed: Machine Learning Algorithms for the Prediction of Catheter-Induced Coronary and Aortic Injuries.

Catheter-induced dissections (CID) of coronary arteries and/or the aorta are among the most dangerous complications of percutaneous coronary procedures, yet the data on their risk factors are anecdotal. Logistic regression and five more advanced machine learning techniques were applied to determine the most significant predictors of dissection. Model performance comparison and feature importance ranking were evaluated. We identified 124 cases of CID in electronic databases containing 84,223 records of diagnostic and interventional coronary procedures from the years 2000-2022. Based on the f1-score, Extreme Gradient Boosting (XGBoost) was found to have the optimal balance between positive predictive value (precision) and sensitivity (recall). As by the XGBoost, the strongest predictors were the use of a guiding catheter (angioplasty), small/stenotic ostium, radial access, hypertension, acute myocardial infarction, prior angioplasty, female gender, chronic renal failure, atypical coronary origin, and chronic obstructive pulmonary disease. Risk prediction can be bolstered with machine learning algorithms and provide valuable clinical decision support. Based on the proposed model, a profile of 'a perfect dissection candidate' can be defined. In patients with 'a clustering' of dissection predictors, a less aggressive catheter and/or modification of the access site should be considered.

Catheter-induced coronary artery and aortic dissections. A study of the mechanisms, risk factors, and propagation causes.

BACKGROUND: Only the incidence, management, and prognosis of catheter-induced coronary artery and aortic dissections have been systematically studied until now. We sought to evaluate their mechanisms, risk factors, and propagation causes. METHODS: Electronic databases containing 76,104 procedures and complication registries from 2000-2020 were searched and relevant cineangiographic studies adjudicated. RESULTS: Ninety-six dissections were identified. The overall incidence was 0.126%, and 0.021% for aortic injuries. The in-hospital mortality rate was 4.2%, and 6.25% for aortic dissections. Compared to the non-complicated population, patients with dissection were more often female (48% vs. 34%, p = 0.004), with a higher prevalence of comorbidities such as hypertension (56% vs. 25%, p < 0.001) or chronic kidney disease (10% vs. 4%, p = 0.002). They more frequently presented with acute myocardial infarction (72% vs. 43%, p < 0.001), underwent percutaneous coronary intervention (85% vs. 39%, p < 0.001), and were examined with a radial approach (77% vs. 65%, p = 0.011). The most prevalent predisposing factor was small ostium diameter and/or atheroma. Deep intubation for support, catheter malalignment, and vessel prodding were the most frequent precipitating factors. Of the three dissection mechanisms, 'wedged contrast injection' was the commonest (the exclusive mechanism of aortic dissections). The propagation rate was 30.2% and led to doubling of coronary occlusions and aortic extensions. The most frequent progression triggers were repeat injections and unchanged catheter. In 94% of cases, dissections were inflicted by high-volume operators, with ≥ 5-year experience in 84% of procedures. The annual dissection rate increased over a 21-year timespan. CONCLUSIONS: Catheter-induced dissection rarely came unheralded and typically occurred during urgent interventions performed in high-risk patients by experienced operators.

Analysis of reported cases of left main coronary artery injury during catheter ablation: In search of a pattern.

INTRODUCTION: Left main coronary artery (LMCA) injury is a rare but potentially fatal complication of catheter ablation. Due to LMCA large perfusion area, its occlusion is usually a dramatic event. METHODS AND RESULTS: Reports of LMCA injury complicating catheter ablations from 1987 to 2018 were searched in electronic databases. Twenty-two cases of serious LMCA damage have been identified. Additionally, four reports of direct mechanical trauma involving major LMCA branches induced by inadvertent catheter insertion have been studied. Typically 86% LMCA injury presented as an acute/subacute complication of retrograde ablation in left ventricle/left ventricular outflow tract or aortic cusps. In at least 86% of patients with an in-hospital presentation, the LMCA trauma manifested dramatically as a life-threatening arrhythmia, cardiogenic shock, or severe hypotension requiring vasopressors. In-hospital mortality rate was 32%. Direct stenting has been found to be the most successful strategy. CONCLUSION: LMCA injury, even if initially asymptomatic with normal angiographic appearance, may cause delayed flow deterioration, requiring prolonged monitoring and extended follow-up. Special caution should be given to the prevention whereas survival depends on prompt detection and treatment.