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ABSTRACT Introduction and objectives: Distal embolization and no-reflow are common complications in primary angioplasty and the information available on the role played by the deflation speed of the stent delivery system is scarce. Our aim is to analyze how the deflation speed of the stent delivery system impacts the results of primary angioplasty. Methods: From December 2016 through February 2019, all consecutive patients with ST-segment elevation myocardial infarction undergoing urgent coronary angiography at our institution and who were eligible for thrombectomy, IIB-IIIA inhibitors, and direct stenting were randomized in a 1:1 ratio to rapid (group 1, n = 103) or slow deflation of the stent delivery system, at 1 atm/second, (group 2, n = 107). Pre- and postdilatation was not allowed per protocol. The primary outcomes were myocardial blush ≥ 2 and ST-segment resolution ≥ 70% while the size of myocardial damage, the ejection fraction both at discharge and at the 12-month follow-up, and the overall and 12-month cardiovascular mortality rates were the secondary outcomes. Results: The study was stopped prematurely with 50% of the estimated sample size due to futility. Myocardial blush ≥ 2 occurred in 77 (74.7%) vs 79 (75.2%) of the patients, P = .93, and ST-segment resolution ≥ 70% occurred in 54 (53.9%) vs 59 (55.5%) of the patients, P = .75 in groups 1 and 2, respectively without any differences being reported in any of the secondary endpoints. Conclusions: In our series, the deflation speed of the stent delivery system in primary angioplasty did not modify the myocardial blush ≥ 2, the ST-segment resolution ≥ 70% or impacted the clinical outcomes, the size of myocardial infarction according to the biomarkers or the ejection fraction.

RESUMEN Introducción y objetivos: La embolización distal y el fenómeno de no-reflow son complicaciones frecuentes de la angioplastia primaria. La información disponible sobre la influencia de la velocidad de desinflado del sistema de liberación del stent es escasa. Nuestro objetivo es analizar la influencia de este factor en los resultados de la angioplastia primaria. Métodos: Entre diciembre de 2016 y febrero de 2019, todos los pacientes consecutivos con infarto de miocardio con elevación del segmento ST sometidos a coronariografía urgente en nuestro centro y que eran susceptibles de trombectomía, inhibidores de IIB-IIIA e implante directo de stent fueron aleatorizados 1:1 a un desinflado rápido del sistema de liberación (grupo 1, n = 103) o a un desinflado lento a 1 atm/s (grupo 2, n = 107). Por protocolo, no se permitió la predilatación previa ni posterior. Los objetivos primarios fueron el grado de blush miocárdico ≥ 2 y la resolución del segmento ST ≥ 70%. Los objetivos secundarios fueron el tamaño del infarto, la fracción de eyección al alta y a los 12 meses, y las mortalidades total y cardiovascular a los 12 meses. Resultados: El estudio se detuvo prematuramente con el 50% del tamaño muestral calculado por futilidad. Se encontró blush ≥ 2 en 77 (74,7%) frente a 79 (75,2%) pacientes (p = 0,93) y resolución del segmento ST ≥ 70% en 54 (53,9%) frente a 59 (55,5%) pacientes (p = 0,75) en los grupos 1 y 2, respectivamente, sin diferencias en ninguno de los objetivos secundarios. Conclusiones: En nuestra serie, la velocidad de desinflado del sistema de liberación del stent en la angioplastia primaria no modificó el blush miocárdico ni la resolución del segmento ST, y tampoco demostró tener influencia en los resultados clínicos, el tamaño del infarto según los biomarcadores ni la fracción de eyección.

RESUMEN Introducción y objetivos: Los aneurismas coronarios son una situación compleja. Planteamos como objetivo principal describir la frecuencia de utilización de stents recubiertos (grafts) para su tratamiento y caracterizar sus resultados a largo plazo en comparación con stents farmacoactivos. Métodos: Estudio observacional ambispectivo, con información procedente del Registro Internacional de Aneurismas Coronarios (CAAR) (NCT-02563626). Se seleccionaron los pacientes que recibieron un stent-graft o un stent farmacoactivo en la zona del aneurisma. Resultados: Un total de 17 pacientes recibieron al menos un stent-graft y 196 un stent farmacoactivo en la zona aneurismática. Se observa un predominio del sexo masculino y una mayor frecuencia de dislipemia, antecedentes de coronariopatía, enfermedad coronaria revascularizada previamente y aneurismas gigantes en la cohorte de stent-graft. Como variables independientes predictoras del desarrollo del evento combinado (muerte por cualquier causa, insuficiencia cardiaca, angina inestable, reinfarto, ictus, embolia sistémica, sangrado o cualquier complicación en el aneurisma), tras una mediana de seguimiento de 38 meses, destacaron la existencia de conectivopatías (hazard ratio [HR] = 5,94; intervalo de confianza del 95% [IC95%], 1,82-19,37), la disfunción del ventrículo izquierdo ≤ 55% (HR = 1,84; IC95%, 1,09-3,1) y la indicación aguda del cateterismo índice (HR = 2,98; IC95%, 1,39-6,3). El uso de stent-grafts comparado con el de stents farmacoactivos no se asoció al desarrollo de más eventos combinados (23,5 frente a 29,6%; p = 0,598). Conclusiones: El uso de stents recubiertos en aneurismas coronarios es factible y seguro a largo plazo. Se necesitan estudios clínicos aleatorizados para decidir el mejor tratamiento de este tipo de lesiones complejas.

