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We assessed the efficacy and safety of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using antegrade dissection re-entry (ADR). We examined outcomes of ADR CTO PCI cases among 1794 procedures performed at 14 experienced US centers from 2012-2016. Mean age was 65±10 years

Retrograde percutaneous interventions (PCI) of native coronary artery chronic total occlusions (CTOs) via left internal mammary artery (LIMA) grafts have received limited study. We compared the clinical and procedural characteristics and outcomes of retrograde CTO PCI through LIMA grafts vs. via

We sought to examine the contemporary outcomes of chronic total occlusion (CTO) percutaneous coronary interventions (PCI). We examined the clinical, angiographic and procedural characteristics of 2,733 CTO interventions of 2677 patients that were performed in 18 centers from the United States and

Background: The hybrid approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) combines all available crossing techniques to optimize procedural success rates, efficiency, and safety. Methods: We examined the clinical, angiographic and procedural characteristics of 1,974

Background: Although coronary chronic total occlusions (CTOs) are treated with percutaneous coronary intervention (PCI) to improve symptoms, studies demonstrating improvement in objective measures, such as peak oxygen uptake (

Background: We examined the impact of the type of collateral vessel used on the outcomes of retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Methods: The baseline clinical and angiographic characteristics and procedural outcomes of 704 retrograde CTO PCIs performed

Background: We examined contemporary use and outcomes of excimer laser coronary atherectomy (ELCA) in percutaneous coronary intervention (PCI). Methods: The baseline clinical and angiographic characteristics; procedural outcomes of 119 consecutive PCIs in which ELCA was performed between 2008 and

Successful percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has been associated with clinical benefit. There are no randomized controlled trials on long-term clinical outcomes after CTO PCI, limiting the available evidence to observational cohort studies. We sought to perform a weighted meta-analysis of the long-term outcomes of successful versus failed CTO PCI. A total of 25 studies, published from 1990 to 2014, with 28,486 patients (29,315 CTO PCI procedures) were included. We analyzed data on mortality, subsequent coronary artery bypass grafting (CABG), myocardial infarction, major adverse cardiac events, angina pectoris, stroke, and target vessel revascularization using random-effects models. Procedural success was 71% (range 51% to 87%). During a weighted mean follow-up of 3.11 years, compared with unsuccessful, successful CTO PCI was associated with lower mortality (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.43 to 0.63), less residual angina (OR 0.38, 95% CI 0.24 to 0.60), lower risk for stroke (OR 0.72, 95% CI 0.60 to 0.88), less need for subsequent coronary artery bypass grafting (OR 0.18, 95% CI 0.14 to 0.22), and lower risk for major adverse cardiac events (0.59, 95% CI 0.44 to 0.79). There was no difference in the incidence of target vessel revascularization (OR 0.66, 95% CI 0.36 to 1.23) or myocardial infarction (OR 0.73, 95% CI 0.52 to 1.03). Outcomes were similar in patients who underwent balloon angioplasty only or stenting with bare metal or drug-eluting stents. Compared with failed procedures, successful CTO PCIs are associated with a lower risk of death, stroke, and coronary artery bypass grafting and less recurrent angina pectoris.

Introduction: Saphenous vein grafts (SVGs) have high rates of both early (≤ 1 year) and late failure following coronary arterial bypass graft surgery (CABG). Hypothesis: Endothelial shear stress (ESS) is a critical determinant of the natural history of coronary atherosclerosis, but the influence on the structural changes of SVGs has not been studied. We evaluated the effect of ESS on the serial anatomic outcomes of SVGs assessed by optical coherence tomography (OCT) during the first postoperative year. Methods: We performed 3-dimensional SVG reconstruction in 8 SVGs using fusion of angiographic and OCT data 5-7 days after surgery (baseline) and at 12-month follow-up. Baseline ESS was assessed using computational fluid dynamics. The reconstructed SVGs were divided in consecutive 3-mm segments (n=181), and we assessed the association of baseline ESS with the anatomic outcomes in the corresponding segments at follow-up: change in lumen area and plaque burden, and neointimal area at follow-up. Baseline ESS was categorized according to the tertiles of the ESS frequency distribution. Results: Median baseline ESS in SVGs was 0.48 Pa [IQR: 0.37-0.61 Pa]). Baseline low ESS was associated with: (i) the largest decrease in lumen area (low ESS category: -8.72±0.95 mm2 vs. moderate ESS category: -5.67±0.95 mm2 vs. high ESS category: -3.64±0.95 mm2; p Conclusions: SVG areas with the lowest local ESS develop the largest lumen constriction, plaque burden increase and neointima formation. These findings provide important insights into the pathogenesis of early SVG failure.

