Efficacy and Safety of the GuideLiner Mother-in-Child Guide Catheter Extension in Percutaneous Coronary Intervention.

BACKGROUND: Percutaneous coronary intervention (PCI) procedures are increasingly performed on complex tortuous and heavily calcified coronary lesions. The GuideLiner® catheter (Vascular Solutions, Inc. Minneapolis, MN) is a rapid exchange guide catheter extension system. There is paucity of data about the efficacy of this device in complex PCI. Therefore, we aim to report the indications, success, and efficacy of GuideLiner use in treating complex lesion subset in the present study. METHODS: We collected data from all patients in whom the GuideLiner was used to facilitate PCI between April 1, 2011 and December 31, 2014 at a tertiary referral center in Toronto, Canada. Demographic and procedural data were obtained from an institutional prospective data registry. Indications for use of the GuideLiner, and angiographic and procedural data specific to the device were also collected. RESULTS: The GuideLiner was utilized in 307 (317 lesions) of 6105 PCI procedures performed at our institution during the study period. The mean age was 68.4 ± 11.2 years and 82% were male. The majority of lesions were types B2 or C (98%), calcified (86.3%), with proximal tortuosity (88.6%). The overall technical success rate of the GuideLiner was 88%. The procedural success rate was 98.7%. The complication rate was low (1.6%). CONCLUSIONS: Use of the GuideLiner catheter facilitated successful completion of PCI procedures in a majority of patients with complex lesions. Operators should be aware of the potential complications associated with GuideLiner use.

Ventricular Fibrillation Precipitated by Intracoronary Adenosine During Fractional Flow Reserve Assessment - A Cautionary Tale.

Fractional flow reserve (FFR) measurement is the current benchmark for assessing the physiologic significance of a coronary stenosis. Intravenous / intra-coronary adenosine is a commonly used agent to induce hyperaemia, required for FFR measurement. In our institute, we have observed three cases of ventricular fibrillation (VF) after intra-coronary adenosine injection. Volume of the injections appeared to be the responsible mechanism, supported by evidence from optical coherence tomography (OCT) experience. Since doubling the concentration of adenosine to reduce the volume of injection by half, no further incidence of VF has been noted.

Rotational atherectomy through the radial artery is associated with similar procedural success when compared with the transfemoral route.

OBJECTIVES: Rotational atherectomy (RA) has traditionally been carried out using 7 or 8 Fr guides through a transfemoral approach to allow for passage of 2.0 mm burrs or larger. With transradial percutaneous coronary intervention becoming more common, our aim was to investigate whether transradial RA would offer equivalent rates of procedural success when compared with transfemoral RA. METHODS: Using a prospective percutaneous coronary intervention registry, we identified all patients who had undergone RA at the University Health Network between January 2001 and December 2012 and compared those in whom the transfemoral approach had been used with those in whom the transradial approach had been used. RESULTS: A total of 119 patients were analyzed (67 femoral, 52 radial). Larger guides were used in the femoral group compared with the radial group (6.79 vs. 6.31 Fr, P<0.001), but there was no significant difference in the number of burrs used or the average size of the burrs. There was no significant difference in the procedural success rate (91 vs. 96%, P=0.46), fluoroscopy time (40.5 vs. 43.8 min, P=0.37), radiation dose (27743 vs. 29939 cGy cm, P=0.50), or contrast use (429 vs. 384 ml, P=0.19) between the two groups. Patients in the femoral group were more likely to have a transvenous pacing wire inserted (25 vs. 6%, P=0.006). Access site crossover tended to occur more frequently in the radial group (6 vs. 0%, P=0.08). CONCLUSION: We have shown that RA through the transradial route is associated with outcomes similar to those achieved through the transfemoral route. Keeping in mind the single-center context and the small number of operators, our data do not suggest an increased rate of failure of RA through the radial route despite the use of smaller guiding catheters.

