Comparison of successful versus failed percutaneous coronary intervention in patients with chronic total occlusion: A systematic review and meta-analysis.

BACKGROUND: The optimal treatment strategy of chronic total occlusion (CTO) is currently debated. This meta-analysis aimed to evaluate the long-term clinical outcomes of successful percutaneous coronary intervention (PCI) of CTO. METHODS: Electronic databases were searched for studies comparing long-term outcomes between successful PCI in patients with CTO using drug-eluting stents and failed procedures. Meta-analysis was conducted with major adverse cardiac events (MACE) and all-cause mortality during the longest follow-up as endpoints. The combined hazard ratios (HRs) were applied to assess the correlation between successful CTO PCI and MACE/all-cause mortality. RESULTS: Eight studies consisting of 6,211 patients published between 2012 and 2020 met our inclusion criteria, and the CTO PCI success rate was 81.2%. Patients in the failed group were much older, and more likely to have morbidities (hypertension and prior myocardial infarction), reduced left ventricular ejection fraction, and severe lesion characteristics (multivessel disease and moderate/severe calcification). Pooled results indicated that successful CTO PCI was significantly associated with prognosis. Compared to failed recanalization, patients receiving successful procedures had an improved MACE (HR: 0.50, 95% CI: 0.40-0.61, p < 0.001). Subgroup analyses further revealed the prognostic value of successful CTO PCI. However, no difference was observed regarding all-cause mortality (HR: 0.79, 95% CI: 0.61-1.02, p = 0.074). CONCLUSIONS: The present study showed that CTO recanalization was associated with improved long-term outcomes. However, randomized trials are needed to confirm the results due to the mismatch of baseline characteristics.

Outcome of alcohol septal ablation in mildly symptomatic patients with hypertrophic obstructive cardiomyopathy: A comparison with medical therapy.

OBJECTIVE: The aim of this study was primarily to determine efficacy after alcohol septal ablation (ASA) in mildly symptomatic patients (NYHA class II) with hypertrophic obstructive cardiomyopathy (HOCM), as compared to medical therapy. METHODS: This retrospective study included 163 mildly symptomatic patients with HOCM evaluated in Beijing Anzhen Hospital between March 2001 and August 2019, consisting of the medical group (n = 105) and the ASA group (n = 58). All-cause mortality and HCM-related death were mainly observed. RESULTS: Follow-up was completed in 161 patients and the median follow-up was 6.0 years. Compared to medically treated patients, patients post-ASA had comparable survival free of all-cause mortality (98.3% and 95.1% vs. 93.0% and 83.1% at 5 and 10 years, respectively; p = 0.374). Survival free of HCM-related death was also similar between ASA and medical groups (98.3% and 95.1% vs. 94.3% and 86.2% at 5 and 10 years, respectively; p = 0.608). However, compared to medical therapy, ASA had advantages on the improvement of NYHA class (1.4 ± 0.6 vs. 2.1 ± 0.5, p = .000) and lower occurrence of new-onset atrial fibrillation (AF) (7.8% vs. 20.4%, p = .048). Multivariate analysis demonstrated that resting LVOT gradient at the last clinical check-up was an independent predictor of all-cause mortality (HR = 1.021, 95%CI 1.002-1.040, p = .027). CONCLUSION: This registry suggests that mildly symptomatic patients with HOCM treated with ASA have comparable survival to that of medically treated patients, with the improvement of NYHA class and lower occurrence of new-onset AF. All-cause mortality is independently associated with resting LVOT gradient at the last clinical check-up.

Endovascular Repair for Thoracic Aortic False Aneurysms: Single-Center Experience in 102 Patients.

BACKGROUND: Thoracic aortic false aneurysm is unusual and experience with endovascular repair is limited. We evaluate the efficacy of endovascular repair in patients with thoracic aortic false aneurysms. METHODS: The early and midterm outcomes of endovascular repair in 102 patients with thoracic aortic false aneurysms were analyzed. RESULTS: There were 80 men and 22 women (age 54.9 ± 13.7 years). Emergent or urgent endovascular repair was done in 19 cases (18.6%) and elective in 83 (81.4%). Procedure was successful in 99.0%. Early death occurred in 4 patients (3.9%). No early death occurred in elective patients. Early complications occurred in 7 patients (6.9%). Follow-up was complete in 100% for 24.0 ± 18.5 months (range, 1.5 to 67.3). Fourteen late deaths occurred (13.7%). Late events occurred in 9 patients (8.8%). Survival at 6 month, 1 year and 3 years was 90.7%, 86.7% and 84.5%, respectively. CONCLUSIONS: Satisfactory early and midterm outcomes have been achieved with endovascular repair in this series. Although emergent or urgent patients had higher rates of early mortality and morbidity, the majority of them achieved stable late survival as long as they survived at least 6 months. These results argue favorably for use of endovascular repair in the management of patients with thoracic aortic false aneurysms.