ABSTRACT Introduction and objectives: Coronary artery aneurysms are a complex situation. Our main objective is to describe the frequency of use of covered stents (grafts) for their management, as well as to characterize their long-term results compared to drug-eluting stents. Methods: Ambispective observational study with data from the International Coronary Artery Aneurysm Registry (CAAR) (NCT-02563626). Only patients who received a stent-graft or a drug-eluting stent where the aneurysm occurred were selected. Results: A total of 17 patients received, at least, 1 stent-graft while 196 received 1 drug-eluting in the aneurysmal vessel. Male predominance, a higher rate of dyslipidemia, a past medical history of coronary artery disease, previously revascularized coronary artery disease, and giant aneurysms were reported in the stent-graft cohort. The independent predictive variables of the composite endpoint of all-cause mortality, heart failure, unstable angina, reinfarction, stroke, systemic embolism, bleeding or any aneurysmal complications at the median follow-up of 38 months were suggestive of the existence of connective tissue diseases (HR, 5.94; 95%CI, 1.82-19.37), left ventricular dysfunction ≤ 55% (HR, 1.84; 95%CI, 1.09-3.1), and an acute indication for heart catheterization (HR, 2.98; 95%CI, 1.39-6.3). The use of stent-grafts was not associated with the occurrence of more composite endpoints (23.5% vs 29.6%; P = .598). Conclusions: The use of stent-grafts to treat coronary aneurysms is feasible and safe in the long-term. Randomized clinical trials are needed to decide what the best treatment is for these complex lesions. Keywords: Coronary aneurysm. Registry. Stent. Stent graft. Angioplasty.

IntroductionIn-stent restenosis (ISR) is a major challenge in interventional cardiology. Both ISR and excessive skin healing are aberrant hyperplasic responses, which may be functionally related. However, the cellular component underlying ISR remains unclear, especially regarding vascular homeostasis. Recent evidence suggest that novel immune cell populations may be involved in vascular repair and damage, but their role in ISR has not been explored. The aims of this study is to analyze (i) the association between ISR and skin healing outcomes, and (ii) the alterations in vascular homeostasis mediators in ISR in univariate and integrative analyses.Methods30 patients with ≥1 previous stent implantation with restenosis and 30 patients with ≥1 stent without restenosis both confirmed in a second angiogram were recruited. Cellular mediators were quantified in peripheral blood by flow cytometry. Skin healing outcomes were analyzed after two consecutive biopsies.ResultsHypertrophic skin healing was more frequent in ISR patients (36.7%) compared to those ISR-free (16.7%). Patients with ISR were more likely to develop hypertrophic skin healing patterns (OR 4.334 [95% CI 1.044–18.073], p=0.033), even after correcting for confounders. ISR was associated with decreased circulating angiogenic T-cells (p=0.005) and endothelial progenitor cells (p

PREGUNTA: ¿Cree que existen suficientes evidencias para indicar el uso de imagen intravascular durante el intervencionismo coronario percutáneo? RESPUESTA: La introducción de la angiografía intracoronaria supuso un avance sin precedentes en el tratamiento de la cardiopatía isquémica. Sin embargo, desde su inicio se hicieron evidentes las limitaciones que tiene esta técnica. La aparición de la ecografía intravascular (IVUS) hace ya 30 años, y posteriormente de la tomografía de coherencia óptica (OCT), ha aportado ventajas importantes tanto en el diagnóstico como en el intervencionismo coronario. Si bien los estudios individuales que han comparado la IVUS con la angiografía han mostrado resultados variables, varios metanálisis1 refuerzan el uso de la primera. Por otra parte, aunque el recorrido de la OCT es mucho más corto y, en consecuencia, el soporte de evidencia científica es menor, su excelente calidad de imagen la ha convertido en la técnica de elección en la caracterización de placas complejas, la detección de complicaciones durante el procedimiento y la evaluación del implante de stent, tanto en la práctica clínica como en estudios clínicos. P.: ¿Para qué contextos anatómicos o clínicos existen más evidencias? R.: Ambas técnicas de imagen han demostrado su mejor coste-eficacia en lesiones complejas. En este contexto, ambas proporcionan información...

