Consequences and Management of Excessive Ostial Stent Protrusion: A Case Report.

Aorto-ostial lesions, especially in the right coronary artery, may be challenging due to their morphological and anatomical features, more so when there is a previous stent which may be protruding. Little is known about the long-term safety of protruding stents and results of re-intervention. Presented here is a case of restenosis of a markedly protruding stent at the right coronary ostium. This case was unusual in its 10-year longevity. Intravascular ultrasound-guided in-stent restenosis intervention using wire bumper technique was performed. Literature review and management are presented.

Comparison between a dedicated stent positioning system and conventional stenting of aorto-ostial lesions: a prospective, multi-center, randomized controlled study.

Background: The accurate placement of stents for treatment of coronary aorto-ostial lesions (AOLs) is technically challenging. The purpose of this study was to evaluate the efficacy and safety of a stent positioning system with a dedicated nitinol device and compare them with those of the conventional approach for stenting of coronary AOLs. Methods: In this prospective, multi-center, open-label, randomized study, conducted from November 2015 to April 2019, patients with coronary AOLs that underwent percutaneous coronary intervention (PCI) were randomly allocated (allocation ratio 1:1) using block randomization method to either a stent positioning system group or a conventional technique group. The primary endpoint was the range of stent slippage when positioning. The following secondary endpoints were applied: (I) the extent of swing of the guiding catheters during stent positioning; (II) the rate of accurate stent placement; (III) the procedure time; and (IV) the incidence of major adverse cardiovascular events (MACEs) including cardiac death, myocardial infarction, target lesion revascularization, and stent thrombosis. Results: During the study period, 139 patients with aorto-ostial coronary artery stenosis were included at 5 centers. A total of 69 patients were allocated to the stent positioning system group and 70 patients to the conventional technique group. Angiographic and clinical success were achieved in 100% of the patients included in both groups. The range of stent slippage was significantly shorter in the stent positioning system group than it was in the conventional technique group [0.64 (0.22; 1.35) vs. 1.11 (0.48; 1.72) mm, P=0.01]. The rate of accurate placement of stents was higher in the stent positioning system group than it was in the conventional technique group (74.6% vs. 57.1%, P=0.03). The extent of guiding catheter swing during the stent positioning [0.24 (0.19; 0.53) vs. 0.23 (0.19; 0.53) mm; P=0.95] and the MACEs rates (1.4% vs. 2.9%, P>0.99) were similar between the 2 groups. The procedural time of the stent positioning system was longer than that of the conventional approach [1.00 (0.50; 1.50) vs. 0.80 (0.50; 1.50) min, P=0.09]. Conclusions: The dedicated stent positioning system was is safer and provides more accurate placement of stents for coronary AOLs than the conventional approach, and the associated prolongation of procedure time is insignificant. Trial Registration: Chinese Clinical Trial Registry (ChiCTR), Unique identifier: ChiCTR2100053869. URL: https://www.chictr.org.cn/showproj.html?proj=133280.

Treatment of Ostial Right Coronary Artery Narrowings: Outcomes From the Multicenter Prospective e-ULTIMASTER Registry.

Background: Treatment of right coronary artery (RCA) aorto-ostial (AO) lesions with bare-metal stents and first-generation drug-eluting stents (DES) was associated with worse outcomes. This study aimed to assess the effect of RCA-AO stenting with current-generation DES on the clinical outcome. Methods: The large all-comer, multicontinental e-ULTIMASTER registry included 37,198 patients of whom 4775 underwent ostial and proximal RCA percutaneous coronary intervention (PCI) using the Ultimaster stent (Terumo). The primary clinical end point was 1-year target lesion failure (TLF), a composite of cardiac death; target vessel-related myocardial infarction; or clinically indicated target lesion revascularization. Results: We compared 591 (12.4%) patients who underwent RCA-AO PCI with 4184 (87.6%) patients who underwent proximal RCA PCI. The RCA-AO group included more men and recorded significantly more comorbidities and more complex coronary anatomy. After propensity matching, the primary end point TLF occurred in 4.49% of the RCA-AO group compared with 3.00% of the proximal RCA group (P = .06). Target vessel revascularization (3.29% vs 1.90%; P = .03) and stent thrombosis (1.23% vs 0.42%, P = .01) were significantly higher among patients with RCA-AO lesions than those among patients with proximal RCA lesions. All-cause mortality was similar between the groups (2.97% vs 2.26%; P = .30). Conclusions: The treatment of RCA-AO with DES is feasible, with similar rates of TLF but with an increased risk of target vessel revascularization and stent thrombosis.