Endovascular repair of Stanford B aortic dissection using two stent grafts with different sizes.

OBJECTIVE: The objective of this study was to introduce a novel strategy for thoracic endovascular aortic repair of Stanford B aortic dissection using two-stent graft implantation (TSI), in which the proximal stent and distal stent with different sizes are sequentially deployed, and to summarize our experience with this technique. METHODS: A retrospective study was conducted of 72 consecutive patients (61 men; mean age, 55 ± 7 years; range, 41-67 years) with Stanford type B aortic dissection who underwent TSI treatment between January 2012 and May 2013. Among all patients, 43 (59.7%) involved the infrarenal aorta and 29 (40.3%) involved the whole thoracic and abdominal aorta; mean aortic involvement length was 226 ± 13 mm (range, 182-312 mm). Eight cases were for acute dissection (within 2 weeks from onset of symptoms), 11 cases were for chronic dissection (>3 months after initial dissection), and 53 cases were for subacute dissection (between 2 weeks and 3 months). Twenty-two cases (30.6%) were uncomplicated type and 50 cases (69.4%) were complicated type. Follow-up was performed postoperatively at 1 month, 6 months, and yearly thereafter. Technique success, aorta morphology, and procedure-related complications were evaluated. RESULTS: Technical success was achieved in 100%; 72 pairs of stent grafts (144 thoracic stent grafts) and 10 left subclavian artery chimney stents were used. The mean aortic length coverage by the stent grafts was 197.6 ± 20.3 mm, and mean taper diameter span was 7.5 ± 1.8 mm. All patients were followed up from 6 to 16 months (mean, 10 ± 4 months); 95.8% (69 of 72) had a thrombosed false lumen in the aortic coverage, and the true lumen expanded on average 57% ± 11% (23%-100%). No significant changes were found in aortic diameters of the proximal and distal ends of the two stent grafts and the angles between centerlines of the distal end of the stent and the aorta during follow-up. Procedure-related complications included transient paraplegia (coverage of the left subclavian artery without revascularization and extensive coverage of aorta >220 mm) due to acute spinal cord ischemia (n = 1) and malapposition of the distal stent (primary tear closed, true lumen expansion led to oversize rate insufficient in distal stent diameter; n = 1). No death or malperfusion complications were observed during the perioperative period and follow-up. CONCLUSIONS: Short-term outcomes showed TSI to be a flexible and effective approach to accurately repair Stanford B aortic dissection that could potentially address the limitations of currently available stent grafts. Further prospective clinical studies are warranted to evaluate its long-term efficacy.

[Efficacy of personalized endovascular repair using two stent-grafts for patients with Stanford B aortic dissection].

