J-chronic total occlusion score predictive capacity for percutaneous coronary intervention success of chronic total occlusion: Results from a European single center cohort with progressive experience over time.

BACKGROUND: Several scoring systems have been described to assess the level of difficulty and to predict the probability of success of percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). The J-CTO score was initially developed to correlate CTO complexity with guidewire time crossing through the lesion within 30 min. Moreover, almost all scoring systems represent procedures performed by seasoned operators. Herein, this study sought to evaluate the predictive capacity of J-CTO for PCI success in a European single-center cohort with growing experience in the approach of CTO. METHODS: Five hundred twenty-six procedures were performed between 2007 and 2020 mainly by a single operator. The predictive power of J-CTO score was assessed by area under the receiver-operator characteristic curve (ROC) in the entire cohort and additionally in two separate periods. The goodnessof- fit of the model was evaluated by the Hosmer and Lemeshow statistic. RESULTS: Successful procedure in first-attempt PCI was 79.5% and the overall success including 47 repeated procedures was achieved in 85.8%. The retrograde approach was attempted in 14.4%. The score was inversely associated with procedural success with lower success rate in more difficult CTOs (p < 0.001). ROC curve for the entire cohort, and first block (case 1-200) and second block (case 201-526) was 0.696, 0.661 and 0.748, respectively. The model showed good calibration for the entire cohort (X2 = 1.7; p = 0.43). CONCLUSIONS: J-CTO score showed an acceptable predictive power for procedural success in this cohort although its discriminatory power is better as the level of experience is improved.

New scoring system for predicting percutaneous coronary intervention of chronic total occlusion success: Impact of operator's experience.

BACKGROUND: Several scoring systems have been developed in order to predict percutaneous coronary intervention (PCI) result of chronic total occlusion (CTO). The scores principally include anatomic and clinical variables. Operator experience is a decisive factor for achieving successful result. We sought to assess the real impact of operator growing experience on CTO-PCI success. METHODS: The angiographic and clinical variables of CTO-PCIs performed in our center between May 2007 and April 2021 were collected, and variables with potential association with procedural result were thoroughly reviewed. The influence of operator experience based on the number of previous CTO-PCIs was statistically assessed. A scoring system with combination of anatomic variables and operator experience was devised. RESULTS: A total of 540 PCIs in 457 patients were performed in our institution. The scoring model was developed from the derivation set (2/3 of the cohort). The final variables in logistic regression model were CTO length ≥ 20 mm, blunt stump, vessel tortuosity > 45o and operator experience < 100 PCIs. The model showed good performance in the derivation set (area under curve [AUC]: 0.768; confidence interval [CI]: 0706-0.830; p < 0.001) with no significant shrinkage in the validation set (AUC: 0.704; CI: 0.613-0.796; p < 0.001). CONCLUSIONS: This new score (E-CTO score) adequately predict the probability of CTO-PCI failure. The model includes a variable representing operator experience along with other anatomic variables.

Angiographic Characteristics and Outcomes of Percutaneous Coronary Intervention of Reattempted Chronic Total Occlusion: Potential Contributing Factors to Procedural Success.

This study aimed to analyze angiographic characteristics of new attempted percutaneous coronary intervention (PCI) on chronic total occlusion (CTO) compared to first attempt group. The cohort of 527 CTO-PCIs was divided into first-attempt and re-attempt groups, and angiographic characteristics, level of complexity, and contributing factors to failure were analyzed. Between-group success rate difference and potential angiographic and technical aspects contributing to the success in new attempts were scrutinized. A total of 47 new PCIs in 39 patients were performed. The reattempt group showed higher J-CTO score compared to the first-attempt group (2.4 ± 1.06 vs. 1.2 ± 1.06; p < 0.001). The use of more complex techniques and devices such as retrograde approach (29.8% vs. 12.9%) and IVUS (48.9 vs. 27.3%; p: 0.002) were more frequent in the reattempt group. Both procedural and fluoroscopy time were higher in the reattempt group (197 ± 83.9 vs. 150.1 ± 72.3 and 97.7 ± 55.4 vs. 68.7 ± 43, respectively; p < 0.001). There was no between-group difference in terms of technical success (79.8 vs. 76.6% for first attempt vs. reattempt group, respectively; p: 0.6). The overall success rate increased by 6.1%, achieving 85.9% in the entire cohort. Reattempted CTO-PCIs required more complex techniques and had comparable technical success rate with regard to the first-attempt group.