Association between drug-eluting stent type and clinical outcomes in patients with chronic kidney disease undergoing percutaneous coronary intervention.

BACKGROUND: The comparative efficacy of first- vs second-generation drug-eluting stents (DESs) in patients with chronic kidney disease (CKD) undergoing percutaneous coronary intervention (PCI) is unknown. METHODS: A retrospective analysis of consecutive patients undergoing PCI at a tertiary PCI center from 2007-2011 was performed, with linkage to administrative databases for long-term outcomes. CKD was defined as creatinine clearance (CrCl) < 60 mL/min. Propensity matching by multivariable scoring method and Kaplan-Meier analyses were performed. RESULTS: Of 6481 patients with available CrCl values undergoing a first PCI during the study period, 1658 (25%) had CKD. First- and second-generation DESs were implanted in 320 (19.3%) and 128 (7.7%) patients with CKD, respectively. At 2 years, no significant differences were observed between first-generation (n = 126) and second-generation (n = 126) propensity-matched DES cohorts for the outcomes of death (19% vs 16%; P = 0.51), repeat revascularization (10% vs 10%; P = 1.00), and major adverse cardiovascular and cerebrovascular events (MACCE) (36% vs 37%; P = 0.90). The 2-year Kaplan-Meier survival was also similar (P = 0.77). In patients with CKD, second-generation DES type was not an independent predictor for death (P = 0.49) or MACCE (P = 1.00). CONCLUSIONS: Although the use of first- and second-generation DESs was associated with similar 2-year safety and efficacy in patients with CKD, our results cannot rule out a beneficial effect of second- vs first-generation DESs owing to small sample size. Future studies with larger numbers of patients with CKD are needed to identify optimal stent types, which may improve long-term clinical outcomes.

Predictors of radial artery size in patients undergoing cardiac catheterization: insights from the Good Radial Artery Size Prediction (GRASP) study.

BACKGROUND: Radial artery occlusion occurs after transradial cardiac catheterization or percutaneous coronary intervention. Although use of a sheath larger than the artery is a risk factor for radial artery occlusion, radial artery size is not routinely measured. We aimed to identify bedside predictors of radial artery diameter. METHODS: Using ultrasound, we prospectively measured radial, ulnar, and brachial artery diameters of 130 patients who presented for elective percutaneous coronary intervention or diagnostic angiography. Using prespecified candidate variables we used multivariable linear regression to identify predictors of radial artery diameter. RESULTS: Mean internal diameters of the right radial, ulnar, and brachial arteries were 2.44 ± 0.60, 2.14 ± 0.53, and 4.50 ± 0.88 mm, respectively. Results for the left arm were similar. The right radial artery was larger in men than in women (2.59 vs 1.91 mm; P < 0.001) and smaller in patients of South Asian descent (2.00 vs 2.52 mm; P < 0.001). Radial artery diameter correlated with wrist circumference (r(2) = 0.26; P < 0.001) and shoe size (r(2) = 0.25; P < 0.001) and weakly correlated with height (r(2) = 0.14; P < 0.001), weight (r(2) = 0.18; P < 0.001), body mass index (r(2) = 0.07; P = 0.002), and body surface area (r(2) = 0.22; P < 0.001). The independent predictors of a larger radial artery were wrist circumference (r(2) = 0.26; P < 0.001), male sex (r(2) = 0.06; P < 0.001), and non-South Asian ancestry (r(2) = 0.05; P = 0.006; final model r(2) = 0.37; P < 0.001). A risk score using these variables predicted radial artery diameter (c-statistic, 0.71). CONCLUSIONS: Wrist circumference, male sex, and non-South Asian ancestry are independent predictors of increased radial artery diameter. A risk score using these variables can identify patients with small radial arteries.

Antithrombotic therapy after coronary stenting in patients with nonvalvular atrial fibrillation.