QUESTION: Do you think there is enough evidence to indicate the use of intravascular imaging during percutaneous coronary interventions? ANSWER: The appearance of intracoronary angiography was a major breakthrough for the management of ischemic heart disease. However, the limitations of this imaging modality became evident right from the start. The arrival of intravascular ultrasound (IVUS) 30 years ago now and then the optical coherence tomography (OCT) brought significant advances regarding diagnosis and percutaneous coronary intervention. Although the independent studied that compared IVUS and angiography showed variable results, several meta-analyses1 reinforce the use of the former. On the other hand, although the OCT is much newer compared to the IVUS and there is less scientific evidence supporting it, the excellent quality of its images has turned it into the imaging modality of choice for the management of complex plaques, the detection of complications during the procedure, and the assessment of stent implantation both in the clinical practice and clinical studies. Q.: Which are the anatomical or clinical contexts with more evidence available? A.: Both imaging modalities have proven their best cost-effectiveness ratio for the management of complex lesions. In this context, both provide very valuable information in calcified lesions. However, each of them has...

INTRODUCTION Due to the commotion caused by the growing number of late thrombosis after drug-eluting stents implantation back in 2005,1 1 year courses of dual antiplatelet therapy (DAPT) were recommended after the implants. The lower rate of this complication thanks to improved designs of the device has made it possible to shorten these courses. The shortest courses of DAPT are still under discussion2-4 (figure 1), yet 1-month courses of DAPT with further withdrawal of 1 of the 2 drugs has been agreed on. However, most 1-month DAPT studies have been conducted with low-risk patients5,6 or have focused on patients with stable coronary artery disease.7

INTRODUCCIÓN A partir de la alarma generada por el incremento del número de casos de trombosis tardía tras el implante de stents farmacoactivos en 20051, se recomendó 1 año de tratamiento antiagregante plaquetario doble (TAPD) después de dicho implante. La reducción en la tasa de esta complicación derivada de la mejoría en el diseño de los dispositivos ha permitido un acortamiento del TAPD. Las pautas más cortas de TAPD están siendo objeto de estudio2-4 (figura 1) y se ha llegado al TAPD de tan solo 1 mes con posterior suspensión de uno de los 2 fármacos. No obstante, la mayoría de los estudios con TAPD de 1 mes se han realizado en pacientes de bajo riesgo5,6 o se han centrado en pacientes con cardiopatía isquémica estable7.

RESUMEN Introducción y objetivos: La escala de puntuación PSP (pre-dilation, sizing and post-dilation), derivada del registro GHOST-EU, evalúa la relación entre la técnica de implante de los armazones bioabsorbibles y los resultados clínicos. El objetivo fue realizar una validación externa de la escala PSP y determinar su efecto en eventos adversos cardiacos en diversos escenarios clínicos y anatómicos. Métodos: Para la validación externa se emplearon los datos del registro REPARA (2.230 pacientes), mientras que se utilizó una base de datos común que combina datos de REPARA y GHOST-EU (3.250 pacientes) para evaluar el efecto de la técnica PSP en varios escenarios clínicos y anatómicos. Se usó PSP-1 y PSP-3 para calificar la calidad de la predilatación, el dimensionamiento de los armazones y la posdilatación. El objetivo primario fue la variable compuesta orientada al dispositivo (muerte cardiaca, infarto de miocardio del vaso diana y revascularización de la lesión diana) a 1 año. También se evaluó la trombosis definitiva o probable del armazón según los criterios del Academic Research Consortium. Resultados: Se trató a 303 (18,2%) pacientes con una PSP-1 óptima y a 182 (8,2%) con una PSP-3 óptima. La validación externa mostró que la escala PSP tiene un valor predictivo negativo muy alto para el objetivo primario compuesto orientado al dispositivo y la trombosis del armazón (91,8 y 89,1% para PSP-1; 98,4 y 97,3% para PSP-3, respectivamente). En pacientes con PSP-3 óptimo, el objetivo primario compuesto orientado al dispositivo y la trombosis del armazón fueron numéricamente inferiores en comparación con los pacientes sin PSP-3 óptimo (0,5 frente a 2,9%; p = 0,085; y 0,5 frente a 1,8%; p = 0,248, respectivamente). En la base de datos combinada, los beneficios de la escala PSP se observaron en diversos escenarios, excepto en el de infarto de miocardio con elevación del segmento ST, en el que se observó una tendencia hacia laausencia de beneficios de una técnica de PSP óptima (pinteracción = 0,100). Conclusiones: Una técnica de PSP óptima no se asoció con una tasa más baja del objetivo primario compuesto orientado al dispositivo. Se necesitan nuevos estudios para evaluar el impacto de la técnica de PSP con un seguimiento más prolongado.