Coronary ostial angioplasty for juvenile Takayasu arteritis involving the coronary artery using external iliac artery grafts.

Takayasu arteritis can affect the coronary ostia, leading to myocardial ischemia. Coronary ostial angioplasty effectively treats coronary artery ostial lesions associated with Takayasu arteritis. We present a case of juvenile Takayasu arteritis with bilateral subclavian artery occlusions treated with a novel coronary artery ostial angioplasty using the external iliac artery.

Accurate Stent Placement in Challenging Percutaneous Coronary Interventions Using the Stent Positioning Assist System.

OBJECTIVE: To evaluate safety and accuracy of stent placement by Stent Positioning Assistance System (SPAS), an innovative device that allows for mm-precise manipulation and placement of stents in percutaneous coronary interventions (PCI). BACKGROUND: In PCI, controlled stent manipulation and precise stent placement remain compromised despite developments in stents and imaging. METHODS: Sixty-seven patients with various lesion types that required precise stenting were included in this study. All patients were treated with the support of SPAS. Safety was evaluated by looking at procedural success, occurrence of intraprocedural complications and incidence of (device related) adverse events. In subsets of procedures, usability feedback was collected and stent positioning accuracy was assessed with intravascular imaging. RESULTS: In 67 patients, 84 stents were implanted by 5 operators. Intravascular Ultrasound (IVUS, n = 6) and Optical Coherence Tomography (OCT, n = 15) was used to assess stent position after placement. Using SPAS, procedural success was achieved in all 67 (100%) cases. There were no intraprocedural complications nor any adverse events. In most procedures, SPAS provided significant support to the operator and the positive procedure impact was rated as major. OCT results showed accurate stent placement with a positioning error of <1 mm (n = 11), 1-2 mm (n = 2) and 3 mm (n = 1) relative to predefined targets; generally the ostium of a side branch or of the coronary artery, and a stent overlap of 1-3 mm in 5 stent-to-stent situations. CONCLUSION: SPAS is safe and allows for enhanced control and accurate stent placement in different types of PCI procedures without impairing procedural workflow.

Ostial lesion of the anterior descending coronary artery treated via Szabo technique supported by stent boost imaging: a case report.

BACKGROUND: Stenosis at the opening and bifurcation of the anterior descending branch and circumflex branch around the end of the left main trunk is difficult to repair. Accurate positioning of a stent is the key problem. CASE PRESENTATIONS: Here we report the case of a 61-year-old man who suffered from paroxysmal chest pain for 1 year, without history of diabetes or hypertension. The coronary computed tomography showed mixed plaques in the proximal part of the anterior descending artery, with stenosis severe at 80-90%. The emergency coronary angiography showed occlusion of the anterior descending artery. During percutaneous coronary intervention, a drug-eluting stent was implanted into the anterior descending artery using the Szabo technique, supported by stent boost (StentBoost) imaging to pinpoint the location of the lesion. The patient's paroxysmal chest pain was relieved after the procedure. CONCLUSION: We used StentBoost to verify the accuracy of stent placement and the Szabo technique to rectify long-term coronary stenosis, which achieved satisfactory results. Combining the Szabo technique with StentBoost imaging was helpful to accurately evaluate the area and locate the stent when treating this ostial lesion of the anterior descending coronary artery.

Determination of optimal fluoroscopic angulations for aorto-coronary ostial interventions from coronary computed tomography angiography.

