Dual guidewire balloon antegrade fenestration and re-entry technique for coronary chronic total occlusions percutaneous coronary interventions.

OBJECTIVES: To describe the experience of coronary chronic total occlusions (CTOs) percutaneous coronary interventions (PCI) using antegrade fenestration and re-entry (AFR) technique with a dedicated dual guidewire balloon (DGB). BACKGROUND: Antegrade dissection and re-entry (ADR) techniques has been emphasized in recent worldwide CTO consensus documents. We investigated the feasibility and safety of DGB as a dedicated device to perform guidewire-based AFR. METHODS AND RESULTS: Fourteen consecutive patients with complex CTO (J-CTO score: 3.1 ± 0.9) underwent DGB-AFR in the years 2020-2021. DGB-AFR consists in advancing the DGB over a guidewire that reached the vessel distal to the CTO in an extra plaque fashion, inflating/deflating the DGB to create fenestration between subintimal space and the true lumen and advancing a proximal re-entry guidewire through fenestration in the true lumen. DGB-AFR alone was successful in 10 of 14 (71%) cases, a rescue wire-based ADR was needed in two cases for re-entry into the true lumen with a total success rate in 12 of 14 (86%) cases. Among all DGB-AFR cases, four (28%) were performed as a first-line strategy while the remaining 10 (71%) cases were performed as a bail-out strategy after failure of other antegrade crossings for 30 min of procedural time. No DGB-related complications were observed. CONCLUSIONS: DGB-AFR is a user-friendly reliable strategy for the treatment of many CTO lesions. It can be used as bail-out after failure of conventional antegrade wiring techniques, achieving high procedural success rate and low occurrence of procedural adverse events.

Myocardial infarction with non-obstructive coronary arteries (MINOCA): Intracoronary imaging-based diagnosis and management.

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is defined by clinical evidence of myocardial infarction (MI) with normal or near-normal coronary arteries on angiography. This condition is present in about 5% to 25% of patients presenting with acute coronary syndromes. MINOCA is a working diagnosis. Current guidelines and consensus recommend identification of underlying causes of MINOCA in order to optimize treatment, improve prognosis, and promote prevention of recurrent myocardial infarction. An accurate evaluation of patient history, symptoms and use of invasive and non-invasive imaging should lead to identification of epicardial or microvascular causes of MINOCA and differentiation from non-ischemic myocardial injury due to both cardiac (e.g. myocarditis) and non-cardiac disease (e.g. pulmonary embolism). In this review, we highlight the role of coronary imaging in differential diagnosis of patients presenting with MINOCA. Intravascular ultrasound and optical coherence tomography are well known technologies used in different settings from acute to chronic coronary syndromes. In MINOCA patients, coronary imaging could help to identify pathological alterations of the epicardial vessels that are not visible by coronary angiography such as plaque disruption, coronary dissection, coronary thromboembolism, coronary spasm, and coronary artery disease in patients presenting with takotsubo syndrome. In future, the widespread use of these technologies, in the right clinical context, could lead to optimization and personalization of treatment, and to better prognosis of patients presenting with MINOCA.

Clinical Outcomes Following Intravascular Imaging-Guided Versus Coronary Angiography-Guided Percutaneous Coronary Intervention With Stent Implantation: A Systematic Review and Bayesian Network Meta-Analysis of 31 Studies and 17,882 Patients.

OBJECTIVES: The authors sought to explore the comparative clinical efficacy of different imaging modalities for guiding percutaneous coronary interventions (PCI). BACKGROUND: Coronary angiography (CA) is the standard imaging modality for intraprocedural guidance of PCI. Intracoronary imaging techniques, including intravascular ultrasound (IVUS) and optical coherence tomography (OCT), can overcome some limitations of CA. METHODS: Comprehensive hierarchical Bayesian network meta-analysis of randomized clinical trials and adjusted observational studies comparing clinical outcomes of PCI with stent implantation guided by CA, IVUS, or OCT. RESULTS: A total of 31 studies encompassing 17,882 patients were included. Compared with CA guidance, the risks of all-cause death (odds ratio [OR]: 0.74; 95% credible interval [CrI]: 0.58 to 0.98), myocardial infarction (OR: 0.72; 95% CrI: 0.52 to 0.93), target lesion revascularization (OR: 0.74, 95% CrI: 0.58 to 0.90) and stent thrombosis (OR: 0.42; 95% CrI: 0.20 to 0.72) were significantly reduced by IVUS guidance. PCI guidance using either IVUS or OCT was associated with a significant reduction of major adverse cardiovascular events (OR: 0.79; 95% CrI: 0.67 to 0.91 and OR: 0.68; 95% CrI: 0.49 to 0.97, respectively) and cardiovascular death (OR: 0.47; 95% CrI: 0.32 to 0.66 and OR: 0.31; 95% CrI: 0.13 to 0.66, respectively). No differences in terms of comparative clinical efficacy were found between IVUS and OCT for all the investigated outcomes. Pooled estimates were consistent across several sensitivity analyses. However, the treatment effect of IVUS on all-cause death was neutralized in the analysis restricted to randomized clinical trials (OR: 1.03; 95% CrI: 0.41 to 2.14). CONCLUSIONS: Compared with CA, the use of intravascular imaging techniques for PCI guidance reduces the risk of cardiovascular death and adverse events.