Safety and efficacy of coronary laser ablation as an adjunctive therapy in percutaneous coronary intervention: a single-centre experience.

BACKGROUND: Coronary laser is a long-established coadjuvant therapy in interventional cardiology. This study aimed to present our experience regarding the safety and efficacy of laser assistance to percutaneous coronary intervention (PCI) in different scenarios of coronary artery disease. METHODS: We used coronary laser as an adjunctive therapy for PCI between May 2014 and March 2020. The safety of laser ablation was evaluated by studying any complication associated with the laser application. Besides, the laser contribution to PCI and 1 year of follow-up for adverse cardiac events was studied. RESULTS: Coronary laser was performed in 81 lesions and 75 patients in different scenarios to assist PCI. The average age was 66 ± 11.7 years and 72 (88.9%) were men. Coronary laser was used in 30 (37%) cases for in-stent-material debulking; 26 (32.1%) in primary angioplasty, 19 (23.4%) in chronic total occlusion and 5 (6.2%) in saphenous vein grafts. Procedural success was achieved in 77 (95.1%) with 1 (1.2%) type III coronary perforation. One year of follow-up for combined adverse cardiac events consisting of death due to any cause, myocardial infarction or target vessel failure showed an event-free rate of 0.82 (95% confidence interval, 0.72-0.91). CONCLUSIONS: Our preliminary experience reveals the safety and efficacy of the current modality of coronary laser as a coadjuvant therapy in PCI with a low rate of adverse cardiac events in 1-year of follow-up. Further studies are needed to establish more precisely the contribution of laser application in different contexts of coronary artery disease.

Excimer Laser in Percutaneous Coronary Intervention of Device Uncrossable Chronic Total and Functional Occlusions.

Device uncrossable lesions are a challenge in interventional cardiology and despite improvements in balloon and microcatheter profile, rotational atherectomy is necessary in some circumstances in order to ablate and traverse the lesion. Nevertheless, the application of rotational atherectomy requires utilization of a specific wire, Rotawire, which is not always so easily navigable. Debulking of device uncrossable lesions can be performed by coronary laser over any kind of angioplasty guidewire. We present a series of six patients with chronic total (100%) and functional occlusions (99% stenosis) in whom after successful wire crossing, microcatheter failed to traverse the lesion. After coronary laser performance, 5 out of 6 lesions were successfully dilated, achieving a successful final angiographic result of 83.3%.

Procedure Time Comparison between Radial Versus Femoral Access in ST-Segment Elevation Acute Myocardial Infarction Patients Undergoing Emergent Percutaneous Coronary Intervention: A Meta-analysis of Controlled Randomized Trials.

INTRODUCTION: There are inconclusive data about the potential delay of procedure time in emergent percutaneous coronary intervention (PCI) by radial compared with femoral approach in patients with ST-segment elevation myocardial infarction (STEMI). AIMS: The purpose of the current study is to conduct a comprehensive meta-analysis of controlled randomized trials (CRTs) comparing the procedure time in STEMI patients undergoing emergent PCI with radial versus femoral access. METHODS: Formal search of CRTs through electronic databases (Medline and PubMed) was performed from January 1990 to October 2014 without language restrictions. Mean difference (MD) of procedure time was evaluated as overall effect. RESULTS: Twelve studies were included with 2052 and 2121 patients in radial and femoral group, respectively. Variability in the definition of procedure time was found with unavailability of a precise definition in 41.6% of studies. When all studies were included, no significant longer procedure time in radial approach was detected (MD [95% confidence interval [CI] = 1.6 min [-0.10, 3.3], P = 0.07, P het = 0.56). After deleting RIVAL trial, procedure time was significantly longer in radial group (MD [95% CI] = 1.5 min [0.71, 2.3], P < 0.001, P het = 0.20). Meta-analysis of three studies with similar definition of procedure time showed (MD [95% CI] = 1.26 min [-0.43, 2.95], P = 0.14, P het = 0.85). CONCLUSIONS: Although the procedure time in STEMI patients undergoing emergent PCI by radial access is generally comparable with femoral approach, there is an absence of uniformity in its definition, which leads to divergent results. A standardized definition of procedure time is required to elucidate this relevant matter.