BACKGROUND: An optimal aorto-coronary angiographic projection, characterized by an orthogonal visualization of the proximal coronary artery, is crucial for interventional success. We determined the distribution of optimal C-arm positions and assessed their feasibility by invasive coronary angiography. METHODS: Orthogonal aorto-coronary ostial angulations were determined in 310 CT data sets. In 100 patients undergoing subsequent invasive angiography, we assessed if the CT-predicted angulations were achievable by the C-arm system. If the predicted projection was not achievable due to mechanical constraints of the C-arm system, the most close, achievable angulation was determined. Patient characteristics were analyzed regarding the distribution of optimal angulations and its feasibility by the C-arm system. RESULTS: For the left ostium, CT revealed a mean angulation of LAO 23 â€‹± â€‹21°/cranial 25 â€‹± â€‹23° (90% of patients with a LAO/cranial angulation, 3% LAO/caudal, 4% RAO/cranial, 3% RAO/caudal) and were achievable by the C-arm system in 87% of patients. For the right ostium, the mean CT-predicted orthogonal angulation was LAO 36 â€‹± â€‹37°/cranial 36 â€‹± â€‹51° (84% LAO/cranial, 2% LAO/caudal, 14% RAO/caudal) and achievable by the C-arm system in 45% of patients. For the left ostium, a higher body weight was associated with a steeper LAO/cranial angulation being less feasible by the C-arm system due to mechanical constraints. CONCLUSIONS: Orthogonal aorto-left coronary angulations show a relative narrow distribution predominately in LAO/cranial position whereas a wider range of angulations was found for the right coronary ostium. The feasibility of CT-predicted angulations by the C-arm system is more restricted for the right than the left coronary ostium.

Comparison of Clinical Characteristics of Stent Thrombosis Between the Right Coronary Artery and the Left Coronary Artery　- A Subanalysis of the REAL-ST Registry.

BACKGROUND: Stent thrombosis (ST) remains a severe complication following stent implantation. We previously reported the risk factors for ST after 2nd-generation drug-eluting stent (DES) in the REAL-ST (Retrospective Multicenter Registry of ST After First- and Second-Generation DES Implantation) registry.Methods and Results:In this subanalysis, we aimed to reveal the difference in ST between right coronary (RCA) and left (LCA) coronary arteries. A total of 307 patients with ST were divided into the RCA-ST group (n=93) and the LCA-ST group (n=214). Multivariate analysis revealed younger age (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.93-0.99, P=0.01), ostial lesion at the time of index percutaneous coronary intervention (OR 4.37, 95% CI 1.43-13.33, P=0.01), bifurcation lesion at the time of index PCI (OR 0.05, 95% CI 0.02-0.12, P<0.01), chronic total occlusion (CTO) lesion at the time of index PCI indication (OR 4.19, 95% CI 1.05-16.71, P=0.04), and use of prasugrel at the time of ST (OR 7.30, 95% CI 1.44-36.97, P=0.02) were significantly associated with RCA-ST. CONCLUSIONS: Younger age, ostial or CTO lesion, and use of prasugrel at the time of ST were prominent factors in RCA-ST, whereas bifurcation lesion was associated with LCA-ST. We should pay attention to the differences between RCA-ST and LCA-ST to prevent ST.

In-Hospital Outcomes After Recanalization of Ostial Chronic Total Occlusions.

BACKGROUND: Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) still remains a major challenge in interventional cardiology. Recanalization of ostial lesions is challenging and complex. This present study aims to evaluate the outcome of patients with ostial and non-ostial CTO-PCI with regard to acute, in-hospital outcome. METHODS: Between 2012 and 2018 we included 600 patients. Ostial lesions (OL) were defined as a coronary arterial stenosis within 3 mm of the vessel origin. Antegrade and retrograde CTO-PCI techniques were used and a composite safety endpoint comprising in-hospital death, vascular complications, cardiac tamponade, stroke and acute myocardial infarction. RESULTS: The majority of the patients were male (82.3%) and the mean age was 62.1 years (±10.3 years). The right coronary artery (RCA) was the most frequent target vessel in 58.5%, followed by the left circumflex artery (LCX) (15.4%) and the left anterior descending artery (LAD) (26.2%). The success (p = .439) and complication rates (p = .169) were independent of the target vessel. We determined that examination and fluoroscopy time were longer in patients with OL (120.7 min vs. 99.0 min, p < .001 and 44.9 min vs. 34.5 min, p < .001) and that in this group of patients the retrograde approach was used more frequent (38.8% vs. 18.2%, p < .001). Overall success rates were lower in OL than compared to NOL (74.6% vs. 86.5%, p = .016). CONCLUSIONS: Our retrospective study suggests that recanalization of ostial CTO lesions is associated with reduced PCI success rates as well as long examination and high fluoroscopy times.

