Use of the retrograde approach for primary percutaneous coronary intervention of an inferior ST-segment elevation myocardial infarction.

Percutaneous coronary intervention (PCI) during ST-segment elevation myocardial infarction (STEMI) can be challenging due to limited distal vessel visualization. We present a case of challenging antegrade wiring during PCI of an inferior STEMI resulting in inadvertent subintimal wiring and ballooning. Recognition of this scenario prior to stenting allowed vessel rescue using the retrograde chronic total occlusion revascularization technique.

Embolic capture angioplasty in peripheral artery interventions.

PURPOSE: To report a single-center experience with the Proteus embolic capture angioplasty balloon catheter for the treatment of symptomatic lower extremity peripheral artery disease. METHODS: Between June 2010 and January 2012, 36 lower extremity lesions were treated in 30 patients (29 men; mean age 65±9 years) with symptomatic peripheral artery disease. Nearly half of the patients had diabetes mellitus. The mean lesion length was 140 mm, and three quarters of the lesions were considered complex owing to severe calcification, chronic total occlusion (≥3 months), in-stent stenosis, and/or length >150 mm. The volume of debris retrieved in the balloon was estimated from the number and size of particles, and a debris score was assigned and classified as low (≤2), moderate (2-4), or high (>4). RESULTS: Immediate procedural success was 86%, and no in-hospital serious adverse events (e.g., death, amputation, or surgical intervention) were reported. Embolic debris was captured in 32 (89%) of 36 cases. Debris scores for totally occluded, long, and in-stent stenotic lesions were 4.8±3.3, 4.6±3.0, and 3.8±2.5, respectively. Angiographic distal embolizations were reported in 2 (5.5%) procedures. CONCLUSION: Embolic capture angioplasty with the Proteus angioplasty balloon catheter during peripheral artery interventions is technically feasible and captures debris in a large proportion of the cases.

Pilot trial of cryoplasty or conventional balloon post-dilation of nitinol stents for revascularization of peripheral arterial segments: the COBRA trial.

OBJECTIVES: The purpose of this study is to compare post-dilation strategies of nitinol self-expanding stents implanted in the superficial femoral artery of diabetic patients with peripheral arterial disease. BACKGROUND: Endovascular treatment of superficial femoral artery disease with nitinol self-expanding stents is associated with high rates of in-stent restenosis in patients with diabetes mellitus. METHODS: We conducted a prospective, multicenter, randomized, controlled clinical trial of diabetic patients to investigate whether post-dilation of superficial femoral artery nitinol self-expanding stents using a cryoplasty balloon reduces restenosis compared to a conventional balloon. Inclusion criteria included diabetes mellitus, symptomatic peripheral arterial disease, and superficial femoral artery lesions requiring implantation of stents>5 mm in diameter and >60 mm in length. Primary endpoint was binary restenosis at 12 months, defined as ≥2.5-fold increase in peak systolic velocity by duplex ultrasonography. RESULTS: Seventy-four patients, with 90 stented superficial femoral artery lesions, were randomly assigned to post-dilation using cryoplasty (n=45 lesions) or conventional balloons (n=45 lesions). Mean lesion length was 148±98 mm, mean stented length was 190±116 mm, mean stent diameter was 6.1±0.4 mm, and 50% of the lesions were total occlusions. Post-dilation balloon diameters were 5.23±0.51 mm versus 5.51±0.72 mm in the cryoplasty and conventional balloon angioplasty groups, respectively (p=0.02). At 12 months, binary restenosis was significantly lower in the cryoplasty group (29.3% vs. 55.8%, p=0.01; odds ratio: 0.36, 95% confidence interval: 0.15 to 0.89). CONCLUSIONS: Among diabetic patients undergoing implantation of nitinol self-expanding stents in the superficial femoral artery, post-dilation with cryoplasty balloon reduced binary restenosis compared to conventional balloon angioplasty. (Study Comparing Two Methods of Expanding Stents Placed in Legs of Diabetics With Peripheral Vascular Disease [COBRA]; NCT00827853).

Use of embolic capture angioplasty for the treatment of occluded superficial femoral artery segments.

Treatment of peripheral chronic total occlusion (CTO) is one of the most challenging lesion subsets in peripheral revascularization. Advanced wire technology, novel re-entry catheters and imaging techniques help in crossing such lesions. Subintimal dissection using blunt microdissection devices along with true lumen reentry techniques have added to the success rates of treating peripheral CTOs. After crossing the occlusion, balloon angioplasty and the placement of self-expanding nitinol stents are usually performed. Peripheral embolization is a known complication of peripheral artery interventions, leading to significant lower-extremity ischemia and complications. Such interventions of peripheral CTOs have been shown to have higher rates of distal embolization. Though no dedicated distal embolic protection strategies are currently available for lower-extremity interventions, use of debris capture angioplasty balloon (Proteus™) may be a feasible alternative. We report 3 cases where this device has been used during recanalization of peripheral CTOs.