OBJECTIVE: To observe the feasibility and clinical efficacy of thoracic endovascular aortic repair (TEVAR) for patients with Stanford B aortic dissection using personalized two stent-grafts implantation (TSI). METHODS: This retrospective review included 56 patients who underwent TSI during TEVAR for Stanford B aortic dissection from Jan 2012 to May 2013 in Beijing Anzhen hospital. There were 8 patients in acute phase (within 2 weeks from onset of symptoms), 11 patients in chronic phase (greater than 2 months following initial dissection) and 37 patients in subacute phase (between 2 weeks and 2 months from onset of symptoms). Infrarenal aorta was involved in 34 patients (60.7%) and suprarenal aorta involved in 22 patients (39.3%), the mean aortic lesion length was (226 ± 13)mm. Thoracic and abdominal aortic angiography was performed during operation to measure aortic diameters of proximal and distal landing zone, and the distance between them. The proximal stent-grafts were implanted in distal aorta to the origin of left subclavian artery with oversize rate of 10%-15% according to proximal landing zone according to procedural guideline. Then the distal newly customized large tapered stent-grafts were sequentially deployed according to the diameters of both the distal end of proximal stent and distal landing zone (aortic true lumen), and overlapping length of the two stent-grafts was more than 30 mm. Patients were followed-up at 3 months, 6 months, and yearly thereafter post operation. RESULTS: TSI procedure was successful in all patients and 122 stent-grafts were implanted. The mean length of implanted stent-grafts was (197.6 ± 20.3)mm. The mean diameter taper span was (7.5 ± 1.8)mm with proximal oversize rate of (12.8 ± 3.4)% and distal oversize rate of (11.2 ± 4.1)%. The mean angle between the distal end of stent and aorta was (2.3 ± 1.3)°. The diameter of proximal and distal landing zone, and angle between the distal end of stent and aorta remained unchanged during follow up (mean: (10.0 ± 4.0) months). The total thrombosis rate of the false lumen was 98.2% (55/56), thrombosis rate of stent segment was 82.1% (46/56) . Stent-related complications were observed in 2 patients (3.6%) , including acute spinal cord ischemia due to paraplegia (n = 1) and malposition of distal stent (n = 1). CONCLUSIONS: Encouraging short-term outcomes are obtained from current personalized two stent-grafts implantation strategy for patients with Stanford B aortic dissection. Further prospective clinical studies are warranted to evaluate the long-term efficacy of this procedure.

The chimney technique for preserving the left subclavian artery in thoracic endovascular aortic repair.

OBJECTIVES: The objective of the present study was to evaluate short- and mid-term outcomes of the left subclavian artery (LSA) chimney stent implantation (LSACSI) during thoracic endovascular aortic repair (TEVAR), and to summarize our experience with this technique. METHODS: From June 2010 to September 2012, 59 patients (49 men; mean age of 57.4 ± 13.3 years, range from 26 to 83 years) who underwent TEVAR and LSACSI were enrolled. Patients suffered from Stanford type B aortic dissection (n = 27), penetrating aortic ulcer (n = 18), aortic arch aneurysm (n = 9), pseudoaneurysm of the aortic arch (n = 4) and proximal type I endoleak after TEVAR of aortic dissection (n = 1). Elective settings were performed in 72% and emergent in 38% of all patients. Follow-up was performed at postoperative 3 months, 6 months and yearly thereafter. RESULTS: The technical success rate was 98.3% (58/59), and 69 thoracic stent grafts were used. Sixty-two chimney stents, including 55 uncovered and 7 covered stents, were implanted in 59 LSAs. The overall immediate endoleak rate was 15.3% (9/59); type I endoleak was observed in 5 patients and type II in 4 patients. The difference in the immediate endoleak rate related to the anatomy between the outer and the inner curvature was statistically significant (35 vs 4%, P = 0.018). Chimney stent compression was observed in 3 patients and another stent was deployed inside the first one. Perioperative complications included stroke (3.4%, 2/59) and left upper limb ischaemia (1.7%, 1/59). The median follow-up period was 16.5 (range 1-39 months). The mortality rate during follow-up was 5.4% (3/56). Complications during follow-up included endoleak [overall, n = 8 (14.3%, 8/56); type I, n = 5; type II, n = 3], retrograde type A aortic dissection (n = 1), collapse (n = 3, 5.4%) or occlusion (n = 2, 3.6%) of the chimney stent. CONCLUSIONS: Short- and mid-term results showed that it is feasible to preserve the patency of the LSA in TEVAR with the chimney technique for thoracic aortic pathologies close to the LSA. However, TEVAR combined with LSACSI was not advocated for lesions located at the outer curve of the aortic arch due to a high possibility of endoleak.

A novel approach for hybrid repair of type B aortic dissection associated with coarctation of the aorta.

We report the case of an acute type B aortic dissection in association with an unknown isthmic coarctation in a 53-year-old man. An intimal tear was located just distal to the coarctation, and the intimal flap extended to the level of the renal arteries. Hybrid repair was performed successfully 4 months later, without deep hypothermic circulatory arrest. An extra-anatomic bypass connected the ascending aorta to the abdominal aorta. The coarctation was occluded using a ventricular septal defect occluder. The hybrid repair was safe and effective for the patient.