Marcadores angiográficos negativos en la intervención coronaria percutánea de las oclusiones totales crónicas / Negative angiographic markers in percutaneous coronary intervention of chronic total occlusions

Resumen Objetivos: El objetivo de este estudio es evaluar variables angiográficas predictivas negativas y la presencia de la rama lateral en la proximidad de la capa distal de la oclusión en el resultado de la intervención coronaria percutánea de las oclusiones totales crónicas. Método: Las variables angiográficas potencialmente negativas fueron evaluadas retrospectivamente en 156 oclusiones totales crónicas sometidas a intervención coronaria percutánea. Se utilizó regresión logística binaria con una finalidad predictiva para identificar un modelo de variables que en su conjunto puedan predecir satisfactoriamente el resultado negativo de la intervención. Resultados: Las variables asociadas de forma independiente al fracaso de procedimiento fueron la enfermedad multivaso (odds ratio = 5,12; intervalo de confianza del 95%, 1,94-13,5; P = 0.001), la presencia de muñón ambiguo (odds ratio = 5,08; IC intervalo de confianza del 95%, 2,22- 11,63; P < 0.001), longitud de la oclusión ≥20 mm (odds ratio = 3,7; IC intervalo de confianza del 95%, 1,37-9,97; P = 0.01) y la localización ostial de la oclusión (odds ratio = 6,53; intervalo de confianza del 95%, 1,67-25,63; P = 0.007). La rama lateral en la proximidad de la capa distal no permaneció en el modelo predictivo. Conclusión: La enfermedad multivaso, muñón ambiguo, una longitud ≥20 mm y la localización ostial son factores independientes y predictivos de un resultado desfavorable de la angioplastia. La rama lateral en la capa distal de la oclusión no se asoció al fracaso de la intervención. © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Publicado por Masson Doyma México S.A. Este es un artículo Open Access bajo la licencia CC BY-NC-ND (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Abstract Objective: The purpose of this study is to identify negative angiographic predictive variables and the presence of a side branch close to the distal cap of the occlusion in the chronic total occlusion percutaneous coronary intervention outcome. Methods: Potential negative angiographic variables were retrospectively evaluated in 156 chronic total occlusions that had undergone a percutaneous coronary intervention. Binary logistic regression with predictive purpose was used to identify a model of variables which, all in all, could successfully predict a negative intervention result. Results: Variables independently associated with the procedural failure were multivessel disease (odds ratio = 5.12; 95% confidence interval (CI); 1.94-13.5; P = .001), ambiguous stump presence (odds ratio = 5.08; 95% CI; 2.22-11.63 P < .001), occlusion length ≥20 mm (odds ratio = 3.7; 95% CI; 1.37-9.97 P = .01), and ostial location (odds ratio = 6.53; 95% CI; 1.67-25.63; P = .007). Side branch at distal cap proximity did not remain in the predictive model. Conclusions: Multivessel disease, ambiguous stump, a length ≥20 mm, and an ostial location of a chronic total occlusion are independent predictive factors of an unfavourable angioplasty result. A side branch at occlusion distal cap was not associated with the procedural failure. © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Published by Masson Doyma México S.A. This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0/).

When intravascular ultrasound becomes indispensable in percutaneous coronary intervention of a chronic total occlusion.

Percutaneous coronary intervention of chronic total occlusion is a particular interventional area which requires high level of operator's experience and the support of additional tools based on intracoronary image such as intravascular ultrasound in many cases to clarify difficulties during procedures and to increase success rate. Implantation of long stents in many cases, the presence of stump ambiguity, and the use of specific techniques in this kind of interventions, such as reverse controlled antegrade and retrograde subintimal tracking (CART) and reverse CART make necessary in many cases the use of intravascular ultrasound for a better understanding of the situation, for reducing eventual complications and increasing procedural success rate. We made a review of literature related to most challenging situations in which the use of intravascular ultrasound during chronic total occlusion percutaneous coronary intervention becomes rather indispensable to safely continue and finish the procedure. Besides, two complex percutaneous coronary interventions of chronic total occlusion with unfavourable anatomic features in which intravascular ultrasound was crucial for the procedural success are presented in this manuscript along with support of the literature.