Embolic capture angioplasty of lower extremity lesion following distal embolization.

Peripheral embolization is a known complication of peripheral artery interventions. It can lead to occlusion of distal vessels leading to significant lower extremity ischemia and complications. Peripheral artery interventions involving chronic total occlusions have been shown to have higher rates of complications including distal embolization. Although distal embolic protection strategies are available, they are seldom utilized during lower extremity interventions, especially during treatment of totally occluded vessels. Proteus embolic capture angioplasty balloon may provide operators with the option of balloon dilation of stenotic lesion in the peripheral arterial bed, along with embolic capture. We report a case where use of this novel device helped in achieving a successful angioplasty outcome along with evacuation of distal embolus and restoration of antegrade flow.

Clinical outcomes following predilation with a novel 1.25-mm diameter angioplasty catheter.

OBJECTIVE: An unmet need is represented in angioplasty catheters that permit the predilation stage of treating complex coronary anatomy oftentimes not amenable to conventional device therapies. BACKGROUND: Lesion preparation with balloon angioplasty prior to stent placement remains the most common method of percutaneous coronary revascularization. METHODS: Clinical and angiographic outcomes were evaluated following a treatment strategy of coronary artery disease that included predilation with a low-profile, 1.25-mm angioplasty catheter prior to stent placement. The study primary end point of procedural success was defined as successful device delivery and lesion treatment, including the absence of clinically significant perforation, arrhythmia, flow-limiting dissection, or reduction in baseline Thrombolysis In Myocardial Infarction (TIMI) grade with final achievement of TIMI 3 flow. RESULTS: Among 51 patients (54 lesions), predilation using a 1.25 mm angioplasty catheter was associated with procedural and device-related success rates of 100%. In-hospital target lesion failure occurred in one patient (2.0%) related to postprocedural myocardial infarction. Patient and angiographic characteristics included diabetes, 43.1%; lesion length ≥ 20 mm, 20.4%; bifurcation lesion, 31.5%; lesion classification B2/C, 74.1%; and baseline TIMI 0/1 flow, 13.0%. No subsequent in-hospital adverse events occurred. CONCLUSIONS: Percutaneous coronary revascularization involving a predilation strategy with a low profile, 1.25-mm angioplasty catheter is associated with favorable procedural safety and efficacy and may represent an effective initial treatment for complex coronary anatomy.

Cardiac resynchronization therapy in patients with chronic atrial fibrillation.

Heart failure (HF) and atrial fibrillation (AF), 2 of the most common cardiovascular disorders, often coexist in the same patient, as 1 condition can lead to the other. The best approach to AF management in patients with HF is currently under investigation, but there seems to be an abundance of evidence in support of cardiac resynchronization therapy (CRT) in this group of patients. In addition, CRT is emerging as a superior option to stand-alone right ventricular pacing in patients with structural heart disease. However, in patients with AF, an adequate rate control is critical for this therapy to be highly effective. As control of the ventricular response can be difficult to achieve in many of those patients, often a nonpharmacologic intervention is required, such as ablation of the atrioventricular node to create heart block. The definitive role for CRT with or without atrioventricular nodal ablation in patients with AF and HF is yet to be studied in large, well-designed, randomized, controlled clinical trials.

Risk of noncardiac surgery after coronary drug-eluting stent implantation.

We examined the records of 38 patients who underwent 41 major and 18 minor noncardiac surgeries after successful drug-eluting stent (DES) implantation (57% sirolimus-eluting stents and 43% paclitaxel-eluting stents) at the Dallas Veterans Affairs Medical Center from April 2003 to January 2006. The mean patient age was 62 +/- 9 years, and all patients were men. A total of 41 major noncardiac surgeries (34% abdominal, 22% vascular, 17% genitourinary, and 27% other) were performed in 28 patients a median of 260 days after DES implantation. Also, 18 minor noncardiac surgeries (44% skin surgery, 44% injections, and 12% other) were performed in 10 patients a median of 297 days after DES implantation. No major adverse cardiac events or death occurred during or after the 41 major (0%, 95% confidence interval 0% to 9%) and 18 minor noncardiac (0%, 95% confidence interval 0% to 19%) surgeries. In conclusion, although our data were limited by the small sample size, they suggest a low risk of major cardiac complications in patients undergoing noncardiac surgery after coronary DES implantation.