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Background In the GLOBAL LEADERS trial, ticagrelor monotherapy beyond 1 month compared with standard antiplatelet regimens after coronary stent implantation did not improve outcomes at intention‐to‐treat analysis. Considerable differences in treatment adherence between the experimental and control groups may have affected the intention‐to‐treat results. In this reanalysis of the GLOBAL LEADERS trial, we compared the experimental and control treatment strategies in a per‐protocol analysis of patients who did not deviate from the study protocol. Methods and Results Baseline and postrandomization information were used to classify whether and when patients were deviating from the study protocol. With logistic regressions, we derived time‐varying inverse probabilities of nondeviation from protocol to reconstruct the trial population without protocol deviation. The primary end point was a composite of all‐cause mortality or nonfatal Q‐wave myocardial infarction at 2 years. At 2‐year follow‐up, 1103 (13.8%) of 7980 patients in the experimental group and 785 (9.8%) of 7988 patients in the control group qualified as protocol deviators. At per‐protocol analysis, the rate ratio for the primary end point was 0.88 (95% CI, 0.75–1.03; P =0.10) on the basis of 274 versus 325 events in the experimental versus control group. The rate ratio for the key safety end point of major bleeding was 1.00 (95% CI, 0.79–1.26; P =0.99). The per‐protocol and intention‐to‐treat effect estimates were overall consistent. Conclusions Among patients who complied with the study protocol in the GLOBAL LEADERS trial, ticagrelor plus aspirin for 1 month followed by ticagrelor monotherapy was not superior to 1‐year standard dual antiplatelet therapy followed by aspirin alone at 2 years after coronary stenting. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01813435.

Background Several coronavirus disease-19 (COVID-19)-associated complications are being increasingly reported, including arterial and venous thrombo-embolic events that may lead to amputation of the affected limbs. So far, acute upper limb ischaemia (ULI) has been reported only in critically ill patients. Case summary Herein, we aimed to present a case of a 29-year-old, otherwise healthy male volleyball player, with acute ischaemic signs in the upper extremity who was diagnosed with COVID-19 1 month before the ischaemic event. It has been shown that volleyball players experience repetitive stress that involves their hands and, in particular, their fingers. Repetitive trauma can lead to local vascular abnormalities, such as reduced capillarization and lower resting blood flow that can lead to pain and cold digits, but never acute ULI. Discussion To our knowledge, this is the first case of such a hypercoagulable synergistic mechanism that leads to a high thrombus burden. Intra-arterial local thrombolysis and percutaneous transluminal angioplasty failed to succeed, and percutaneous large-bore embolectomy with the Indigo Aspiration System (Penumbra Inc., CA, USA) was deemed necessary.

Background: Once occluded, the radial artery becomes unsuitable for repeat interventions and obligates the need for alternative vascular access, such as the femoral approach, which is not encouraged by current guidelines. With the dissemination of distal radial access (DRA), which allows the cannulation of the artery in its distal segment and which remains patent even in the case of radial artery occlusion (RAO), the option to perform angioplasty at this level becomes feasible. Methods: Thirty patients with RAO were enrolled in this pilot study. Recanalization was performed through DRA using hydrophilic guidewires. The feasibility endpoint was procedural success, namely the successful RAO recanalization, the efficacy endpoint was patency of the artery at 30 days, and the safety endpoint was the absence of periprocedural vascular major complications or major adverse cardiac and cerebrovascular events. Results: The mean age of the patients was 63 ± 11 years, and 15 patients (50%) were men. Most patients had asymptomatic RAO (n = 28, 93.3%), and only two (6.6%) reported numbness in their hands. The most common indication for the procedure was PCI (19, 63.2%). Total procedural time was 41 ± 22 min, while the amount of contrast used was 140 ± 28 mL. Procedural success was 100% (n = 30). Moreover, there were no major vascular complications (0%); only two small hematomas were described (10%) and one had an angiographically visible perforation (3%). One case of periprocedural stroke was reported (3%), with onset immediately after the procedure and recovering 24 h later. Twenty-seven radial arteries (90%) remained patent at the one-month follow-up. Conclusions: RAO recanalization is feasible and safe, and by using dedicated hydrophilic guidewires, the success rate is high without significantly increasing procedural time or the amount of used contrast.