Clinical impact of the gap-angle ratio in patients with ostial lesions of the right coronary artery undergoing percutaneous coronary intervention.

The aim of this study was to investigate the incidence of binary restenosis and its predictors in patients with ostial lesions of the right coronary artery (RCAos) who underwent percutaneous coronary intervention (PCI). RCAos are associated with a high incidence of restenosis, and the implantations of drug-eluting stents for RCAos have not been fully elucidated. The study participants included 75 patients (72.3 ± 9.5 years, 72% men) who underwent PCI for RCAos at our institution between November 2001 and May 2017. The angle between the greater curvature of the aortic wall and the right coronary artery take-off in the diastolic and systolic phases in the left anterior oblique position view was investigated. Clinical outcome was defined as binary restenosis at follow-up coronary angiography. We also evaluated target lesion failure (TLF) defined as a composite of cardiac mortality, target vessel myocardial infarction, and target lesion revascularization (TLR). The incidence of binary restenosis was 48.0% (n = 36) of the entire cohort. The incidence of TLF was 49.3% (n = 37) of the entire cohort, which was mainly driven by TLR (36.0%, n = 27). The area under the curve of the gap-angle ratio [(difference between the maximum and minimum angles)/(minimum angle); GAR] for binary restenosis was 0.73, and the cutoff value was 0.306 (sensitivity 67%, specificity 82%). The patients were divided into two groups: a low-GAR (< 0.306; n = 30) and high-GAR group (> 0.306; n = 45). Binary restenosis was more frequent in the high-GAR group than in the low-GAR group (76.7% vs. 28.9%, p = 0.007). The cumulative rate of TLF was significantly higher in the high-GAR group when compared with the low-GAR group (53.3% vs. 40.0%, p = 0.01), which was mainly driven by TLR (56.7% vs. 22.2%, p = 0.01). High-GAR (> 0.306) [OR 2.66 (1.34-5.31), p = 0.005] and stent under expansion [OR 2.37 (1.10-5.11), p = 0.03] were found to be independent predictors of binary restenosis after adjustment for multiple confounders. Multivariable analysis also revealed that high-GAR (> 0.306) [OR 2.06 (1.02-4.14), p = 0.03] and stent under expansion [OR 2.82 (1.28-6.19), p = 0.01] were independent predictors of TLF. We suggest that GAR (> 0.306) predicts binary restenosis and TLF in patients undergoing PCI for RCAos.

Potent Stent-Less Procedure Using Rotational Atherectomy and Drug-Coated Balloon to Right Coronary Ostial Lesion.

BACKGROUND: Even in the drug-eluting stent era, ostial lesion of the right coronary artery (RCA) still remains therapeutic challenge for interventional cardiologists. Case Series Case 1 (76 y.o. male) with angina on effort underwent transradial stent-less percutaneous coronary intervention (PCI) using rotational atherectomy (RA) followed by drug-coated balloon (DCB) dilation alone (RA/DCB) against a calcified de novo RCA ostial lesion. Case 2 (86 y.o. female) with recurrent unstable angina and hemodialysis underwent transfemoral RA/DCB against a severe repeat in-stent restenosis probably due to calcified nodule in the RCA ostium. In the both patients, PCI was successfully completed under intravascular ultrasound imaging (IVUS) guidance without complications. Follow-up CAG performed 4-5 months after the procedure revealed no significant lumen narrowing in the both RCA ostial lesions. CONCLUSIONS: The both cases suggest that stent-less PCI using RA/DCB under IVUS might be an alternative revascularization therapy of choice for calcified RCA ostial lesions.

Comparison of mid-term clinical outcomes after treatment of ostial right coronary artery lesions with early and new generation drug-eluting stents: Insights from an international multicenter registry.