Background: In percutaneous coronary intervention (PCI) of coronary chronic total occlusions (CTOs), inability to cross the lesion with a balloon is the second most common cause of technical failure following inability to cross the lesion with a guidewire. While various techniques have been reported for such "balloon uncrossable" CTOs, the frequency and outcomes of these techniques have received limited study. Methods: We retrospectively examined 373 consecutive CTO PCIs performed at our institution between 2005 and 2013 to determine the frequency and outcomes of “balloon uncrossable” CTOs. Results: Mean age was 63.7 ± 8.3 years and 98.9% of the patients were men. Twenty four patients (6.4%) were found to have a "balloon uncrossable" CTO. These patients had similar clinical and angiographic characteristics compared to the other CTO PCI patients (Table). Successful crossing of the lesion was achieved in 22 of 24 patients (91.7%) using a variety of techniques, such as successive balloon inflations (43.5%), microcatheter advancement (21.7%), laser (8.7%), increased guide catheter support (13.0%), and subintimal lesion crossing (13.0%) (Figure). Patients with “balloon uncrossable” CTOs had longer procedure time (184.5 ± 77.9 vs. 134.0 ± 69.0 min, p Conclusion: “Balloon uncrossable” CTOs occur in 6.4% of contemporary CTO PCIs and can be successfully treated in most patients using a variety of techniques.

Background: The RadiCure study examined the impact of real-time radiation monitoring on patient and operator exposure during cardiac catheterization. We sought to identify the factors associated with increased radiation exposure of the first operator. Methods: We studied the baseline clinical characteristics and procedural outcomes of 505 patients that were enrolled in the RadiCure study from January 2012 to May 2014. Multivariable analysis of high (above median or >1.0 mrem) exposure of the first operator was performed. Variables with a significant (p Results: Mean age was 65±8 years and most patients were men (99%) with a high prevalence of diabetes mellitus (54%), and prior coronary artery bypass graft surgery (30%). Median procedure time was 27 (14-51) minutes; radial access was used in 18% of cases and chronic total occlusion (CTO) interventions constituted 7% of the procedures. Median fluoroscopy time was 6.2 (2.5-12.5) minutes; median patient Air Kerma (AK) radiation exposure was 0.908 (0.602-1.636) Gray; and median first operator exposure was 1.0 (0.5-2.2) mrem. On multivariable analysis, radial access (Odds ratio [OR] 6.62, 95% Confidence Interval [CI] 3.13-14.76), followed by CTO intervention (OR 5.53, 95% CI 1.73-20.71) and patient AK radiation exposure > 0.9 Gray (OR 4.56, 95% CI 2.32-9.19) were found to be the strongest independent predictors of high first operator exposure. Real-time radiation exposure monitoring and use of a radioabsorbent drape were shown to have a significant protective effect (OR 0.33, 95% CI 0.19-0.57; and OR 0.38, 95% CI 0.18-0.77; respectively) (Figure 1). Conclusions: In the RadiCure study, high patient AK exposure, radial access and CTO intervention were associated with high first operator exposure. Real-time radiation monitoring and use of a radioabsorbent drape were independently associated with lower operator radiation exposure.

Variations in radiation dose between various X-ray systems have received limited study.We examined the impact of X-ray system type on patient radiation dose during cardiac catheterization.An anthropomorphic phantom was used in a series of standardized experiments that involved 15 sec of continuous cineangiography in 7 projections. Three to seven experiments were performed in four commonly used X-ray systems: Innova IGS (GE Healthcare), Integris Allura FD20 (Philips), Allura Clarity (Philips), and Artis one (Siemens). Phantom radiation dose was measured with a dedicated X-ray dosimetry system (Gafchromic radiology film and Film QA XR software, Ashland) that was precalibrated at 0, 1, 2, 3, and 4 Gray, and with the X-ray system built-in functions.Radiation dose was lowest with the Allura Clarity system [average film dose 4.2±0.1 cGray, peak film dose 18.3±1.6 cGray, Air Kerma (AK) dose 0.310±0.002 Gray, Dose Area Product (DAP) dose 23.72±0.84 Gray*cm2], intermediate with the Integris Allura FD20 (average film dose 4.4±1.1 cGray, peak film dose 29.4±15.5 cGray, AK 0.482±0.189 Gray, DAP 45.18±21.90 Gray*cm2), and highest with the Artis one system (average film dose 7.4±0.8 cGray, peak film dose 66.9±0.09 cGray, AK 0.746±0.085 Gray, DAP 75.93±9.11 Gray*cm2) and the Innova IGS system (average film dose 7.2±1.0 cGray, peak film dose 49.3±28.9 cGray, AK 0.874±0.340 Gray, DAP 92.28±14.73 Gray*cm2; P=0.011 for average film dose, P=0.019 for maximum film dose, P=0.033 for AK, and P=0.008 for DAP).The X-ray system type has significant impact on patient radiation dose during cardiac catheterization.

