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Gender-specific data addressing percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) in female patients are scarce and based on small sample size studies.We aimed to analyze gender-differences regarding in-hospital clinical outcomes after CTO-PCI.Data from 35,449 patients enrolled in the prospective European Registry of CTOs were analyzed. The primary outcome was the comparison of procedural success rate in the two cohorts (women vs. men), defined as a final residual stenosis less than 20%, with Thrombolysis In Myocardial Infarction grade flow = 3. In-hospital major adverse cardiac and cerebrovascular events (MACCEs) and procedural complications were deemed secondary outcomes.Women represented 15.2% of the entire study population. They were older and more likely to have hypertension, diabetes, and renal failure, with an overall lower J-CTO score. Women showed a higher procedural success rate (adjusted OR [aOR] = 1.115, confidence interval [CI]: 1.011-1.230, p = 0.030). Apart from previous myocardial infarction and surgical revascularization, no other significant gender differences were found among predictors of procedural success. Antegrade approach with true-to-true lumen techniques was more commonly used than retrograde approach in females. No gender differences were found regarding in-hospital MACCEs (0.9% vs. 0.9%, p = 0.766), although a higher rate of procedural complications was observed in women, such as coronary perforation (3.7% vs. 2.9%, p < 0.001) and vascular complications (1.0% vs. 0.6%, p < 0.001).Women are understudied in contemporary CTO-PCI practice. Female sex is associated with higher procedural success after CTO-PCI, yet no sex differences were found in terms of in-hospital MACCEs. Female sex was associated with a higher rate of procedural complications.

BackgroundThe postdischarge prognostic implication of periprocedural myocardial injury in patients undergoing percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) remains scarcely studied.AimsThe aim of this study is to assess the prognostic value of periprocedural myocardial injury, defined by increased high-sensitive troponin T (hs-TnT) levels according to updated guidelines, after CTO PCI.MethodsBetween September 2011 and April 2020, 726 patients undergoing CTO PCI at 2 Belgian referral centres were prospectively included and divided into 4 groups based on postprocedural hs-TnT levels (unelevated; ≥5 times the upper limit of normal (ULN); ≥35 times the ULN; ≥70 times the ULN). Postprocedural hs-TnT levels were subsequently related to patient and procedural characteristics, 1-year major adverse cardiac and cerebrovascular events (MACCE; excluding in-hospital MACCE) as well as 1-year mortality.ResultsAt 1 year follow-up (FU), elevated hs-TnT≥5 times and ≥35 times the ULN were associated with higher MACCE rates (p=0.001; p=0.007, respectively). In addition, they also resulted in a higher 1-year mortality rate (p=0.009;p=0.021, respectively). Patients with increased hs-TnT≥5 times the ULN (35% of patients) more frequently had signs of more advanced atherosclerotic disease (previous CABG p48 mm pConclusionPeriprocedural myocardial injury was associated with a significantly higher rate of MACCE and all-cause mortality after 12 months of FU.

IntroductionAlthough recently published evidence favours transradial access (TRA) when using large-bore guiding catheters for percutaneous coronary intervention (PCI) of complex coronary lesions, the femoral artery will still be used in a considerate proportion of patients undergoing complex PCI, especially in PCI of chronic total occlusions (CTO). Ultrasound-guided puncture of the femoral artery may reduce clinically relevant access site complications, but robust evidence is lacking up to date.Methods and analysisA total of 542 patients undergoing complex PCI, defined as PCI of CTO, complex bifurcation, heavy calcified lesion or left main, in which the 7-F or 8-F transfemoral access is required, will be randomised to ultrasound-guided puncture or fluoroscopy-guided puncture. The primary outcome is the incidence of the composite end-point of clinically relevant access site related bleeding and/or vascular complications requiring intervention. Access site complications and major adverse cardiovascular events up to 1 month will also be compared between both groups.Ethics and disseminationEthical approval for the study was granted by the local Ethics Committee (‘Medisch Ethische Toetsing Commissie Isala Zwolle’) for all Dutch sites, ‘Comité Medische Ethiek Ziekenhuis Oost-Limburg’ for Hospital Oost-Limburg, ‘Comité d’éthique CHU-Charleroi—ISPPC’ for Centre Hospilatier Universitaire de Charleroi and ‘Ethik Kommission de Ärztekammer Nordrhein’ for Elisabeth-Krankenhaus). The trial outcomes will be published in peer-reviewed journals of the concerned literature. Theultrasound guidedtransfemoral access incomplexlarge bore PCI trial has been administered in the ClinicalTrials.gov database, reference number:NCT03846752.Registration detailsClinicalTrials.gov identifier:NCT03846752.

Objectives The authors sought to examine the outcomes of percutaneous coronary intervention (PCI) for in-stent restenosis (ISR) chronic total occlusions (CTOs). Background The outcomes of PCI for ISR CTOs have received limited study. Methods The authors examined the clinical and angiographic characteristics and procedural outcomes of 11,961 CTO PCIs performed in 11,728 patients at 107 centers in Europe, North America, Latin America, and Asia between 2012 and 2020, pooling patient-level data from 4 multicenter registries. In-hospital major adverse cardiovascular events (MACE) included death, myocardial infarction, stroke, and tamponade. Long-term MACE were defined as the composite of all-cause death, myocardial infarction, and target vessel revascularization. Results ISR represented 15% of the CTOs (n = 1,755). Patients with ISR CTOs had higher prevalence of diabetes (44% vs. 38%; p Conclusions ISR CTOs represent 15% of all CTO PCIs and can be recanalized with similar success and in-hospital MACE as de novo CTOs.