ABSTRACT Introduction and objectives: The PSP (pre-dilation, sizing and post-dilation) score, derived from the GHOST-EU registry, has evaluated the relationship between the implantation technique of bioresorbable scaffolds and the clinical outcomes. The objective was to perform an external validation of the PSP technique and to determine its effect on adverse cardiac events in various clinical and anatomical scenarios. Methods: Data from the REPARA registry (2230 patients) were used for external validation, whereas a common database combining REPARA and GHOST-EU (3250 patients) data was used to evaluate the effect of PSP technique in various clinical and anatomical scenarios. PSP-1 and PSP-3 were used to score the appropriateness of pre-dilation, scaffold sizing, and post-dilation. The primary endpoint was 1-year device-oriented composite endpoint of cardiac death, target-vessel myocardial infarction, and target-lesion revascularization. The definite/probable scaffold thrombosis according to the Academic Research Consortium criteria was also evaluated. Results: A total of 303 (18.2%) patients were treated with an optimal PSP-1, and 182 (8.2%) with an optimal PSP-3. The external validation showed that PSP has a very high negative predictive value for device-oriented composite endpoint and scaffold thrombosis (91.8% and 89.1% for PSP-1; 98.4% and 97.3% for PSP-3, respectively). Patients with an optimal PSP-3 had a numerically lower rate of device-oriented composite endpoint and scaffold thrombosis compared to those without it (0.5% vs 2.9%; P = .085 and 0.5% vs 1.8%; P = .248, respectively). In the merged database, PSP benefits were seen on many scenarios, except in the ST-segment elevation myocardial infarction where a trend towards no benefit of an optimal PSP technique was present (Pinteraction = .100). Conclusions: In the REPARA registry, at 1-year follow-up, an optimal PSP technique was not associated with a lower rate of device-oriented composite endpoint. Further research is necessary to assess the impact of the PSP technique in longer follow-ups.

Abstract The purpose of this systematic review is to evaluate the safety of pre-endovascular abdominal aortic aneurysm repair (EVAR) embolization of aortic side branches - the inferior mesenteric artery and lumbar arteries. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. A search of MEDLINE and DIMENSION databases identified 9 studies published from 2011 to 2021 that satisfied the inclusion and exclusion criteria. These studies were analyzed to detect the incidence of embolization-related complications. A total of 482 patients underwent preoperative aortic side branch embolization, 30 (6.2%) of whom suffered some kind of minor complication. The only major complication observed was ischemic colitis in 4 (0.82%) patients, two (0.41%) of whom died after bowel resection surgery. Regarding these findings, aortic side branch embolization seems to be a safe procedure, with very low percentages of both minor and major complications.

Abstract Background Chronic obstructive pulmonary disease (COPD) is projected to become the third cause of mortality worldwide. COPD shares several pathophysiological mechanisms with cardiovascular disease, especially atherosclerosis. However, no definite answers are available on the prognostic role of COPD in the setting of ST elevation myocardial infarction (STEMI), especially during COVID-19 pandemic, among patients undergoing primary angioplasty, that is therefore the aim of the current study. Methods In the ISACS-STEMI COVID-19 registry we included retrospectively patients with STEMI treated with primary percutaneous coronary intervention (PCI) between March and June of 2019 and 2020 from 109 high-volume primary PCI centers in 4 continents. Results A total of 15,686 patients were included in this analysis. Of them, 810 (5.2%) subjects had a COPD diagnosis. They were more often elderly and with a more pronounced cardiovascular risk profile. No preminent procedural dissimilarities were noticed except for a lower proportion of dual antiplatelet therapy at discharge among COPD patients (98.9% vs. 98.1%, P = 0.038). With regards to short-term fatal outcomes, both in-hospital and 30-days mortality occurred more frequently among COPD patients, similarly in pre-COVID-19 and COVID-19 era. However, after adjustment for main baseline differences, COPD did not result as independent predictor for in-hospital death (adjusted OR [95% CI] = 0.913[0.658–1.266], P = 0.585) nor for 30-days mortality (adjusted OR [95% CI] = 0.850 [0.620–1.164], P = 0.310). No significant differences were detected in terms of SARS-CoV-2 positivity between the two groups. Conclusion This is one of the largest studies investigating characteristics and outcome of COPD patients with STEMI undergoing primary angioplasty, especially during COVID pandemic. COPD was associated with significantly higher rates of in-hospital and 30-days mortality. However, this association disappeared after adjustment for baseline characteristics. Furthermore, COPD did not significantly affect SARS-CoV-2 positivity. Trial registration number: NCT 04412655 (2nd June 2020).