BACKGROUND: There are only a limited number of studies comparing clinical outcomes after treatment of right coronary artery (RCA) aorto-ostial (AO) lesions with early (E-) and new (N-) generation drug-eluting stents (DES). METHODS: From January 2005 to December 2013, 334 de novo RCA AO lesions treated with DES (E-:142 lesions, N-:192 lesions) at 2 high-volume centers (Italy and Japan) were included in this study. The primary endpoint was target lesion failure (TLF) defined as composite of cardiac mortality, target vessel myocardial infarction, and target lesion revascularization (TLR). RESULTS: Baseline and lesion characteristics were well balanced between the 2 groups. The size of the stents deployed (3.35±0.37mm vs 3.39±0.33mm, p=0.29) and non-compliant balloons used for post-dilatation (3.55±0.38mm vs 3.62±0.47mm, p=0.21) were similar between the two groups. The median follow-up period was 1432 (IQR: 703-2197) days in total population. The cumulative rate of TLF at 3years was significantly higher in E-DES group when compared with N-DES group (37.7% vs 14.2%, p<0.001), which was mainly driven by TLR (38.0% vs 11.0%, p<0.001). Multivariable analysis revealed that N-DES [HR 0.22 (0.13-0.38), p<0.001], stent underexpansion [HR 10.59 (6.23-17.97), p<0.001], excessive aortic stent protrusion [HR 3.12 (1.87-5.23), p<0.001], and proximal stent overlap [HR 1.74 (1.03-2.95), p=0.03] were independent predictors of TLF. CONCLUSION: For the treatment of RCA AO lesions, N-DES were associated with a lower incidence of TLF at 3years when compared with E-DES. N-DES use and suboptimal implantation characteristics were independent predictors of TLF.

Precise Retrograde Supera Stenting of the Ostium (PRESTO) of the Superficial Femoral Artery for Complex Femoropopliteal Occlusions: The PRESTO Technique.

PURPOSE: To describe a novel technique designed to safely and precisely deploy the Supera stent accurately at the ostium of the proximal superficial femoral artery (SFA) without compromising the profunda and common femoral arteries. TECHNIQUE: After antegrade crossing of the chronic total occlusion (CTO) at the SFA ostium and accurate predilation of the entire SFA lesion, a retrograde arterial access is obtained. The Supera stent is navigated in retrograde fashion to position the first crown to be released just at the SFA ostium. Antegrade dilation is performed across the retrograde access site to obtain adequate hemostasis. The technique has been applied successfully in 21 patients (mean age 78.1±8.2 years; 13 men) with critical limb ischemia using retrograde Supera stenting from the proximal anterior tibial artery (n=6), the posterior tibial artery (n=2), retrograde stent puncture in the mid to distal SFA (n=2), the native distal SFA/proximal popliteal segment (n=6), and the distal anterior tibial artery (n=5). No complications were observed. CONCLUSION: Distal retrograde Supera stent passage and reverse deployment allow precise and safe Supera stenting at the SFA ostium.

Outcomes of patients with severely calcified aorto-ostial coronary lesions who underwent orbital atherectomy.

OBJECTIVES: We assessed the feasibility and safety of orbital atherectomy in patients with severely calcified aorto-ostial coronary artery lesions. BACKGROUND: The treatment of calcified aorta-ostial coronary artery lesions is technically challenging. Orbital atherectomy can potentially damage the guiding catheter if it is not retracted sufficiently during treatment of ostial lesions. Orbital atherectomy can also excessively whip if the guiding catheter is not close enough to the ostium to provide sufficient support. Several techniques can be performed to successfully treat ostial lesions with orbital atherectomy. METHODS: Our retrospective multicenter registry included 548 real-world patients who underwent orbital atherectomy, 59 (10.8%) of whom underwent treatment for aorto-ostial coronary artery lesions (left main artery [n = 35] and right coronary artery [n = 24]). The primary endpoint was the rate of 30-day major adverse cardiac and cerebrovascular events (MACCE), defined as the occurrence of death, myocardial infarction, target vessel revascularization, and stroke. RESULTS: The primary endpoint was similar in patients with and without ostial lesions (3.4% vs 2.2%, P = 0.2), as were the 30-day rates of death (1.7% vs 1.4%, P = 0.7), myocardial infarction (1.7% vs 1.0%, P = 0.3), target vessel revascularization (0% vs 0%, P > 0.91), and stroke (0% vs 0.2%, P > 0.9). Angiographic complications and stent thrombosis did not occur in patients with ostial lesions. CONCLUSIONS: Despite its technical challenges, orbital atherectomy appears to be a feasible and safe treatment option for calcified aorto-ostial coronary lesions.