[Negative angiographic markers in percutaneous coronary intervention of chronic total occlusions]. / Marcadores angiográficos negativos en la intervención coronaria percutánea de las oclusiones totales crónicas.

OBJECTIVE: The purpose of this study is to identify negative angiographic predictive variables and the presence of a side branch close to the distal cap of the occlusion in the chronic total occlusion percutaneous coronary intervention outcome. METHODS: Potential negative angiographic variables were retrospectively evaluated in 156 chronic total occlusions that had undergone a percutaneous coronary intervention. Binary logistic regression with predictive purpose was used to identify a model of variables which, all in all, could successfully predict a negative intervention result. RESULTS: Variables independently associated with the procedural failure were multivessel disease (odds ratio=5.12; 95% confidence interval (CI); 1.94-13.5; P=.001), ambiguous stump presence (odds ratio=5.08; 95% CI; 2.22-11.63 P<.001), occlusion length ≥20mm (odds ratio=3.7; 95% CI; 1.37-9.97 P=.01), and ostial location (odds ratio=6.53; 95% CI; 1.67-25.63; P=.007). Side branch at distal cap proximity did not remain in the predictive model. CONCLUSIONS: Multivessel disease, ambiguous stump, a length ≥20mm, and an ostial location of a chronic total occlusion are independent predictive factors of an unfavourable angioplasty result. A side branch at occlusion distal cap was not associated with the procedural failure.

Percutaneous retrieval of a port-a-cath using a pigtail catheter combined with snaring technique.

We present a case of a 63-year-old woman who underwent chemotherapy for breast cancer through a port-a-cath inserted in left subclavian vein. The device was withdrawn one year later due to jugular vein thrombosis plus dysfunction of the device. A few years later a chest X-ray for scrutinizing dyspnea showed a catheter located in right heart chambers. Percutaneous retrieval via right subclavian vein was planned. Both catheter ends were impacted against heart structures and were not free to be easily captured by a snare. By using a pig-tail catheter we were able to seize the catheters loop portion and pull it back slightly. Once the catheter ends became free we seized one of the catheter's distal ends with a snare and successfully externalised it.

Reconstruction of an accidentally crushed stent guided by intravascular ultrasound during a left main percutaneous coronary intervention.

We present a case of an accidentally crushed stent due to an unnoticed passage of a guidewire through a lateral stent strut with subsequent stent compression after balloon dilatation, during a planned percutaneous coronary intervention on the left main. The crushed stent segment was reconstructed with step-by-step balloon dilation, guided by intravascular ultrasound.

Embolization of a septal branch perforation using subcutaneous fat during a percutaneous coronary intervention of chronic total occlusion by retrograde approach.

We describe a case of septal branch perforation during percutaneous coronary intervention of a right coronary artery chronic total occlusion. The septal branch perforation was treated with administration of autologous fat into the septal branch with significant reduction of extravasation. This treatment was followed by prolonged balloon inflation at the exit point of the septal branch in the donor artery which definitively sealed the perforation.

Percutaneous coronary intervention of chronically occluded saphenous vein grafts using excimer laser atherectomy as an adjuvant therapy.

We present two cases with chronic total occlusion of the saphenous vein graft in two patients with a history of previous bypass surgery with unfavorable anatomic features for recanalization of the native coronary artery. In the first case, two dedicated attempts for recanalization of chronic total occlusion of the native artery failed and in the second case there was not an adequate visualization of the native vessel beyond the occlusion point, not even by contralateral injection. Excimer laser atherectomy was used in both cases as an adjuvant therapy during recanalization of the saphenous vein graft in combination with a distal protection device in order to reduce distal embolization. The procedures proved successful after stent implantation in the whole length of the saphenous vein grafts and the patients suffered no remarkable events during hospitalization.