As compared with bare metal stents, first-generation drug-eluting stents (DES) improved post-procedural outcomes in aortocoronary saphenous vein graft (SVG) lesions, but there is limited information on outcomes after use of second-generation DES in SVGs.We compared the outcomes of patients who received first- (n = 81) with those who received second-generation (n = 166) DES in SVG lesions at our institution between 2006 and 2013. Major adverse cardiac events (MACE) were defined as the composite of all-cause death, myocardial infarction, and target vessel revascularization.Mean age was 66.0 ± 8.1 years and 97.6% of the patients were men. Mean SVG age was 11.1 ± 0.4 years. First-generation DES were sirolimus-eluting (n = 17) and paclitaxel-eluting (n = 64) stents. Second-generation DES were everolimus-eluting (n = 115) and zotarolimus-eluting (n = 51) stents. Median follow-up was 41 months. At 2-years post-procedure, patients with first- and second-generation DES had similar rates of death (20.91% vs. 20.27%, P = 0.916), target lesion revascularization (16.39% vs. 20.00%, P = 0.572), target vessel revascularization (20.97% vs. 23.16%, P = 0.747), myocardial infarction (26.15% vs. 23.00%, P = 0.644), and MACE (43.5% vs. 40.87%, P = 0.707), respectively.Outcomes with first- and second-generation DES in SVGs are similar. Novel stent designs are needed to further improve the clinical outcomes in this challenging patient and lesion subgroup. © 2015 Wiley Periodicals, Inc.

Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is challenging and has been associated with low success rates. However, recent advancements in equipment and the flexibility to switch between multiple technical approaches during the same procedure ("hybrid" percutaneous algorithm) have dramatically increased the success of CTO-PCI. We sought to compare the contemporary procedural outcomes of hybrid CTO-PCI with previously published CTO-PCI studies.The procedural outcomes of 497 consecutive CTO-PCIs performed between January 2012 and August 2013 at five high-volume centers in the United States were compared with the pooled success and complication rates reported in 39 prior CTO-PCI series that included ≥100 patients and were published after 2000.The baseline clinical and angiographic characteristics of the study patients were comparable to those of previous studies. Technical and procedural success was achieved in 455 cases (91.5%) and 451 cases (90.7%), respectively, and were significantly higher than the pooled technical and procedural success rates from prior studies (76.5%, P.001 and 75.2%, P.001, respectively). Major procedural complications occurred in 9/497 patients (1.8%) overall and included death (2 patients), acute myocardial infarction (5 patients), repeat target vessel PCI (1 patient), and tamponade requiring pericardiocentesis (2 patients). The incidence of major complications was similar to that of prior studies (pooled rate 2.0%; P=.72).Use of the hybrid approach to CTO-PCI is associated with higher success and similar complication rates compared to prior studies, supporting its expanded use for treating these challenging lesions.

To determine the impact of music intervention on endothelial function, hemodynamics, and patient anxiety before, during, and after cardiac catheterization.The effect of music therapy during cardiac catheterization on endothelial function and patient satisfaction has received limited study.Seventy patients undergoing elective cardiac catheterization were randomized to music therapy (n=36) or no music therapy (n=34). Peripheral arterial tonometry was performed before and after catheterization. A 6 item (24-point scale) questionnaire evaluating patient anxiety and discomfort levels was also administered after the procedure.Both study groups had similar baseline characteristics, fluoroscopy time, and contrast administration. Reactive hyperemia index (RHI) change was 0.14 ± 0.72 in the music group and 0.30 ± 0.58 in the control group (P=.35). Systolic and diastolic blood pressure (BP) changes did not significantly differ between the two groups (systolic BP change -3.3 ± 17.3 mm Hg vs -2.3 ± 19.4 mm Hg; P=.83 and diastolic BP change -1.9 ± 12.2 mm Hg vs. 2.0 ± 13.4 mm Hg; P=.23). Heart rate changes were also comparable between the two groups (-1 ± 6 beats/ min vs -1 ± 7 beats/min; P=.22). Patient satisfaction questionnaire measurements were found to be similar in patients with and without music therapy (8 [7-11] vs 9 [8-12]; P=.36).In this study, music intervention did not elicit a vasodilator response, did not lower blood pressure or heart rate, and did not relieve anxiety or stress discomfort in patients who underwent coronary angiography.