Efficacy of biolimus A9-eluting stent for treatment of right coronary ostial lesion with intravascular ultrasound guidance: a multi-center registry.

The aim of this study was to assess the efficacy of a biolimus A9-eluting stent in patients with a right coronary artery (RCA) ostial lesion. Ostial lesions of the RCA have been a limitation of percutaneous coronary intervention even in the drug-eluting stent (DES) era. However, clinical outcomes after the deployment of a second generation DES to an RCA ostial lesion with intravascular ultrasound (IVUS) guidance have not been fully elucidated. From September 2011 to March 2013, 74 patients were enrolled in 17 centers from Japan. RCA ostial lesion was defined as de novo significant stenotic lesion located within 15 mm from ostium. IVUS was used for all cases to confirm the location of ostium and evaluate stent coverage of ostium. Patients with hemodialysis were excluded. The primary endpoint is a major adverse cardiac event (MACE) at 1 year. Forty two percent of patients had multi-vessel disease. Angiographically severe calcification was observed in 26% of the lesions. The mean stent diameter was 3.3 ± 0.3 mm (3.5 mm, 72%, 3.0 mm, 25%, and 2.75 and 2.5 mm, 3%), stent length was 17.5 ± 5.8 mm, and dilatation pressure of stenting was 15.6 ± 4.1 atm. RCA ostium was covered by stent in all lesions in IVUS findings. Post dilatation was performed for 64% of lesions (balloon size 3.7 ± 0.6 mm). MACE rate at 1 year was 5.4% (target lesion revascularization 5.4%, myocardial infarction 1.2%, and no cardiac death). The biolimus A9-eluting stent for RCA ostial lesions with IVUS guidance showed favorable results at 1-year follow-up.

Independent predictors of in-stent restenosis after drug-eluting stent implantation for ostial right coronary artery lesions.

OBJECTIVES: We evaluated the angiographic patterns and predictors of in-stent restenosis (ISR) for ostial lesions of the right coronary artery (RCA) to clarify the mechanism of insoluble restenosis. BACKGROUND: Although ISR of the RCA still occurs, limited data is available regarding the associated angiographic findings. METHODS: Between January 2005 and September 2013, we recruited consecutive patients undergoing routine angiography 6-18months after implantation of a drug-eluting stent (DES). Multiple logistic regression analysis was used to determine the independent predictors of ISR, and the adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were calculated. RESULTS: Routine angiography revealed that 45 of 131 patients (34.3%) had RCA-ISR, which were classifiable by occlusion type into ostial (24 cases), proximal (17 cases), diffuse (3 cases), and total (1 case). By multivariable analysis, early generation DES was the only independent predictor of overall ISR (aOR, 3.54; 95% CI, 1.59-7.87; p=0.002). In a subgroup analysis of each focal ISR pattern, early generation DES (aOR, 7.76; 95% CI, 2.15-28.0; p=0.002) was associated with increased risk of ostial ISR. On the contrary, larger stent (aOR, 0.21; 95% CI, 0.05-0.84; p=0.027) was associated with decreased risk of ostial ISR. Furthermore, a ratio of the stent to post-balloon size >1.10 (aOR, 3.93; 95% CI, 1.30-11.8; p=0.002) and good left ventricular contractility (ejection fraction >60%) (aOR, 8.27; 95% CI, 1.76-39.0; p=0.008) were associated with increased risk of proximal ISR when stent fracture was observed. CONCLUSION: The focal pattern of RCA-ISR was mostly observed after DES implantation, and the mechanisms of proximal and ostial ISR differed.

Endovascular Management of Flush Common Iliac Artery Occlusive Disease: Challenges and Solutions.