BACKGROUND: The safety and efficacy of triple therapy (TT; warfarin with dual antiplatelet therapy [DAPT]) in post-percutaneous coronary intervention (PCI) patients with atrial fibrillation (AF) are unclear. We aimed to determine whether TT is associated with a decreased stroke rate and an acceptable bleeding rate in this population. METHODS: This was a single-centre, retrospective study. Primary composite outcome was death, ischemic stroke, or transient ischemic attack. Secondary outcomes included components of primary outcome, bleeding, and blood transfusion rates. RESULTS: Of 602 post-PCI patients with AF between 2000 and 2009, 382 received TT, 220 DAPT. Mean follow-up post PCI was 5.9 ± 5.0 months. The TT group had a higher CHADS(2) score (2.6 vs 2.1, P < 0.001), older age (72.9 vs 70.5 years, P = 0.039), more heart failure (72.3% vs 36.9%, P = 0.010), and more strokes (14.4% vs 6.4%, P = 0.010). Neither primary outcome, major bleeding, nor blood transfusion rates differed between treatment groups, but more gastrointestinal bleeding occurred with TT use (2.6% vs 0.5%, P = 0.045). Net clinical benefit was -5.2 (CHADS(2) ≤ 2), 0.9 (CHADS(2) > 2), and -3.2 (overall) per 100 patient-years. CONCLUSIONS: Although we found no association with TT usage and a reduction in cerebrovascular ischemic or major bleeding events in post-PCI patients with AF regardless of CHADS(2) score vs DAPT, the study was likely underpowered to demonstrate a clinically relevant reduction. TT was associated with a 5-fold increase in gastrointestinal bleeding vs DAPT. Net clinical benefit calculations suggest benefits of TT in patients with CHADS(2) > 2. Stratification with CHADS(2) might be useful to determine the optimal antithrombotic therapy post PCI.

Long-term outcomes using a two-stent technique for the treatment of coronary bifurcations.

BACKGROUND: The crush and culotte are probably the most common two-stent techniques utilized for percutaneous coronary intervention (PCI) of complex bifurcation lesions. Long-term outcome associated with the utilization of these techniques is unknown. Our objective was to evaluate the long-term outcomes after bifurcation PCI utilizing these 2 techniques with a prospective PCI registry. METHODS: Between 11/1/2003 and 12/31/2007, 360 patients were treated with either crush (n=304) or culotte (n=56). Primary outcome was the occurrence of major adverse cardiac events (MACE) defined as the composite of death, myocardial infarction and target vessel revascularization. The major secondary outcome measure was MACE or occurrence of CCS Class ≥ 2 angina. RESULTS: After a median follow-up of 4.1 years (3.0-5.1), the occurrence of MACE was 23.9%. MACE or CCS Class ≥ 2 angina occurred in 27.5% of patients. Multivariable analysis revealed that creatinine clearance <60 ml/min (odds-ratio [OR]=1.71, 95% CI 1.08-2.71; p=0.022) and left ventricular ejection fraction <40% (OR=2.14, 95% CI 1.21-3.79; p=0.008) were independent predictors of MACE or CCS Class ≥ 2 angina. A larger main vessel reference diameter (OR=0.57, 95% CI 0.61-0.92), bifurcation angle <50% (OR=0.59, 95% CI 0.35-0.92) and a final kissing-balloon inflation (OR=0.75, 95% CI 0.35-0.99) were associated with a lower risk of MACE or CCS Class ≥ 2 angina. CONCLUSIONS: Application of the crush and culotte techniques is associated with efficacy and safety at long-term follow-up. Bifurcation angle, a final kissing balloon inflation and vessel reference diameter are important variables that impact on very long-term outcomes.

Choice of stent and outcomes after treatment of drug-eluting stent restenosis in highly complex lesions.

