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Background: Patients with angina symptoms and/or signs of ischemia but no obstructive coronary artery disease (INOCA) pose a diagnostic and therapeutic challenge.Objectives: The purpose of ...

Background Chronic total occlusion (CTO) revascularisation has a crucial role in contemporary percutaneous coronary intervention (PCI). Procedural success is influenced by disease complexity, calcific burden and patient characteristics but has substantially improved with the implementation of novel hybrid strategies. However, vascular-access related complications remain a cause of morbidity and mortality. This study aimed to assess the effectiveness of fluoroscopic-guided femoral arterial puncture to minimise this risk during CTO PCI. Methods Standardised data were retrospectively collected from four high-volume UK CTO centres between September 2011 and November 2013. Demographic, clinical and procedural data (vascular access site, sheath size, anticoagulation use) was collated. The anatomical location of the femoral puncture in relation to the femoral bifurcation, femoral head position and inferior epigastric artery were recorded. Adverse events related to vascular access were documented. Results A total of 528 patients were included (676 femoral punctures) with the majority being male (n=432, 81.8%). Large sheaths (8F) were used in 81.2% of cases. Fluoroscopy-enabled punctures were made in the ‘safe zone’ in over > 93% of cases. Vascular closure devices (VCD) were used in 88.3% of cases. The adverse event rate per puncture was 0.89%. Conclusions This study demonstrates an extremely low incidence of vascular-access complications in CTO PCI when fluoroscopic guidance is used to obtain femoral arterial access by default radial operators.

Background: Elderly patients with multi-morbidity are often under-represented in clinical trials. The CABG-ACS pilot trial (NCT01895751) prospectively assessed reasons for entering the trial or registry and subsequent outcomes. Methods: Patients with a non-ST segment elevation acute coronary syndrome (NSTE-ACS) and prior coronary artery bypass graft (CABG) admitted to 4 hospitals were randomized to invasive or non-invasive management. Non-randomized patients entered a follow-up registry. The primary efficacy outcome was a composite of all-cause death, rehospitalization for refractory ischemia/angina, myocardial infarction (MI) and hospitalization due to heart failure. The primary safety outcome was the composite of bleeding, stroke, procedure-related MI and worsening renal function. A blinded Clinical Event Committee independently assessed events. EuroQol-5 Dimensions (EQ-5D) was assessed at 6 monthly intervals for ≥18 months. Results: 217 patients with prior CABG and unplanned hospitalization for suspected ACS were screened. 84 subjects did not consent (≥1 reasons): 43 not NSTE-ACS, 35 unsuitable for invasive management, 9 refractory ischemia, 3 unable to consent. Of 133 eligible subjects, 60 (mean±SD age 71±9 years, 28% female) entered the trial and 73 (age 72±10 years, 27% female) entered the registry (preferences: physician 79%, patient 40% or both 18%). Compared to trial patients, registry patients had significantly more valve disease, lower hemoglobin, worse New York Heart Association class and higher frailty index. Baseline EQ-5D, medications and left internal mammary artery grafts were similar. Registry patients had significantly more medication changes due to recurrent angina and more urgent inpatient invasive procedures. The primary efficacy outcome occurred in 49% registry vs. 43% trial patients (HR (95% CI) 1.12 (0.77,1.63); p=0.601). Primary safety outcomes were similar (22% registry vs. 28% trial; HR 0.76 (0.42,1.38); p=0.425). EQ-5D health status was lower in the registry at 6 months (p=0.011) but not at 1 year (p=0.068). Conclusion: Compared to trial patients, the registry had excess morbidity but their longer term health outcomes were similar.