One Versus 2-stent Strategy for the Treatment of Bifurcation Lesions in the Context of a Coronary Chronic Total Occlusion. A Multicenter Registry.

INTRODUCTION AND OBJECTIVES: There is little evidence on the optimal strategy for bifurcation lesions in the context of a coronary chronic total occlusion (CTO). This study compared the procedural and mid-term outcomes of patients with bifurcation lesions in CTO treated with provisional stenting vs 2-stent techniques in a multicenter registry. METHODS: Between January 2012 and June 2016, 922 CTO were recanalized at the 4 participating centers. Of these, 238 (25.8%) with a bifurcation lesion (side branch ≥ 2mm located proximally, distally, or within the occluded segment) were treated by a simple approach (n=201) or complex strategy (n=37). Propensity score matching was performed to account for selection bias between the 2 groups. Major adverse cardiac events (MACE) consisted of a composite of cardiac death, myocardial infarction, and clinically-driven target lesion revascularization. RESULTS: Angiographic and procedural success were similar in the simple and complex groups (94.5% vs 97.3%; P=.48 and 85.6% vs 81.1%; P=.49). However, contrast volume, radiation dose, and fluoroscopy time were lower with the simple approach. At follow-up (25 months), the MACE rate was 8% in the simple and 10.8% in the complex group (P=.58). There was a trend toward a lower MACE-free survival in the complex group (80.1% vs 69.8%; P=.08). After propensity analysis, there were no differences between the groups regarding immediate and follow-up results. CONCLUSIONS: Bifurcation lesions in CTO can be approached similarly to regular bifurcation lesions, for which provisional stenting is considered the technique of choice. After propensity score matching, there were no differences in procedural or mid-term clinical outcomes between the simple and complex strategies.

Survival analysis after gastrostomy: a single-centre, observational study comparing radiological and endoscopic insertion.

OBJECTIVES: Percutaneous endoscopic gastrostomy (PEG) using the pull through technique is the most widely used insertion method. An alternative is a per-oral image-guided gastrostomy (PIG), which may be advantageous in high-risk patients. As there are no large studies comparing PEG against PIG, we wished to analyse mortality after endoscopic or radiological gastrostomy insertion. METHODS: Patients referred for a gastrostomy are prospectively included in a database along with demographic, biochemical and outcome data. Analysis of gastrostomy insertions from February 2004 to 2007 was performed with reference to method of insertion and 30-day outcome. Patients were subgrouped into cognitive impairment, dysphagic stroke, oropharygeal cancer, neurological cancer and other. RESULTS: One hundred and seventy PIGs and 233 PEGs were inserted (mean age 62 years, 268 males). There were no differences in age between the PIG and the PEG group. The PIG 30-day mortality was 26 of 170 (15.3%) and the PEG 30-day mortality was 25 of 233 (10.7%) (P=0.17). One-year mortality was 92 of 170 (54.1%) for PIG and 131 of 233 (56.7%) for PEG (P=0.60). Subgroup analysis revealed higher 30-day mortality in patients with nasopharyngeal cancer undergoing PIG; 14 of 106 (13.2%) versus one of 69 (1.4%) (P=0.005). However, PIG patients were older than PEG patients (mean age 64 vs. 59.7 years, P=0.019) and had more comorbidities (21.1% in the PEG group and 37.7% in the PIG group). CONCLUSION: Overall PIG and PEG seem to have similar 30-day and 1-year mortality rates. Our data suggest that clinicians may opt for either approach depending on technical considerations and local availability.

Patient doses from fluoroscopically guided cardiac procedures in pediatrics.

Infants and children are a higher risk population for radiation cancer induction compared to adults. Although some values on pediatric patient doses for cardiac procedures have been reported, data to determine reference levels are scarce, especially when compared to those available for adults in diagnostic and therapeutic procedures. The aim of this study is to make a new contribution to the scarce published data in pediatric cardiac procedures and help in the determination of future dose reference levels. This paper presents a set of patient dose values, in terms of air kerma area product (KAP) and entrance surface air kerma (ESAK), measured in a pediatric cardiac catheterization laboratory equipped with a biplane x-ray system with dynamic flat panel detectors. Cardiologists were properly trained in radiation protection. The study includes 137 patients aged between 10 days and 16 years who underwent diagnostic catheterizations or therapeutic procedures. Demographic data and technical details of the procedures were also gathered. The x-ray system was submitted to a quality control programme, including the calibration of the transmission ionization chamber. The age distribution of the patients was 47 for <1 year; 52 for 1-<5 years; 25 for 5-<10 years and 13 for 10-<16 years. Median values of KAP were 1.9, 2.9, 4.5 and 15.4 Gy cm(2) respectively for the four age bands. These KAP values increase by a factor of 8 when moving through the four age bands. The probability of a fatal cancer per fluoroscopically guided cardiac procedure is about 0.07%. Median values of ESAK for the four age bands were 46, 50, 56 and 163 mGy, which lie far below the threshold for deterministic effects on the skin. These dose values are lower than those published in previous papers.