Introduction: Distal radial access (dRA) has recently gained global popularity as an alternative access route for vascular procedures. Among the benefits of dRA are the low risk of entry site bleeding complications, the low rate of radial artery occlusion, and improved patient and operator comfort. The aim of this large multicenter registry was to demonstrate the feasibility and safety of dRA in a wide variety of routine procedures in the catheterization laboratory, ranging from coronary angiography and percutaneous coronary intervention to peripheral procedures. Methods: The study comprised 1240 patients who underwent coronary angiography, PCI or noncoronary procedures through dRA in two Hungarian centers from January 2019 to April 2021. Baseline patient characteristics, number and duration of arterial punctures, procedural success rate, crossover rate, postoperative compression time, complications, hospitalization duration, and different learning curves were analyzed. Results: The average patient age was 66.4 years, with 66.8% of patients being male. The majority of patients (74.04%) underwent a coronary procedure, whereas 25.96% were involved in noncoronary interventions. dRA was successfully punctured in 97% of all patients, in all cases with ultrasound guidance. Access site crossover was performed in 2.58% of the patients, mainly via the contralateral dRA. After experiencing 150 cases, the dRA success rate plateaued at >96%. Our dedicated dRA step-by step protocol resulted in high open radial artery (RA) rates: distal and proximal RA pulses were palpable in 99.68% of all patients at hospital discharge. The rate of minor vascular complications was low (1.5%). A threshold of 50 cases was sufficient for already skilled radial operators to establish a reliable procedural method of dRA access. Conclusion: The implementation of distal radial artery access in the everyday routine of a catheterization laboratory for coronary and noncoronary interventions is feasible and safe with an acceptable learning curve.

Background Although not yet recommended by the guidelines, distal radial access, a new site for cardiovascular interventions, has been rapidly acknowledged and adopted by many centers due to its high rate of success, safety and fewer complications. We present our experience using secondary distal radial access during transcatheter aortic valve implantation (TAVI), proposing a new, even more minimal approach. Methods As of November 2020, a systematic distal radial approach as secondary access site for TAVI was adopted in our center. Primary endpoints were technical success and major adverse events (MAEs). Secondary endpoints: the access site complication rate, hemodynamic and clinical results of the intervention, procedural related factors, crossover rate to the femoral access site, and hospitalization duration (in days). Results From November 2020, 41 patients underwent TAVI using this strategy. Patients had a mean age of 76 ± 11.2 years, 41% were male. Six (14.63%) patients received a balloon-expandable valve and 35 (85.37%) received a self-expandable valve. TAVI was successful in all cases. No complications occurred due to transradial access. Puncture success, defined as completed sheath placement was maximum (N = 41/41,100%) and emergent transfemoral secondary access was not required in any case. Primary transfemoral vascular access site complications occurred in 7 cases (17%) of which 4 (13.63%) were resolved through distal radial access: one occlusion, two flow-limiting stenoses and four perforations of the common femoral artery. There were no additional major vascular complications at 30 days. Overall MACE rate was 2.4%. Conclusion The use of the distal radial approach for secondary access in TAVI is safe, feasible and has several advantages over old access sites.

Abstract: Introduction: There are conflicting data on the prevalence and prognosis of AMI patients with non-obstructive coronary artery disease (MINOCA). Aim: We studied the prevalence and prognosis of MINOCA patients. Method: In the Hungarian Myocardial Infarction Registry (HUMIR) 45,223 patients (pts) with acute myocardial infarction (AMI) were found who were treated between Jan 1, 2014, and June 30, 2018, and coronary arteriography was performed. ST-elevation myocardial infarction was diagnosed in 22,469 pts (49.7%). Patients without obstructive coronary artery disease who had no previous myocardial infarction, heart failure, PCI and CABG procedure were selected to the MINOCA group (n = 2003). Patients with obstructive coronary artery disease belonged to the MICAD group (n = 43,220). We investigated clinical characteristics of the patients, overall survival and reinfarction. Survival curves were estimated with the Kaplan–Meier method and were modeled with the Cox proportional hazards model. Results: The proportion of MINOCA pts among all myocardial infarction was by 4.4% higher in the STEMI pts compared to the NSTEMI group (2.0% vs. 6.8%). The MINOCA pts were younger (age 64.0 ± 14.4 vs. 65.5 ± 12.2 years), and the proportion of women was higher (55.7% vs. 36.5%). Hypertension, diabetes mellitus and peripheral artery disease were more common in the MICAD group (79.1% vs. 73.7%, 33.0% vs. 21.2%, and 12% vs. 8%). The mortality was higher among the MICAD pts. In the MINOCA group, the mortality of men did not differ between STEMI and NSTEMI, as opposed to women: women with STEMI had higher mortality than women with NSTEMI. The risk of reinfarction was higher in the MICAD group, especially in NSTEMI, the risk in the MINOCA group was lower, and there was no substantial difference between types. Conclusion: In this real word, retrospective, observational study, we found a significant difference in the prevalence of MINOCA pts according to different types of myocardial infarction. In the MINOCA group, the mortality of women with STEMI was substantially higher. Orv Hetil. 2019; 160(45): 1791–1797.

