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Aims: To elucidate causes and extent of strut malapposition in angiographically optimized stenting., Methods and Results: Using a new classification system for strut malapposition, the mechanisms of stent strut malapposition were classified as localized lumen enlargement, vessel asymmetry, stent undersizing, strut underexpansion and stent deployment issue. Stent implantations (n = 110) in 100 consecutive patients undergoing optical coherence tomography (OCT) after the operator considered the stent as optimally deployed angiographically were reviewed to determine if strut apposition was complete. 127,894 stent struts in 110 stents were analyzed. There were 6,644 struts malapposed (5.2% ±7.3%), with strut malapposition found in 82 of 110 stents (74.5%). Localized lumen enlargement was the most common cause of malapposition (74.4% of malapposition clusters). Stent undersizing was the second most common cause (46.3%) followed by strut under-expansion in 29.3%, stent deployment issue in 18.2%, and vessel asymmetry in 9.7%., Conclusion: Malapposition of any degree is common after angiographic stent optimization, occurring in up to three-quarters of stents. The most frequent mechanism was localized lumen enlargement. The second most common cause of strut malapposition was stent undersizing, which was angiographically invisible. Whether performing OCT after angiographic optimization improves short- and long-term outcomes requires further study. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Unlabelled: Well-developed collaterals to a myocardial segment supplied by a chronic total occlusion (CTO) and/or left ventricular dysfunction in the CTO regions in patients with chronic stable angina suggest that severe ischemia is unlikely to be present. We evaluated the presence and severity of ischemia using fractional flow reserve (FFR) of the myocardium supplied by a CTO in patients and compared the results with a non-CTO control group., Methods: Patients undergoing FFR and successful percutaneous coronary intervention (PCI) of a CTO were evaluated and compared to a matched non-CTO control group., Results: One hundred patients were included (50 CTO/50 controls). CTO lesions were longer (31.6 ± 18.9 vs 20.2 ± 14.9 mm, P = 0.004) and required more stents (2.2 ± 0.8 vs 1.2 ± 0.5, P = 0.001). FFR was lower (P = 0.0003) with CTO (0.45 ± 0.15) than controls (0.58 ± 0.17) prior to intervention but similar after PCI (CTO 0.91 ± 0.05 vs non-CTO 0.90 ± 0.08). All CTO patients demonstrated an ischemic FFR, even with severe regional dysfunction or well-developed collaterals. Resting ischemia was present in 78% (39/50) of CTO patients as evidenced by a resting Pd /Pa of <0.80., Conclusion: In symptomatic patients, a CTO, even with regional left ventricular impairment and/or excellent collateral development, reveals an ischemic zone. This ischemic zone can be normalized by PCI with outcomes appearing to be comparable to non-CTO patients., (Copyright © 2013 Wiley Periodicals, Inc.)

Background: Case reports have shown that an intermediate stenosis in the donor artery collateralizing the myocardium of a chronic total occlusion (CTO) can produce an ischemic fractional flow reserve (FFR) value which may revert to non-ischemic with CTO revascularization., Methods: A consecutive series of patients with severe angina in which a donor artery with intermediate stenosis (30-70%) had FFR measured before and after successful CTO recanalization were studied., Results: Fourteen of 50 consecutive CTO patients with successful PCI fulfilled the study criteria. Eight had CTO of the right coronary artery (RCA), three circumflex (LCx), and three RCA and LCx. Left anterior descending artery was the donor artery in 13 and LCx in 1 patient. Of nine donor ischemic FFR patient's pre-PCI, six reverted to non-ischemic (FFR pre-PCI 0.76 ± 0.04 and 0.86 ± 0.03 post-PCI). Five patients had normal FFR in the donor artery pre- and post-CTO PCI., Conclusions: In patients with a CTO and an intermediate donor artery stenosis, the frequency of ischemia in the donor artery territory is relatively high and often normalized by successful CTO recanalization. These data recommend recanalizing the CTO first whenever possible as a preferred therapeutic strategy to avoid the need for PCI to the donor artery or multivessel bypass surgery., (Copyright © 2013 Wiley Periodicals, Inc.)