Abstract Background It has been suggested the COVID pandemic may have indirectly affected the treatment and outcome of STEMI patients, by avoidance or significant delays in contacting the emergency system. No data have been reported on the impact of diabetes on treatment and outcome of STEMI patients, that was therefore the aim of the current subanalysis conducted in patients included in the International Study on Acute Coronary Syndromes–ST Elevation Myocardial Infarction (ISACS-STEMI) COVID-19. Methods The ISACS-STEMI COVID-19 is a retrospective registry performed in European centers with an annual volume of > 120 primary percutaneous coronary intervention (PCI) and assessed STEMI patients, treated with primary PCI during the same periods of the years 2019 versus 2020 (March and April). Main outcomes are the incidences of primary PCI, delayed treatment, and in-hospital mortality. Results A total of 6609 patients underwent primary PCI in 77 centers, located in 18 countries. Diabetes was observed in a total of 1356 patients (20.5%), with similar proportion between 2019 and 2020. During the pandemic, there was a significant reduction in primary PCI as compared to 2019, similar in both patients with (Incidence rate ratio (IRR) 0.79 (95% CI: 0.73–0.85, p

Abstract Introduction and objectives: Accessing sharply angulated side branches using intracoronary guidewires sometimes poses great challenges, and even after using its distal end for accessing purposes, it usually prolapses inside the main vessel. We hereby present an easy way to perform these procedures using a specific guidewire for the management of chronic total occlusions. Methods: From January 2017 through September 2018, patients with lesions on sharply angulated side or large branches that required protection in bifurcations were approached using straight, angled tip and/or double-lumen microcatheters with regular guidewires. In cases of unsuccessful access, a specific wire designed for chronic total occlusions was used with the straight tip microcatheter after a drastic overhaul of the shape in its distal end. Results: In 9 patients access to the side branch was not achieved with the initial strategy, in 3 patients due to access inability and in the remaining 6 due to guidewire prolapse when trying to advance the microcatheter. In all 9 cases, the access could be completed using the Gaia First guidewire that combines an excellent torque with enough rigidity to prevent the prolapse of the tip. All procedures were performed without complications. Conclusions: The percutaneous coronary intervention of sharply angulated side branches can be challenging when advancing the guidewire. However, these procedures can be performed easily and quickly with a specific guidewire for the managemenf of chronic total occlusions.

Resumen Introducción y objetivos: El acceso con la guía intracoronaria a las ramas laterales con origen muy angulado en ocasiones presenta gran dificultad, e incluso después de acceder con el extremo distal frecuentemente se produce su prolapso en el vaso principal. Presentamos una forma fácil de realizar estos procedimientos con el uso de una guía específica de oclusión crónica. Métodos: Entre enero de 2017 y septiembre de 2018, los pacientes con lesiones en las ramas laterales o en ramas de gran tamaño que requerían protección en las bifurcaciones cuyo origen era muy angulado se abordaron con microcatéteres recto, angulado o de doble luz con guías regulares; posteriormente, en caso de imposibilidad de acceso, se pasó una guía específica de oclusión crónica con el microcatéter recto tras una modificación muy marcada de la forma del extremo distal de la guía. Resultados: En nueve pacientes no se consiguió el acceso a la rama lateral con la estrategia inicial, en tres de ellos por imposibilidad de acceso y en los seis restantes por prolapso de la guía al intentar progresar el microcatéter. En todos los casos el acceso pudo completarse con una guía Gaia First, que combina un excelente torque con una rigidez suficiente para evitar el prolapso. Todos los procedimientos se realizaron sin complicaciones. Conclusiones: El intervencionismo percutáneo en las ramas laterales con una marcada angulación puede conllevar una gran dificultad para el acceso con la guía. Estos procedimientos pueden realizarse de forma fácil y rápida con una guía específica de oclusión crónica.