OBJECTIVES: Our aim was to compare the outcomes of a same versus different drug-eluting stent (DES) implantation strategy for the treatment of DES instent restenosis (ISR). BACKGROUND: The absence of clear data renders the treatment of DES ISR one of the most challenging situations in interventional cardiology. METHODS: We identified all cases of DES ISR treated with a second DES between January 2004 and January 2009. The lesions were divided into those treated with the same DES as the initial one that restenosed and those treated with a different DES. The main end-point was repeat target lesion revascularization (TLR). RESULTS: We included 116 patients with a total of 132 lesions. The patient population was highly complex: 55.5% with diabetes, 56% with type-C lesions, 15.9% with lesions previously stented with BMS and 18.2% with fluoroscopic evidence of stent fracture. A same and different stent strategy was conducted in 41 lesions (31%) and 91 lesions (69%), respectively. Overall TLR was 31.1% and occurred in 46.3% of patients treated with the same stent and 24.4% of those with a different stent (P = 0.012). Multivariable analysis found same stent strategy (OR 2.84, 95%CI 1.23-6.57;P = 0.014) and occurrence of stent fracture (OR 4.03, 95%CI 1.33-12.01;P = 0.012) to be the only independent predictors of TLR after a median follow-up of 20.4 [12.1-30.2] months. CONCLUSIONS: In highly complex lesions, DES implantation for DES ISR is linked to a high need of future revascularization. An association between implanting a DES type other than the original and lower rate of TLR is suggested.

Long-term outcomes after percutaneous intervention of the internal thoracic artery anastomosis: the use of drug-eluting stents is associated with a higher need of repeat revascularization.

BACKGROUND: There is a lack of data and absence of clear recommendations regarding the optimal treatment of lesions located at the anastomosis of internal thoracic artery (ITA) grafts and native coronary arteries (CAs). The objective of this study was to assess the long-term outcomes of percutaneous coronary intervention (PCI) at the ITA anastomosis according to delivered treatment, namely deployment of a drug-eluting stent (DES), bare-metal stent (BMS), or balloon angioplasty only (POBA). METHODS: We used a prospective PCI registry at a large Canadian teaching hospital to identify all patients who underwent PCI at the ITA-CA anastomosis between June 2000 and June 2010. Our primary end point was repeat target lesion revascularization (TLR) at follow-up. RESULTS: Of the 53 patients included in the study (mean age 67.1 ± 10.7; 84.9% males), 45 (84.9%) underwent a successful PCI procedure. Of these, 23 patients (51.1%) received DES, 18 (40%) BMS, and 4 (8.9%) POBA. After a median follow-up of 29.2 months (interquartile range, 11.1-77.7 months), TLR was 47.8% with DES, 7.1% with BMS, and 50% with POBA (P = 0.032). Patients who underwent repeat revascularization were more likely to have longer stents than those who did not (18.2 mm vs 14.2 mm, P = 0.043). CONCLUSIONS: Deployment of a DES for the treatment of ITA anastomotic lesions appears to be associated with a higher rate of repeat revascularization compared with BMS. Further studies will be necessary to evaluate if the present results might reflect different underlying pathophysiology in anastomotic and native coronary atherosclerotic lesions.

Decreased risk of stent fracture-related restenosis between paclitaxel-eluting stents and sirolimus eluting stents: results of long-term follow-up.

OBJECTIVE: To compare the outcomes between paclitaxel-eluting stents (PES) and sirolimus-eluting stents (SES) for the treatment of drug-eluting stent (DES) fracture. BACKGROUND: DES fracture is considered as an important predictor of in-stent restenosis (ISR). However, little data are available evaluating the optimal treatment for this complication of coronary stenting. METHODS: From January 1, 2004 to December 31, 2008, patients with DES ISR treated with a second DES were identified and evaluated for stent fracture. Stent fracture was defined by the presence of strut separation in multiple angiographic projections, assessed by two independent reviewers. Target lesion revascularization (TLR) at 6 and 12 months were the primary end points. RESULTS: Of 131 lesions with DES ISR treated with a second DES, we found 24 patients (24 lesions, 18.2%) with angiographically confirmed stent fracture. Of these, 20 patients (20 lesions) treated with either PES (n = 11/55%) or SES (n = 9/45%) were included in the study. TLR at 6 months occurred in 9% of patients treated with PES and 22% of those treated with SES (P = 0.41). After 12 months, TLR was 9% and 55.5%, respectively (P = 0.024). CONCLUSIONS: This study demonstrates a high incidence of stent fracture in patients presenting with DES ISR in need of further treatment with another DES. The suggested association between treatment of stent fracture-associated DES ISR with PES as compared with SES, and better long-term outcomes, is in need of confirmation by larger prospective registries and randomized trials.