The hybrid approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has significantly increased procedural success rates, yet some cases still fail. We sought to evaluate the causes of failure in a contemporary CTO PCI registry.We examined 380 consecutive patients who underwent CTO-PCI at 4 high volume CTO PCI centers in the United States using the "hybrid" approach. Clinical, angiographic, complication, and efficiency outcomes were compared between successful and failed cases. Failed cases were individually reviewed by an independent reviewer to determine the cause of failure.Procedural success was 91.3%. Compared with patients in whom CTO PCI was successful, those in whom CTO PCI failed had similar baseline clinical characteristics, but were more likely to have longer occlusion length, more tortuosity, more proximal cap ambiguity and blunt stump, and higher mean J-CTO scores (2.8 ± 1.1 vs. 3.5 ± 1.0, P 0.001), and less likely to have collaterals suitable for the retrograde approach (66% vs. 45%, P = 0.021). Failure was due to a complication in 10 cases (30%). In the remaining 23 cases (70%) failure was due to inability to wire the lesion (n = 21, 4 of which were CTOs due to in-stent restenosis), or poor antegrade flow after PCI (n = 5).Compared with successful cases, failed CTO-PCI cases are more likely to have higher J-CTO scores, longer occlusion length, ambiguous proximal cap and no appropriate collaterals for retrograde crossing. Development of novel CTO crossing techniques is needed to further increase CTO PCI success rates.

The objective of the present study was to perform a systematic review and meta-analysis of studies reporting outcomes after first- and second-generation drug-eluting stent (DES) implantation in chronic total occlusions (CTOs).The effect of second- vs first-generation DESs on the outcomes after CTO percutaneous coronary intervention (PCI) has received limited study.As of May 2013, thirty-one published studies reported outcomes after DES implantation in CTOs: thirteen uncontrolled studies (3161 patients), three randomized (220 patients) and ten non-randomized (2150 patients) comparative studies with bare-metal stents (BMSs), and two non-randomized (685 patients) and three randomized (489 patients) comparative studies between first- and second-generation DESs. Data from the five studies comparing first with second-generation DESs were pooled using random-effects meta-analysis models.The median and mean duration of follow-up were 12 and 14.4 months, respectively. Compared to first-generation DESs, second-generation DESs were associated with lower incidence of death (odds ratio [OR], 0.37; 95% confidence intervals [CI], 0.15-0.91), target vessel revascularization (OR, 0.59; 95% CI, 0.40-0.87), binary angiographic restenosis (OR, 0.68; 95% CI, 0.46-1.01) and reocclusion (OR, 0.35; 95% CI, 0.17-0.71), but similar incidence of myocardial infarction (OR, 0.45; 95% CI, 0.10-1.95) and stent thrombosis (OR, 0.34; 95% CI, 0.07-1.59).Compared to first-generation DESs, second-generation DESs are associated with improved angiographic and clinical outcomes in CTO PCI and are the preferred stents for these challenging lesions.

To examine the success and complication rates in percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) caused by in-stent restenosis (ISR).PCI for in-stent total occlusive disease has traditionally been associated with low success rates. We sought to examine angiographic and procedural outcomes of patients who underwent CTO PCI due to ISR using the novel "hybrid" algorithm, and compare them with patients with de novo CTOs.We examined 521 consecutive patients who underwent CTO PCI at five high-volume PCI centers in the United States using the "hybrid" approach. Clinical, angiographic, and procedural outcomes were compared between CTOs due to ISR and de novo CTOs.The target CTO was due to ISR in 57 of 521 patients (10.9%). Compared to patients with de novo CTOs, those with CTO due to ISR had higher frequency of diabetes (56.1% vs. 39.6%, P = 0.02) and less calcification (5.3% vs. 16.2%, P0.001), but longer occlusion length [38 (29-55) vs. 30 (20-51), P = 0.04]. Technical success in the ISR and de novo group was 89.4% and 92.5% (P = 0.43), respectively; procedural success was 86.0% and 90.3% (P = 0.31), respectively; and the incidence of major adverse cardiac events was 3.5% and 2.2% (P = 0.63), respectively.Use of the "hybrid" approach to CTO PCI was associated with similarly high procedural success and similarly low major complication rates in patients with de novo and ISR CTOs.