Efficacy and safety of Tornus catheter in percutaneous coronary intervention of hard or balloon-uncrossable chronic total occlusion.

BACKGROUND: Balloon advancement and dilation through chronic total occlusion segment could be challenging in some cases after successful wire crossing. The purpose of this study was to evaluate efficacy and safety of Tornus catheter (Asahi Intecc; Aichi, Japan) in percutaneous coronary intervention of chronic total occlusion in hard or balloon-uncrossable chronic total occlusion. METHODS: The present study is a retrospective and descriptive analysis of 14 hard or balloon-uncrossable chronic total occlusions treated percutaneously in our catheterization laboratory (cath lab). Tornus catheter was used to penetrate and eventually cross the chronic total occlusion segment. Procedure success was defined when Tornus penetrated at least partly into chronic total occlusion segment making possible the subsequent balloon dilatation and stent implantation achieving a final TIMI III angiographic result with residual stenosis less than 30%. Switch to other microcatheter was considered as an unsuccessful procedure. Complications associated with the Tornus use were analyzed in order to evaluate device safety. RESULTS: The average age of patients was 65.2 ± 9.6 and 11 out of 14 (78.6%) were male. In 7 (50%) cases, Tornus was used after an unsuccessful balloon passage through occluded segment. In 11 (78.6%) out of 14 cases the procedure was successful and in 3 (21.4%) cases, the operator switched to another microcatheter to continue with the procedure. No complication occurred during all procedures. CONCLUSION: Tornus catheter can be effectively and safely used in a subgroup of patients undergoing percutaneous coronary intervention of chronic total occlusion with hard or balloon-uncrossable lesions and could facilitate the treatment of this type of lesions.

Corrección de disección del seno de Valsalva guiada por ultrasonido intravascular / Valsalva sinus dissection correction guided by intravascular ultrasound

Paciente de 60 años, exfumador e hipercolesterolémico, con antecedentes de infarto agudo de miocardio no Q en 2006, que ameritó intervencionismo coronario percutáneo (ICP) con implantación de stents convencionales en la coronaria derecha distal y posterolateral, remitido por angor inestable. La coronariografía mostró reestenosis intrastent oclusiva en la coronaria derecha distal, con circulación colateral heterocoronaria. Al cateterizar la coronaria derecha se produjo disección espiroidea, desde la coronaria derecha proximal a la distal (fig. 1, flechas delgadas), con extensión al seno de Valsalva derecho. Refirió dolor torácico con ligera elevación del ST en la cara inferior. Se procedió a cruzar una guía convencional que no avanzó por entrada en luz falsa, consiguiéndose pasar una segunda guía, más allá de la reestenosis intrastent oclusiva, hasta la rama descendente posterior. Se implantaron varios stents convencionales desde el ostium hasta la descendente posterior de la coronaria derecha, de modo que se restableció el flujo, pero persistió imagen de retención de contraste, correspondiente a disección del seno de Valsalva derecho (fig. 2, flecha gruesa). Dada la persistencia de imagen angiográfica de disección del seno de Valsalva derecho, se decidió realizar un ultrasonido intravascular (IVUS) con técnica Chroma-Flow. De esta manera se comprobó la persistencia de flap a nivel ostial (fig. 3, flecha gruesa), se constató, además, que el ostium de la coronaria derecha no estaba cubierto completamente por el stent y se visualizó flujo sanguíneo en luz verdadera, con entrada parcial del mismo en luz falsa (fig. 3, flecha delgada). Se implantó un stent convencional de 4 × 12 mm, solapado al anterior, en el ostium de la coronaria derecha protruyendo en la aorta, con disminución marcada de la retención de contraste en el seno de Valsalva, y por tanto con cierre del punto de entrada de la disección (fig. 4, flecha gruesa). Se dio por finalizado el procedimiento y el paciente fue remitido a su hospital de referencia, asintomático y estable desde el punto de vista hemodinámico.

Long-term clinical performance of paclitaxel-eluting stents coated with a bioactive polymer (P-5) containing a triflusal derivative: results of the REWAC registry.