Stent fracture after everolimus-eluting stent implantation.

Compared with bare-metal stents, drug-eluting stents (DES) have greatly reduced the risk of in-stent restenosis (ISR) by inhibiting neointimal growth. Nevertheless, DES are still prone to device failure, which may lead to cardiac events. Recently, stent fracture (SF) has emerged as a potential mechanism of DES failure that is associated with ISR. Stent fracture is strongly related to stent type, and prior reports suggest that deployment of sirolimus eluting stents (SES) may be associated with a higher risk of SF compared to other DES. Everolimus eluting stents (EESs) represent a new generation of DES with promising results. The occurrence of SF with EES has not been well established. The present paper describes two cases of EES fracture associated with ISR.

Selective use of embolic protection devices during saphenous vein grafts interventions: a single-center experience.

OBJECTIVES: To report on outcomes with selective use of embolic protection devices (EPD) during percutaneous coronary intervention (PCI) to saphenous vein grafts (SVG). BACKGROUND: PCI to SVG is associated with increased risk and the use of EPD is recommended in this setting. METHODS: Angiographic and clinical outcomes were prospectively obtained from 534 consecutive patients who underwent PCI to SVG with or without EPD at a tertiary cardiac centre. Long-term outcomes were obtained by linkage to a provincial registry. RESULTS: EPD, deployed in 198 of 373 SVGs (53%) suitable for deployment of a distal EPD, were used more often in ectatic (33% vs. 19%, P = 0.003), ulcerated (17% vs. 9%, P = 0.03), thrombotic (26% vs. 10%, P < 0.0001) vein grafts, with longer degenerated segments (P = 0.002), and in lesions involving the body of the graft (85% vs. 66%, P < 0.0001), and less with lesions involving the graft ostium (29% vs. 44%, P = 0.003). Patients suitable for but not receiving EPD tended to be more likely to have a periprocedural myocardial infarction. During 3 years of follow-up, 49% of the patients had a cardiovascular event. Cumulative mortality was 8.4%, 18.8% and 14.7% in patients unsuitable for distal EPD, suitable but without EPD, and with EPD (p = 0.11). Nonuse of EPD was an independent predictor of MACE at 3 years. (P = 0.02). CONCLUSIONS: Selective use of EPD is associated with low in-hospital cardiovascular event rates. Long-term outcomes are manifested by a high rate of events, especially in patients with SVG's suitable for but not receiving EPD. This suggests that routine use of distal EPD may be warranted in unselected patients with suitable SVG anatomy.

The adverse long-term impact of renal impairment in patients undergoing percutaneous coronary intervention in the drug-eluting stent era.