Abstract: Introduction: The actual guidelines of cardiovascular prevention lay special emphasis on the lipid-lowering therapy of patients suffering from acute coronary syndrome (ACS). Aim: To evaluate the occurrence of high-intensity statin therapy, recommended by guidelines, at discharge in a Hungarian county hospital with hemodynamic laboratory in patients who underwent percutaneous intervention, furthermore the LDL-cholesterol (LDL-C) levels and goal attainment rate in the first year. Method: Retrospective data collection from the hospital database regarding the therapy at discharge and the lipid levels in the year following the intervention due to ACS in 2015. Results: Due to ACS event, 454 patients had coronary intervention in 2015, at discharge more than 90% of them received high-intensity statin (more than 80% rosuvastatin, 40 mg) or corresponding combination therapy. In 154 cases we found half-year lipid results; the median of LDL-C was 1.9 mmol/L, the 1.8 mmol/L target value attainment rate was 48.7%. Results after one year were found in 292 cases (73% without the deceased and foreign patients); the LDL-C median proved to be 2.0 mmol/L, the target level attainment rate was 37.3%. There was no significant difference between the results of patients from the three different ACS forms and between those of men and women. Conclusions: The lipid lowering therapy of the revascularized patients who come back for medical visits is acceptable, but greater emphasis has to be laid on increasing the rate of controlled patients compared to the present two-thirds. Orv Hetil. 2018; 159(12): 478–484.

Background We hypothesised that ticagrelor, in combination with aspirin for 1 month, followed by ticagrelor alone, improves outcomes after percutaneous coronary intervention compared with standard antiplatelet regimens. Methods GLOBAL LEADERS was a randomised, open-label superiority trial at 130 sites in 18 countries. Patients undergoing percutaneous coronary intervention with a biolimus A9-eluting stent for stable coronary artery disease or acute coronary syndromes were randomly assigned (1:1) to 75-100 mg aspirin daily plus 90 mg ticagrelor twice daily for 1 month, followed by 23 months of ticagrelor monotherapy, or standard dual antiplatelet therapy with 75-100 mg aspirin daily plus either 75 mg clopidogrel daily (for patients with stable coronary artery disease) or 90 mg ticagrelor twice daily (for patients with acute coronary syndromes) for 12 months, followed by aspirin monotherapy for 12 months. Randomisation was concealed, stratified by centre and clinical presentation (stable coronary artery disease vs acute coronary syndrome), and blocked, with randomly varied block sizes of two and four. The primary endpoint at 2 years was a composite of all-cause mortality or non-fatal centrally adjudicated new Q-wave myocardial infarction as assessed by a core lab in a blinded manner. The key secondary safety endpoint was site-reported bleeding assessed according to the Bleeding Academic Research Consortium criteria (grade 3 or 5). Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01813435, and is closed to new participants, with followup completed. Findings Between July 1, 2013, and Nov 9, 2015, 15 968 participants were randomly assigned, 7980 to the experimental group and 7988 to the control group. At 2 years, 304 (3.81%) participants in the experimental group had died or had a non-fatal centrally adjudicated new Q-wave myocardial infarction, compared with 349 (4.37%) participants in the control group (rate ratio 0.87 [95% CI 0. 75-1. 01]; p=0.073]). There was no evidence for a difference in treatment effects for the primary endpoint across prespecified subgroups of acute coronary syndromes and stable coronary artery disease (p=0.93). Grade 3 or 5 bleeding occurred in 163 participants in the experimental group and 169 in the control group (2.04% vs 2.12%; rate ratio 0.97 [95% CI 0. 78-1. 20]; p=0.77). Interpretation Ticagrelor in combination with aspirin for 1 month followed by ticagrelor alone for 23 months was not superior to 12 months of standard dual antiplatelet therapy followed by 12 months of aspirin alone in the prevention of all-cause mortality or new Q-wave myocardial infarction 2 years after percutaneous coronary intervention. Copright (C) 2018 Elsevier Ltd. All rights reserved. European Clinical Research Institute; Biosensors International; AstraZeneca; Medicines Company; Canada Research Chairs Programme