Background We sought to determine whether outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) vary according to CTO target vessel: left anterior descending artery (LAD), left circumflex artery (LCX), and right coronary artery (RCA). Methods We evaluated the clinical and angiographic characteristics and procedural outcomes of 636 patients who underwent CTO PCI at 6 high-volume centres in the United States between January 2012 and March 2014. Results The CTO target vessel was the RCA in 387 cases (61%), LAD in 132 (21%), and LCX in 117 (18%). LCX lesions were more tortuous and RCA lesions had greater occlusion length and Japanese Chronic Total Occlusion (J-CTO) score, but were less likely to have a side branch at the proximal cap and had more developed collateral circulation. The rate of procedural success was lower in LCX CTOs (84.6%), followed by RCA (91.7%), and LAD (94.7%) CTOs ( P = 0.016). Major complications tended to occur more frequently in LCX PCI (4.3% vs 1.0% for RCA vs 2.3% for LAD; P = 0.07). LCX and RCA CTO PCI required longer fluoroscopy times (45 [interquartile range (IQR), 30-74] minutes vs 45 [IQR, 21-69] minutes for RCA vs 34 [IQR, 20-60] minutes for LAD; P = 0.018) and LCX CTOs required more contrast administration (280 [IQR, 210-370] mL vs 250 [IQR, 184-350] mL for RCA and 280 [IQR, 200-400] mL for LAD). Conclusions In a contemporary, multicentre CTO PCI registry, LCX was the least common target vessel. Compared with LAD and RCA, PCI of LCX CTOs was associated with a lower rate of procedural success, less efficiency, and a nonsignificant trend for higher rates of complications.

To examine the impact of transradial access on the procedural outcomes of chronic total occlusion (CTO) percutaneous coronary interventions (PCI).The efficacy and safety of transradial access in CTO PCI has received limited study.We compared the technique and outcomes of transradial vs. transfemoral access among 650 CTO PCI cases performed between January 2012 and March 2014 at 6 US centers.Most patients were men (87%) with high frequency of diabetes mellitus (42%) and prior coronary artery bypass graft surgery (36%). The CTO target vessel was the right coronary (59%), left anterior descending (20%), or circumflex (17%) artery. TR access was used in 110 (17%) of the 650 cases, as follows: bilateral radial access (63%); bilateral radial access plus unilateral or bilateral femoral access (7%); unilateral radial access plus unilateral or bilateral femoral access (26%); and unilateral radial access (4%). Six and eight French guide catheters were used through the radial and femoral artery, respectively. Compared to transfemoral, transradial cases had similar technical (92.6% vs. 93.0%, P = 0.87) and procedural (91.1% vs. 90.0%, P = 0.95) success and major complication rates (1.7% vs 1.8%, P = 0.99). However, transradial access was associated with higher mean procedure (142 ± 83 vs. 120 ± 60 min, P = 0.008) and fluoroscopy (58 ± 40 vs. 49 ± 31 min, P0.026) time, and number of crossing approach changes (0.7 ± 1.0 vs. 0.5 ± 0.7, P = 0.008).Transradial CTO PCI can be performed with similar success and complication rates with transfemoral CTO PCI, but is associated with longer procedural and fluoroscopy times. © 2015 Wiley Periodicals, Inc.

Saphenous vein graft (SVG) percutaneous coronary intervention (PCI) currently accounts for approximately 6 % of all PCIs and is associated with increased risk for distal embolization and subsequent SVG failure compared with native coronary artery PCI. To minimize the risk for distal embolization, embolic protection devices should be used during SVG PCI when technically feasible. To minimize the risk for in-stent restenosis and the need for repeat PCI, drug eluting stents should be utilized in patients without contraindications to long-term antiplatelet therapy. Treating native coronary artery lesions is preferable to SVG PCI when technically feasible.

To assess the outcomes of the "hybrid" approach to chronic total occlusion (CTO) percutaneous coronary interventions (PCIs).The "hybrid approach" to CTO PCI advocates appropriate and early change of crossing strategy to maximize success, safety, and efficiency.We prospectively recorded and analyzed detailed step-by-step procedural data in 73 consecutive CTO PCI cases performed by a single operator between July 2011 and August 2012.Technical success was achieved in 66 of 73 cases (90.4%). Mean patient age was 65 ± 7 years, and 30% had prior coronary artery bypass surgery. Dual injection was used in 78%. The primary approach was retrograde in 9 cases (12.5%) and antegrade in 64 cases (87.5%), of whom 25 cases (39.1%) underwent retrograde attempt after failed antegrade approach. The initial crossing approach was successful in 40 cases (54.8%), but 32 cases (44%) required 3.6 ± 1.4 approach changes (range 2-7). Antegrade wire escalation, antegrade dissection/reentry, and retrograde crossing were utilized in 97.2%, 46.6%, and 46.6% of cases, respectively. Among successful cases, the final CTO crossing technique was antegrade wire escalation in 50.0%, antegrade dissection/reentry in 24.2%, and retrograde in 25.8%. The mean procedure time, fluoroscopy time, and air kerma radiation exposure until CTO crossing or stopping the procedure were 66 ± 55 minutes, 25 ± 23 minutes, and 2.3 ± 1.9 Gray, respectively. Three patients (4.1%) had a major complication.In the "hybrid approach" to CTO PCI, changes in crossing strategy were needed in approximately half the cases, resulting in high success and low complication rates.

Percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has been traditionally associated with lower success rates in patients with previous coronary artery bypass graft surgery (CABG). We sought to examine the success and complication rates of CTO PCI using the "hybrid" crossing algorithm among patients with a history of previous CABG. The procedural outcomes of 496 consecutive CTO PCIs performed at 5 high-volume PCI centers in the United States from January 2012 to August 2013 were assessed. The outcomes of patients with previous CABG were compared with those of patients without previous CABG. Compared with patients without previous CABG (n = 320), patients with previous CABG (n = 176, 35%) were older, had more coronary artery disease risk factors, and had less favorable baseline angiographic CTO characteristics. Technical and procedural success was slightly lower among patients with previous CABG (88.1% vs 93.4%, p = 0.044 and 87.5 vs 92.5%, p = 0.07, respectively). Patients with previous CABG more commonly underwent CTO PCI using the retrograde approach (39% vs 24%, respectively, p

The J-CTO (Multicenter Chronic Total Occlusion [CTO] Registry in Japan) score was developed to predict the probability of successful guidewire crossing within 30 minutes. However, guidewire crossing alone does not ensure final success of CTO PCI. We therefore sought to develop a novel parsimonious

We present a systematic review and meta-analysis of the frequency, consequences, and treatment of stent loss during percutaneous coronary intervention (PCI).Stent loss during PCI has received limited study.We conducted a meta-analysis of 18 case series and 45 case reports published between 1991 and 2012 on stent loss during PCI. Data on the frequency of stent loss, treatment strategies, and clinical outcomes were collected.A total of 1048 stents were lost in 968 PCIs. Stent loss occurred in 919 of 71,655 PCIs (1.3%; 95% confidence interval, 0.8%-2.8%). The incidence of stent loss in studies published before 2000, between 2000 and 2005, and after 2005 was 5%, 1%, and 0.3%, respectively (P.001). Of the 1048 lost stents, 698 (66%) were successfully retrieved from the coronary circulation, 130 (12%) were deployed, 27 (3%) were crushed, and 28 (3%) were left untreated; treatment of 165 stents (16%) was not reported. A complication occurred in 171 patients (19%), of whom 98 (57%) had coronary artery bypass graft surgery, 31 (18%) myocardial infarction, 33 (19%) died, 10 (6%) had bleeding requiring transfusion, 5 (3%) had vascular access complications, and 1 patient (0.6%) had a cerebrovascular accident (some patients had more than one event).The incidence of stent loss during PCI is low and has been decreasing. Although the lost stents were successfully retrieved in most cases, stent loss was associated with high rates of complications, such as coronary artery bypass graft surgery, myocardial infarction, and death.

The Boston Scientific CrossBoss and Stingray Coronary CTO Crossing and Re-Entry devices (formerly the BridgePoint Medical System) can improve success rates in chronic total occlusion (CTO) percutaneous coronary intervention (PCI), but there are no published data on long-term clinical outcomes.The acute and long-term outcomes of 170 consecutive patients who underwent CTO PCI at our institution were reviewed, including 60 patients in whom the CrossBoss and Stingray devices were used and 110 patients treated with other crossing strategies.Baseline characteristics were similar between the two cohorts. Patients in whom the CrossBoss/Stingray was utilized had more prior CTO PCI attempts (13.1% vs 1.6%; P=.003), required longer fluoroscopy times (46 ± 22 minutes vs 35 ± 20 minutes; P.001), higher contrast dose (390 ± 141 mL vs 323 ± 132 mL; P.99), and more guidewires for lesion crossing (8.0 ± 6.5 vs 4.7 ± 2.3; P.001), but procedural success (75.8% vs 76.2%; P.99) and major complication rates (4.8% vs 3.2%; P=.69) were similar. During a median follow-up of 1.81 years, the CrossBoss/Stingray group had no difference in target lesion revascularization (40.9% vs 29.6%; P=.13) and major adverse clinical events (40.3% vs 35.2%; P=.42).Use of the CrossBoss/Stingray devices for CTO PCI is associated with equally high success and equally low complication rates as other techniques, both immediately post procedure and during long-term follow-up, in spite of its use in higher complexity cases.