BACKGROUND: An observational study determining the long-term impact of chronic kidney disease (CKD) on patients undergoing percutaneous coronary intervention at a tertiary cardiac referral center. CKD is associated with poor in-hospital outcomes after percutaneous coronary intervention, but its effect beyond 1 year, particularly in the drug-eluting stent (DES) era, has not been reported. METHODS AND RESULTS: Baseline creatinine was available for 11,953 patients entered into a prospective registry (April 2000 to September 2007). Patients were stratified: those with or without at least moderate CKD (creatinine clearance, <60 mL/min). Follow-up data were obtained through linkage to a provincial registry. Kaplan-Meier analysis was performed. Cox multiple-regression analysis identified independent predictors of late mortality and major adverse cardiac events (MACE) and examined the association between DES use and late outcomes in the presence or absence of CKD. CKD was present in 3070 patients (25.7%). In-hospital mortality and MACE were significantly increased in CKD (3.34% versus 0.44%, P<0.001 and 5.73% versus 2.2%, P<0.001). Survival and MACE-free survival at 7 years were reduced (64.5+/-1.4% versus 89.4+/-0.5%, P<0.001; 44.0+/-1.4% versus 63.4+/-0.8%, P<0.001). CKD was an independent predictor of late mortality and MACE (hazard ratio [HR]: 2.18, CI: 1.90 to 2.49, P<0.0001; HR: 1.37, CI: 1.25 to 1.49, P<0.0001). DES use was associated with a significant reduction in both (HR: 0.71, CI: 0.60 to 0.83, P<0.0001; HR: 0.70, CI: 0.63 to 0.78, P<0.0001). In patients with CKD, DES use was associated with reduced revascularization (HR: 0.68, CI: 0.53 to 0.88, P=0.004) and reduced MACE (HR: 0.81, CI: 0.69 to 0.95, P=0.011) but not reduced mortality (HR: 0.85, CI: 0.69 to 1.05, P=0.1). CONCLUSIONS: In a large registry of "all comers" for percutaneous coronary intervention, CKD was an independent predictor of adverse late outcomes. DES use may be associated with improved long-term outcomes in this high-risk cohort, but further prospective studies are required.

Mental-stress-induced platelet activation among patients with coronary artery disease.

OBJECTIVE: To study patients with coronary artery disease (CAD) scheduled for coronary angioplasty and to examine platelet activation in response to mental stress as a potential mechanism involved in the association between psychosocial factors and cardiac outcomes. Psychosocial factors have been identified as risk factors for CAD and adverse cardiac outcomes, although the underlying mechanisms are poorly understood. METHODS: Markers of platelet activation and platelet reactivity in response to experimentally induced mental stress (mental arithmetic and anger recall) were examined, using flow cytometry analysis and beta-thromboglobulin (BTG) assays among 249 CAD patients (age = 60.3 +/- 9.0 years, 15% women) who were scheduled to undergo elective percutaneous coronary intervention. RESULTS: Mental stress-induced increases in platelet activation (CD41 (GP IIb/IIIa), p = .002; percent of mononuclear cells positive for CD41, p = .01; CD62P (P-selectin) expression, p = .005; and percent platelets positive for CD62P, p < .001). The degree of platelet reactivity was not related to demographic, clinical, or psychological variables, or cardiovascular hemodynamic changes. CONCLUSIONS: Experimentally induced mental stress induced platelet activation in patients with CAD. This mechanism may partially explain the link between psychosocial variables and the development of adverse cardiac outcomes in patients with CAD.

The Toronto score for in-hospital mortality after percutaneous coronary interventions.

BACKGROUND: Benchmarking the performance of providers is an increasing priority in many health care economies. In-hospital mortality represents an important and uniformly assessed measure on which to examine the outcome of percutaneous coronary intervention (PCI). Most existing prediction models of in-hospital mortality after PCI were derived from 1990s data, and their current relevance is uncertain. METHODS: From consecutive PCIs performed during 2000-2008, derivation and validation cohorts of 10,694 and 5,347 patients, respectively, were analyzed. Logistic regression for in-hospital death yielded integer risk weights for each independent predictor variable. These were summed for each patient to create the Toronto PCI risk score. RESULTS: Death occurred in 1.3% of patients. Independent predictors with associated risk weights in parentheses were as follows: age 40 to 49 y (1), 50 to 59 y (2), 60 to 69 y (3), 70 to 79 y (4), and > or =80 y (5); diabetes (2); renal insufficiency (2); New York Heart Association class 4 (3); left ventricular ejection fraction <20% (3); myocardial infarction in the previous month (3); multivessel disease (1); left main disease (2); rescue or facilitated PCI (3); primary PCI (4); and shock (6). The model had a receiver operator curve of 0.96 and Hosmer-Lemeshow goodness-of-fit P = .16 in the validation set. Four previously published external models were tested in the entire data set. Three models had ROC curves significantly less than the Toronto PCI score, and all 4 showed significant levels of imprecision. CONCLUSIONS: The Toronto PCI mortality score is an accurate and contemporary predictive tool that permits evaluation of risk-stratified outcomes and aids counseling of patients undergoing PCI.