Introduction. Transradial (TR) approach for coronary and peripheral angiography has become a popular technique. The Allen's test (AT) could be used to determine the presence of collateral flow in the hand. Recently, angiographic background of modified AT was evaluated, but patients with peripherial arterial disease (PAD) were excluded in these studies. Therefore, the present study was designed to assess reliability of AT in patients with symptomatic PAD. Methods. The present study comprised 92 symptomatic patients with PAD (Rutherford class 2-6). Perfusion of the hand was assessed with AT before outpatient peripheral angiography. Results. Significant RA stenosis (n=6, 12.5%) and UA stenosis (n=26, 54.2%) were found in 30 patients with positive AT (62.5%). In patients with negative AT, only UA showed significant stenoses (n=6, 13.6%). Thirty-eight patients with positive AT had anatomic abnormality in the forearm arteries or in the palmar arch (79.2%). Anatomic abnormality in the forearm arteries or in the palmar arch could be detected in 15 cases with negative AT (34.1%, p

Objectives We aimed to evaluate the long-term safety and efficacy of drug-eluting stent (DES) implantation in the treatment of diffuse bare metal stent (BMS) restenosis as compared to the treatment of de novo coronary lesions in high restenosis risk patient population. Background To date limited long-term data are available about the treatment of BMS restenosis with DES. Methods Five hundred and fourteen consecutive patients who underwent DES implantation between January 2003 and October 2006 at our institute were studied: 201 patients received DES for treatment of BMS restenosis and 313 patients received DES for high restenosis risk de novo lesions. Outcomes were calculated using propensity score adjustment. Mean follow-up length was 45.6 ± 21.5 months. Results The rates of acute coronary syndrome, three-vessel disease, and diabetes were high in both restenosis and de novo groups: 44.8% versus 46.3%, 20.9% versus 28.7%, and 34.3% versus 38.9%, respectively. The incidence of ischemia-driven target lesion revascularization (TLR) yielded similar results in the restenosis group and de novo group at 4 years (10.4% vs 12.4%, P = 0.490). All-cause mortality was lower in the restenosis group at 4 years (7.4% vs 14.7%, P = 0.032); however, the incidence of definite and probable stent thrombosis did not differ (1.9% vs 1.6%, P = 0.708) between the 2 groups. Conclusions DESs are safe in the treatment of diffuse BMS restenosis and the rate of additional TLR is acceptable as compared to the use of DES in de novo lesions. (J Interven Cardiol 2013;26:271–277)

Coronary stent fracture is an often unrecognized cause of target vessel failure, however, it has been reported more frequently in the drug-eluting stent era. Clinical presentation of stent fracture may range from benign in-stent restenosis to potentially fatal acute stent thrombosis. Interventional treatment of stent thrombosis can be carried out by high pressure balloon dilatation or second stent implantation into the stented segment after thrombus aspiration. Intravascular ultrasound is mandatory in order to exclude mechanical problems in the background of the stent thrombosis and to achieve good final stent apposition and expansion. We report on a stent fracture induced stent thrombosis occurring in a highly calcified proximal right coronary artery. (Treated previously with rotational atherectomy in the middle part, but not in the aortoostial location.) Our case emphasizes the importance of opitimal plaque modification with rotational atherectomy in a calcified aorto-ostial segment of right coronary artery to prevent long term complications such as stent thrombosis or restenosis due to stent fracture.

The metabolism of vitamin D is unique in the human body and its diverse effects are present in almost every organ. Vitamin D deficiency is one of the most prominent health issues in the civilized world. For the solution of this concern an extensive collaboration is imperative. Recognizing this necessity the most prominent Hungarian medical associations fighting with the effects of vitamin D deficiency worked out a collective consensus on the importance, diagnosis, prevention and suggested therapy of vitamin D deficiency. Along with the clinical guidelines of the different associations, the result of this consensus could serve as guidance for the practicing doctors in the prevention and therapy of vitamin D deficiency. In addition the consensus aims to direct the attention of decision-makers and the general public on the significance of this issue.

Here we investigated how a coating of intravascular balloon with paclitaxel (drug-coated balloon; DCB, Freeway™) impacted porcine peripheral artery vascular function and remodeling. Domestic swine (n = 54) underwent percutaneous overstretch balloon dilation of femoral and iliac arteries, controlled by angiography and optical coherence tomography (OCT). Paclitaxel tissue uptake was measured at 1 h and 1, 3, and 9 days post-dilation. At these time-points and at 32 ± 2 days, vascular function of the dilated arteries was assessed using the organ chamber model. Neointimal growth and remodeling indices were determined using OCT and histology at 32 ± 2 days. Intima and media fibrosis were quantified by picrosirius red staining. Post-inflation femoral artery tissue drug levels were 460 ± 214, 136 ± 123, 14 ± 6, and 0.1 ± 0.1 ng/mg at 1 h and 1, 3, and 9 days, respectively. Compared to plain balloon, Freeway™ resulted in a significantly smaller neointimal area (P