The aim of this study was to assess the difficulties met with possible recommendations in management of flush common iliac artery occlusive disease (FCIAOD). This a prospective study assessing FCIAOD along the period of 24 months. We defined FCIAOD as more than 90% occlusion of diameter of common iliac artery (CIA) with less than 2 mm patent iliac stump from its origin from the abdominal aorta. Our study included 51 cases. Technical success was achieved in 47 patients (92%); 82.5% of cases were done via two accesses (65% of cases were done using bilateral femoral). Primary stenting was done in all cases. Sixty-eight percent of cases were treated by unilateral stents (81.3% of them were done using self-expandable) and 32% of cases were treated by kissing stents (50% using self-expandable). Prestent dilatation was selectively used in 77% of cases. Follow-up (12 months) revealed primary patency of 82.5% and secondary patency was 98% with no amputation done. Mortality rate was 4%. Endovascular treatment provides a successful option for the management of FCIAOD with a technical success rate of 92%, the option of selective use of prestent dilatation. FCIAOD does not preclude the use of unilateral stent in CIA, which can be completed to kissing stents if needed.

Comparison of early- and new-generation drug-eluting stent implantations for ostial right coronary artery lesions.

BACKGROUND: Percutaneous coronary intervention (PCI) with early-generation drug-eluting stent (eDES) implantation for ostial right coronary artery (RCA) lesions is challenging because of the frequent need for repeat revascularization. We compared midterm clinical outcomes following eDES or new-generation DES (nDES) implantation for ostial RCA lesions. METHODS: The study included 150 patients with ostial RCA lesions, 76 treated with eDES and 74 with nDES between January 2005 and September 2013. Study endpoints were major adverse cardiac events (MACEs), specifically all-cause death, target lesion revascularization (TLR), or myocardial infarction within 2 years after PCI. RESULTS: Patient characteristics between the groups were similar. The MACE rate was significantly lower in patients treated with nDES compared with those treated with eDES, mainly driven by the lower rates of TLR in the nDES group. Cox regression analysis identified severe chronic kidney disease (CKD) and the use of nDES as the independent predictors of MACE. CONCLUSIONS: The implantation of nDES for ostial RCA lesions significantly reduced the MACE rate compared with early-generation DES, mainly driven by a reduction in the TLR rate. However, nDES implantations for ostial RCA lesions may still be challenging in patients with severe CKD.

Dynamic Respiratory Tortuosity of the Vertebral Artery Ostium.

PURPOSE: To determine the prevalence of dynamic respiratory tortuosity (DRT) of the vertebral artery ostium (VAO) as well as to evaluate its correlation with in-stent restenosis (ISR) and stent fracture. METHODS: From March 2012 to June 2015, 178 consecutive patients (mean age 65.2±5.8 years; 124 men) with symptoms of atherosclerotic vertebrobasilar ischemia underwent angiography prior to stent implantation in the vertebral, subclavian, and/or carotid arteries. In this cohort, 54 patients (mean age 67.3±5.3 years; 40 men) had VAO stent implantation. Angiography of the vertebral artery was recorded in 2 phases with breath-hold: deep inspiration (DIP) and deep expiration (DEP). Obvious VAO tortuosity was defined as any VAO angle ≤120° in DIP. Obvious VAO-DRT was defined as any VAO angle increasing ≥60° from DIP to DEP. Computed tomography angiography (CTA) or digital subtraction angiography was used in follow-up to detect ISR and stent fracture. RESULTS: Of the 178 patients in this study, 21 (11.8%) had obvious VAO tortuosity and 8 (4.5%) had obvious VAO-DRT. Two of the 21 patients with obvious VAO tortuosity also had obvious VAO-DRT. Three of the 54 VAO stent patients had VAO-DRT. There were no correlations between VAO-DRT and age, sex, risk factors, body mass index, chronic obstructive pulmonary disease, asthma, or obvious VAO tortuosity (p>0.05). Over a mean follow-up of 28±10 months, there were 4 (7.4%) asymptomatic VAO ISR cases. Two (3.7%) were occlusions at 6 and 12 months, respectively; both were associated with stent fracture in patients with obvious VAO-DRT before stenting. Both stents fractured at the tortuous VAO region. VAO-DRT was correlated with stent fracture (Spearman ρ=0.81, p<0.01) and ISR (Spearman ρ=0.55, p<0.01). CONCLUSION: VAO-DRT could be a risk factor for stent fracture and restenosis after VAO stent implantation. Angiography in both inspiration and expiration phases, especially the latter, should be considered before VAO stenting. Using a shorter stent to avoid crossing the tortuosity could reduce the occurrence of fracture.