Decreased complication rates using the transradial compared to the transfemoral approach in percutaneous coronary intervention in the era of routine stenting and glycoprotein platelet IIb/IIIa inhibitor use: a large single-center experience.

BACKGROUND: Studies evaluating the efficacy and safety of the transradial approach for percutaneous coronary intervention (PCI) were carried out mainly before the widespread use of stents and glycoprotein (GP) IIb/IIIa inhibitors. We sought to determine the association between the choice of the vascular access site and procedural complications after PCI performed with routine stenting and GP IIb/IIIa inhibition. METHODS: The data source was a prospective registry of 13,499 consecutive cases of PCI at the University Health Network, Toronto, Canada, from April 2000 to September 2006. Logistic regression was used to calculate the probability of selection to the radial access group. Using propensity score methodology, 3,198 patients with femoral access were randomly matched to 3,198 patients with radial access based on clinical, angiographic, and procedural characteristics. Multivariable logistic regression analysis was used to identify the independent predictors of access site-related complications. Major adverse cardiac event was defined as death, myocardial infarction, abrupt vessel closure, or coronary artery bypass surgery. RESULTS: Use of the transradial approach was associated with fewer vascular access complications (1.5% vs 0.6%, P<.001) and a shorter length of hospital stay. Multivariable analysis revealed transradial access (OR 0.39, 95% CI 0.2-0.7) to be an independent predictor of lower risk, whereas primary PCI (OR 4.36, 95% CI 1.4, 13), recent myocardial infarction (OR 2.0 95% CI 1.2, 3.4), age (per 10 years increase: OR 1.37, 95% CI 1.1-1.7) and female gender (0R 2.78 95% CI 1.7, 4.6) were independent predictors of a higher risk of access site complications. CONCLUSIONS: Use of transradial access for PCI is safe and is independently associated with a reduced rate of in-hospital access site complications and reduced length of hospital stay.

Long-term outcomes after percutaneous coronary intervention of bifurcation narrowings.

The optimal approach to percutaneous coronary intervention (PCI) of bifurcation lesions remains unclear, reflecting lack of long-term follow-up and heterogeneity of lesions encountered. We evaluated the long-term outcome of patients undergoing bifurcation PCI followed in the prospective bifurcation registry at the University Health Network, Toronto, Ontario, Canada. Of 526 patients undergoing bifurcation PCI between November 2003 and March 2005, most (n = 406) were treated by main vessel stenting only (n = 266) or crush/culotte stenting (n = 140). After median follow-up of 26.5 months, major adverse cardiac events (MACEs) and Canadian Cardiovascular Society class > or =2 angina occurred in 28.5% and 22.3% of patients in these groups, respectively (p = 0.190), whereas MACE rates were 20.8% for main vessel stenting and 18.7% for crush/culotte stenting (p = 0.670). A low bifurcation angle was associated with better outcomes in the crush/culotte group but had no effect on outcome of patients treated with main vessel stenting only. Use of crush/culotte techniques independently predicted freedom from MACEs or Canadian Cardiovascular Society class > or =2 angina compared with main vessel stenting only (odds ratio 0.55, 95% confidence interval 0.32 to 0.94, p = 0.029). In conclusion, the use of crush/culotte stenting is safe, with efficacy and MACE rates being similar to main vessel stenting alone. Our observations regarding the effect of lesion characteristics such as bifurcation angle and extent of side branch disease on outcome underscore the need for randomized trials that are inclusive of patients with complex side branch disease.