a complete coronary revascularization as compared to patients with incomplete revascularization (96% 3% vs. 78% 7%; p1⁄40.002); completeness of revascularization was inversely related to the risk of death (HR 0.10; p1⁄40.029). Conclusions: In patients with multiple CTOs a successful PCI of all CTOs was associated with increased cardiac survival, and completeness of revascularization was a strong predictor of survival.

We sought to examine the prevalence and management of coronary chronic total occlusions (CTO) within a contemporary veteran population. We collected clinical and angiographic data on 1,699 consecutive patients that underwent coronary angiography at our institution between January 2011 and December

Background The efficacy and safety profile of retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We sought to perform a weighted meta-analysis of the success and complication rates of retrograde CTO PCI. Methods We conducted a meta-analysis of 26 studies published between 2006 and April 2013 reporting in-hospital outcomes of retrograde CTO PCI. Data on procedural success, frequency of death, emergent coronary artery bypass graft surgery (CABG), stroke, myocardial infarction (MI), perforation, tamponade, stent thrombosis, major vascular or bleeding events, contrast nephropathy, and radiation skin injury were collected. Results A total of 26 studies with 3482 patients and 3493 target CTO lesions were included. Primary retrograde CTO PCI was attempted in 52.4%. Pooled estimates of outcomes were as follows: procedural success 83.3% [95% confidence interval (CI): 79.0% to 87.7%]; death 0.7% (95% CI: 0.5% to 1.2%); urgent CABG 0.7% (95% CI: 0.4% to 1.2%); tamponade 1.4% (95% CI: 1.0% to 2.2%); collateral perforation 6.9% (95% CI: 4.6% to 10.4%); coronary perforation 4.3% (95% CI: 1.2% to 15.4%); donor vessel dissection 2% (95% CI: 0.9% to 4.5%); stroke 0.5% (95% CI: 0.2% to 1.0%); MI 3.1% (95% CI: 0.2% to 5.0%); Q wave MI 0.6% (95% CI: 0.4% to 1.1%); vascular access complications 2% (95% CI: 0.9% to 4.5%); contrast nephropathy 1.8% (95% CI: 0.8% to 3.7%); and wire fracture and equipment entrapment 1.2% (95% CI: 0.6% to 2.5%). Conclusions Retrograde CTO PCI is associated with high procedural success rate and acceptable risk for procedural complications.

This study sought to compare and contrast use and radiation exposure using radial versus femoral access during cardiac catheterization of patients who had previously undergone coronary artery bypass graft (CABG) surgery.Limited information is available on the relative merits of radial compared with femoral access for cardiac catheterization in patients who had previously undergone CABG surgery.Consecutive patients (N = 128) having previously undergone CABG surgery and referred for cardiac catheterization were randomized to radial or femoral access. The primary study endpoint was contrast volume. Secondary endpoints included fluoroscopy time, procedure time, patient and operator radiation exposure, vascular complications, and major adverse cardiac events. Analyses were by intention-to-treat.Compared with femoral access, diagnostic coronary angiography via radial access was associated with a higher mean contrast volume (142 ± 39 ml vs. 171 ± 72 ml, p0.01), longer procedure time (21.9 ± 6.8 min vs. 34.2 ± 14.7 min, p0.01), greater patient air kerma (kinetic energy released per unit mass) radiation exposure (1.08 ± 0.54 Gy vs. 1.29 ± 0.67 Gy, p = 0.06), and higher operator radiation dose (first operator: 1.3 ± 1.0 mrem vs. 2.6 ± 1.7 mrem, p0.01; second operator 0.8 ± 1.1 mrem vs. 1.8 ± 2.1 mrem, p = 0.01). Fewer patients underwent ad hoc percutaneous coronary intervention (PCI) in the radial group (37.5% vs. 46.9%, p = 0.28) and radial PCI procedures were less complex. The incidences of the primary and secondary endpoints was similar with femoral and radial access among PCI patients. Access crossover was higher in the radial group (17.2% vs. 0.0%, p 0.01) and vascular access site complications were similar in both groups (3.1%).In patients who had previously undergone CABG surgery, transradial diagnostic coronary angiography was associated with greater contrast use, longer procedure time, and greater access crossover and operator radiation exposure compared with transfemoral angiography. (RADIAL Versus Femoral Access for Coronary Artery Bypass Graft Angiography and Intervention [RADIAL-CABG] Trial; NCT01446263).