IntroductionPercutaneous interventional procedures in the renal arteries are usually performed using a femoral or brachial vascular access. The transradial approach is becoming more popular for peripheral interventions, but limited data exists for renal artery angioplasty and stenting.MethodsWe have analyzed the clinical, angiographic and technical results of renal artery stenting performed from radial artery access between 2012 and 2013. The radial artery anatomy was identified with aortography using 100 cm pig tail catheter. After engagement of the renal artery ostium with a 6F Multipurpose or 6F JR5 guiding catheter, the stenosis was passed with a 0.014″ guidewire followed by angioplasty and stent implantation.ResultsIn 27 patients (mean age: 65.4 ± 9.17) with hemodynamically relevant renal artery stenosis (mean diameter stenosis: 77.7 ± 10.6%; right,n= 7; left,n= 20), interventional treatment with angioplasty and stenting was performed using a left (n= 3) or right (n= 24) radial artery access. Direct stenting was successfully performed in 13 (48%) cases, and predilatations were required in ten cases 10 (37%). Primary technical success (residual stenosis ConclusionTransradial renal artery angioplasty and stenting is technically feasible and safe procedure.

A koszorúér-betegség alapját jelentő atheroscleroticus folyamatok gyógyszeres kezelése mellett a percutan intervenciós módszer szerepe az utóbbi évtizedekben egyre jelentősebb. A stentek elterjedésével a percutan koszorúér-intervenció akut sikerrátája jelentős javulást mutatott, azonban a hagyományos fémstentekben keletkezett instentrestenosis újabb kihívást (és anyagi ráfordítást) jelent az intervenciós kardiológia számára. Az instentrestenosis csökkentése hatékonyan kivitelezhető gyógyszerkibocsátó stentek alkalmazásával, ahol a stent fémvázára felvitt polimerhez citosztatikus anyag kapcsolódik. Az intimaproliferáció gátlásával az instentrestenosis gyakorisága 10% alá csökkenthető. A gyógyszerkibocsátó stentekben megjelenő restenosis kezelése azonban jelenleg megoldatlan probléma. Egyes elméletek szerint az érfal reaktivitását kiváltó/fenntartó fém, illetve polimer kiküszöbölése jelenthet megoldást. A kutatások két irányba folytatódnak ezek alapján: 1. biológiailag lebomló polimer, illetve stent; 2. gyógyszerkibocsátó ballon. Jelen dolgozatukban a szerzők egy tanulságos eset kapcsán adnak áttekintést az utóbbi módszerről. Orv. Hetil., 2010, 37, 1509–1514.

The "comet-tail" is an ultrasound sign detectable with ultrasound chest instruments; this sign consists of multiple comet-tails fanning out from the lung surface. They originate from water-thickened interlobular septa and would be ideal for nonradiologic bedside assessment of extravascular lung water. To assess the feasibility and value of ultrasonic comet signs, we studied 121 consecutive hospitalized patients (43 women and 78 men; aged 67 +/- 12 years) admitted to our combined cardiology-pneumology department (including cardiac intensive care unit); the study was conducted with commercially available echocardiographic systems including a portable unit. Transducer frequencies (range 2.5 to 3.5 MHz) were used. In each patient, the right and left chest was scanned by examining predefined locations in multiple intercostal spaces. Examiners blinded to clinical diagnoses noted the presence and numbers of lung comets at each examining site. A patient lung comet score was obtained by summing the number of comets in each of the scanning spaces. Within a few minutes, patients underwent chest x-ray, with specific assessment of extravascular lung water score by 2 pneumologist-radiologists blinded to clinical and echo findings. The chest ultrasound scan was obtained in all patients (feasibility 100%). The imaging time per examination was always

Critical hand ischaemia (CHI) of the upper extremity is rarely encountered. Axillary, brachial and below-the-elbow (BTE) disease is often asymptomatic due to highly developed collaterals, but in diffuse- multiple and thrombotic disease CHI can develop. The aim of this prospective study was to assess

ObjectivesWe sought to examine the association between aortic valve sclerosis (AVS) and systemic endothelial manifestations of the atherosclerotic process.BackgroundClinical and experimental studies suggest that AVS is a manifestation of the atherosclerotic process. Systemic endothelial dysfunction is an early sign of the atherosclerotic process and can be assessed by ultrasonography of the brachial artery.MethodsA total of 102 in-hospital patients (76 men; mean age 63.5 ± 9.7 years) referred to the stress echocardiography laboratory underwent: 1) transthoracic echocardiography, with specific assessment of AVS (thickened valve leaflets with a transaortic flow velocity