Thrombocytopenia at baseline is a predictor of inhospital mortality in patients undergoing percutaneous coronary intervention.

BACKGROUND: Thrombocytopenia (TP) is a common baseline abnormality in patients undergoing percutaneous coronary intervention (PCI). Whether TP has any influence on the outcome of PCI patients is unknown. Our aim was to determine if TP at baseline impacts on inhospital mortality in patients undergoing PCI at our institution. METHODS: From April 2000 until October 2005, 11,021 PCI procedures were performed at the University Health Network in Toronto, Canada. Baseline platelet count was recorded in 10,821 (98.2%) cases. Patients with platelets <150 x 10(9)/L were assigned to the TP group (n = 639), and those with > or =150 x 10(9)/L to the normal platelet group (n = 10,182). Clinical, angiographic, procedural, and inhospital outcome data were collected prospectively. Multivariable analysis was performed using logistic regression. RESULTS: In-hospital death rate was higher in the TP group (1.9% vs 0.6%, P < .001) due to an increased mortality in TP patients undergoing urgent (3.55% vs 1.15%, P < .001) but not elective (0% vs 0.04%, P = 1.0) PCI. Major bleeding (1.7% vs 0.8%, P < .05) and gastrointestinal bleeding (1.1% vs 0.5%, P < .05) complications were greater in the TP group. Multivariate analysis demonstrated that baseline TP was an independent predictor of inhospital mortality (odds ratio 2.07 [1.1-4.1], P = .035). CONCLUSIONS: Baseline TP is an independent predictor of inhospital mortality in patients undergoing PCI for urgent indications. Thrombocytopenia should be considered an important addition to PCI risk prediction models to improve their precision and clinical applicability.

Impact of renal insufficiency on angiographic, procedural, and in-hospital outcomes following percutaneous coronary intervention.

Patients with chronic renal insufficiency (RI) have higher in-hospital mortality and major adverse cardiac event (MACE) rates after percutaneous coronary intervention (PCI). The mechanisms of this adverse course are not well understood. It was hypothesized that this worse outcome may be caused by inadequate PCI results secondary to more complex coronary anatomy in patients with RI. Baseline, procedural, and outcome variables of all PCI cases at the University Health Network are entered prospectively in the PCI Registry. All PCI cases between April 1, 2000, and October 31, 2005, excluding patients in shock, who had preprocedural creatinine clearance (CrCl) measured were included in this study (n = 10,821 of 11,023 patients). Moderate RI (CrCl <60 ml/min) was evaluated as an independent predictor of procedural outcomes, death, and MACE (defined as death, myocardial infarction, abrupt closure, or coronary artery bypass grafting). Moderate RI (CrCl <60 ml/min) independently predicted the procedural outcomes of worse residual stenosis >20% (p = 0.03), number of undeliverable stents (p = 0.003), and smallest stent diameter (p <0.001). Worst residual stenosis >20% and any undeliverable stent were significantly associated with in-hospital MACEs (odds ratio [OR] 3.97, 95% confidence interval [CI] 3.0 to 5.3, p <0.001 and OR 1.89, 95% CI 1.2 to 2.9, p = 0.002) and mortality (OR 3.82, 95% CI 2.2 to 6.7, p <0.001 and OR 3.0, 95% CI 1.6 to 5.9, p = 0.002). These risks were independent of all other measured variables. In conclusion, moderate to severe RI was a strong predictor of worse procedural results during PCI, which, in turn, were independent predictors of in-hospital MACE and mortality and independent contributors to the higher risk of in-hospital adverse events observed after PCI in patients with RI.