Optical coherence tomography (OCT) coronary imaging requires displacement of red blood cells from the vessel lumen. This is usually accomplished using radiographic contrast. Low molecular weight dextran has low cost and is safe in low volumes. In the present study, we compared dextran with contrast for coronary OCT imaging.Fifty-one vessels in 26 patients were sequentially imaged using manual injection of radiographic contrast (iodixanol) and dextran. OCT images were analyzed at 1 mm intervals to determine the image clarity (defined as a visible lumen border270°) and to measure the lumen area and lumen diameter. To correct for the refractive index of dextran, the dextran area measurements were multiplied by 1.117 and the dextran length measurements were multiplied by 1.057.A total of 3,418 cross-sections (1,709 with contrast and 1,709 with dextran) were analyzed. There were no complications related to OCT imaging or to contrast or dextran administration. Clear image segments were observed in 97.0% vs. 96.7% of the cross-sections obtained with contrast and dextran, respectively (P = 0.45). The mean lumen areas were also similar: 6.69 ± 1.95 mm(2) with iodixanol vs. 7.06 ± 2.06 mm(2) with dextran (correlation coefficient 0.984).The image quality and measurements during OCT image acquisition are similar for dextran and contrast. Dextran could be used instead of contrast for OCT imaging, especially in patients in whom contrast load minimization is desired.

Stent loss is an infrequent but potentially grave complication of percutaneous coronary intervention (PCI). We performed a systematic review to determine the frequency, treatment and consequences of stent loss during PCI. We identified and reviewed all published literature in English on stent loss

The frequency and success of CTO PCI has been increasing in recent years. We sought to examine the contemporary perspectives and practices on chronic total occlusion (CTO) percutaneous coronary intervention (PCI). An online questionnaire on CTO PCI was created and distributed to cardiologists

Intravascular imaging can facilitate chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We examined the frequency of use and outcomes of intravascular imaging among 619 chronic total occlusion (CTO) percutaneous coronary interventions (PCIs) performed between 2012 and 2015 at 7

There is ongoing controversy about the optimal crossing strategy selection for chronic total occlusion (CTO) percutaneous coronary intervention (PCI), especially regarding the relative merits of antegrade dissection/re-entry and the retrograde approach.We retrospectively examined the clinical outcomes of 173 consecutive patients who underwent successful CTO PCI at our institution between January 2012 and March 2015.The mean age was 65 ± 8 years, and 98% of the patients were men with a high prevalence of diabetes (60%), previous coronary artery bypass grafting (CABG) (31%), and previous PCI (54%). The successful CTO crossing strategy was antegrade wire escalation in 79 patients (45.5%), antegrade dissection/re-entry in 58 patients (33.5%), retrograde wire escalation in 11 patients (6.4%), and retrograde dissection and re-entry in 25 patients (14.5%). The retrograde approach was more commonly used in lesions with interventional collaterals (P0.0001), moderate/severe calcification (P = 0.02), blunt stump (P = 0.01), and a higher Japan Chronic Total Occlusion score (P = 0.0002). Use of dissection and re-entry (both antegrade and retrograde) was associated with bifurcation and the distal cap (P = 0.004), longer CTO occlusion length (P0.0001), and longer stent length (P0.0001). Median follow-up was 11 months. The 12-month incidence of death, myocardial infarction, and the composite of acute coronary syndrome/target lesion revascularization/target vessel revascularization was 2.5%, 4.9%, and 24.4%, respectively, and was similar with intimal and subintimal crossing strategies.Antegrade dissection/re-entry and retrograde approaches are frequently used during CTO PCI and were associated with similarly favorable intermediate-term outcomes as antegrade wire escalation.

We sought to examine the efficacy and safety of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using the retrograde approach. We compared the outcomes of the retrograde vs. antegrade only approach to CTO PCI among 1,301 procedures performed at 11 US centers between 2012 and

We prospectively examined the impact of side-holes and guide catheter disengagement on fractional flow reserve (FFR) measurements. Twenty-five patients undergoing clinically-indicated FFR measurement for intermediate coronary artery stenosis were enrolled. Four FFR measurements were made in random

We sought to examine the effect of patient age on the outcomes of percutaneous coronary intervention (PCI) of chronic total occlusions (CTO). We examined clinical and angiographic data as well as outcomes of 1,216 CTO PCIs performed in 1,195 patients divided into three age groups (