AIMS: Although drug-eluting stents have dramatically reduced angiographic restenosis and clinical need for repeat revascularization procedures, some adverse effects, such as late stent thrombosis, have been described. We evaluated clinical performance of paclitaxel-eluting stents coated with a new bioactive polymer system (P-5) based on a copolymer of an acrylic derivative of triflusal in patients with coronary artery disease. METHODS AND RESULTS: This was a multicenter, observational, prospective study to assess the incidence of target lesion revascularization (TLR) at 6 months and clinical major adverse cardiac events (MACEs) at 1 and 6 months and 1 and 2 years post-stent implantation in 537 patients. After stent implantation, only 1 case of thrombus and acute occlusion was reported in 1 lesion (0.14%). The incidence of new TLR was 0.89% at 6 months, 1.08% at 1 year, and 1.49% at 2 years, with a cumulative incidence of 3.54%. MACEs included cardiac death (0.93%), myocardial infarction (0.37%), and cardiac surgery (0.19%). No cases of late or very late stent thrombosis were recorded. CONCLUSION: Under routine clinical practice, the implantation of paclitaxel-eluting stents coated with P-5 is associated with favorable clinical outcomes in both the short and long term (2 years) in patients with coronary artery disease.

[Percutaneous intervention to a radial coronary artery graft. Initial results and follow-up]. / Intervencionismo coronario percutáneo a injerto de arteria radial. Resultado inicial y seguimiento.

The use of radial artery grafts for coronary bypass surgery is becoming more frequent. However, experience with percutaneous coronary intervention for radial artery graft failure is limited. We describe a patient with a radial artery graft in whom angina reappeared because of de novo stenosis in the graft. The patient was successfully treated with balloon angioplasty and stenting. At 6 months he again had angina due to a second de novo stenosis of the radial artery graft, which was also treated with angioplasty. At follow-up the patient remained asymptomatic with no evidence of ischemia.

Intervencionismo coronario percutáneo a injerto de arteria radial. Resultado inicial y seguimiento / Percutaneous intervention to a radial coronary artery graft. Initial results and follow-up

La utilización de la arteria radial como injerto arterial en la cirugía de revascularización coronaria es cada vez más frecuente. Hay escasa experiencia sobre intervencionismo coronario percutáneo en este tipo de injerto arterial. Presentamos el caso de un paciente con injerto de arteria radial en el que la reaparición de la sintomatología anginosa se relacionó con la presencia de una estenosis de novo en dicho injerto. Este paciente fue tratado satisfactoriamente mediante angioplastia con balón e implantación de stent. A los 6 meses presentó angina por una segunda estenosis de novo del injerto radial, también abordada con angioplastia. En el seguimiento, el enfermo se mantuvo asintomático y sin evidencia de isquemia

La utilización de la arteria radial como injerto arterial en la cirugía de revascularización coronaria es cada vez más frecuente. Hay escasa experiencia sobre intervencionismo coronario percutáneo en este tipo de injerto arterial. Presentamos el caso de un paciente con injerto de arteria radial en el que la reaparición de la sintomatología anginosa se relacionó con la presencia de una estenosis de novo en dicho injerto. Este paciente fue tratado satisfactoriamente mediante angioplastia con balón e implantación de stent. A los 6 meses presentó angina por una segunda estenosis de novo del injerto radial, también abordada con angioplastia. En el seguimiento, el enfermo se mantuvo asintomático y sin evidencia de isquemia

[Irreversible acute heart failure caused by cardiac hemochromatosis secondary to multiple transfusions]. / Insuficiencia cardíaca aguda irreversible debido a hemocromatosis cardíaca secundaria a transfusiones múltiples.

We report a 64 years old male, admitted for dyspnea and edema of two weeks duration. A sideroblastic anemia, requiring multiple transfusions, was diagnosed four years earlier. The chest X-ray showed an enlarged heart and right pleural effusion. A low left ejection fraction was evidenced by echocardiogram. Doppler analysis of the mitral flow revealed a restrictive hemodynamic pattern. A diagnosis of secondary cardiac hemochromatosis deposit was made. Nine days after admission the patient died due to heart failure. The clinical presentation of cardiac hemochromatosis as a sudden and irreversible heart failure, as well as the importance of early diagnosis and surveillance of high-risk patients is emphasized.