Item does not contain fulltext OBJECTIVES: The aim of this study was to investigate whether transradial (TR) percutaneous coronary intervention (PCI) is superior to transfemoral (TF) PCI in complex coronary lesions with large-bore guiding catheters with respect to clinically relevant access site-related bleeding or vascular complications. BACKGROUND: The femoral artery is currently the most applied access site for PCI of complex coronary lesions, especially when large-bore guiding catheters are required. With downsizing of TR equipment, TR PCI may be increasingly applied in these patients and might be a safer alternative compared with the TF approach. METHODS: An international prospective multicenter trial was conducted, randomizing 388 patients with planned PCI for complex coronary lesions, including chronic total occlusion, left main, heavy calcification, or complex bifurcation, to either 7-F TR access (TRA) or 7-F TF access (TFA). The primary endpoint was defined as access site-related clinically significant bleeding or vascular complications requiring intervention at discharge. The secondary endpoint was procedural success. RESULTS: The primary endpoint event rate was 3.6% for TRA and 19.1% for TFA (p

Background Recent improvement in clinical skills, technology and hardware has resulted in improved success rates with chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We performed a study level pooled analysis from the five largest registries of percutaneous coronary intervention (PCI) of CTO. Research design and methods We conducted pooled analysis of 9500 patients in registries and data on procedural characteristics, technical success, and MACCE was collected. Results A total of 9500 patients were included in the analysis. Mean age was 65.4 years with previous CABG in 24.8%, reattempt procedure in 24.8% and mean JCTO score was 2.2. Final wiring strategy in hybrid algorithm-based registries was AWE in 40.8-58%, Retrograde in 24-35%, ADR in 16-25% and in Expert JCTO and EURO CTO was AWE in 72-75% and retrograde in 25-28%. Technical success was achieved in 87.8%. In hospital MACCE was 2.5 % (95% CI: 1.8 to 3.4%), mortality 0.44% (95% CI: 0.23 to 0.84%), stroke 0.2% (95% CI: 0.1 to 0.3%); myocardial infraction 1.6% (95% CI: 1.1 to 2.2%); and cardiac tamponade 0.8% (95% CI: 0.5 to 1.3 %). Conclusion CTO PCI is currently performed with high technical success rates and low complication rates in experienced hands utilizing various techniques.

A 56-year-old women without a coronary past presented to the emergency room with complaints of typical persistent chest pain. The electrocardiogram showed negative T waves in anterior leads, and th...

© 2021 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC By-NC-ND License (http://creativecommons.org/licenses/by-nc-nd/4), The authors developed a global chronic total occlusion crossing algorithm following 10 steps: 1) dual angiography; 2) careful angiographic review focusing on proximal cap morphology, occlusion segment, distal vessel quality, and collateral circulation; 3) approaching proximal cap ambiguity using intravascular ultrasound, retrograde, and move-the-cap techniques; 4) approaching poor distal vessel quality using the retrograde approach and bifurcation at the distal cap by use of a dual-lumen catheter and intravascular ultrasound; 5) feasibility of retrograde crossing through grafts and septal and epicardial collateral vessels; 6) antegrade wiring strategies; 7) retrograde approach; 8) changing strategy when failing to achieve progress; 9) considering performing an investment procedure if crossing attempts fail; and 10) stopping when reaching high radiation or contrast dose or in case of long procedural time, occurrence of a serious complication, operator and patient fatigue, or lack of expertise or equipment. This algorithm can improve outcomes and expand discussion, research, and collaboration.

IntroductionThe radial artery has become the standard access site for percutaneous coronary intervention (PCI) in stable coronary artery disease and acute coronary syndrome, because of less access site related bleeding complications. Patients with complex coronary lesions are under-represented in randomised trials comparing radial with femoral access with regard to safety and efficacy. The femoral artery is currently the most applied access site in patients with complex coronary lesions, especially when large bore guiding catheters are required. With slender technology, transradial PCI may be increasingly applied in patients with complex coronary lesions when large bore guiding catheters are mandatory and might be a safer alternative as compared with the transfemoral approach.Methods and analysisA total of 388 patients undergoing complex PCI will be randomised to radial 7 French access with Terumo Glidesheath Slender (Terumo, Japan) or femoral 7 French access as comparator. The primary outcome is the incidence of the composite end point of clinically relevant access site related bleeding and/or vascular complications requiring intervention. Procedural success and major adverse cardiovascular events up to 1 month will also be compared between both groups.Ethics and disseminationEthical approval for the study was granted by the local Ethics Committee at each recruiting center (‘Medisch Ethische Toetsing Commissie Isala Zwolle’, ‘Commissie voor medische ethiek ZNA’, ‘Comité Medische Ethiek Ziekenhuis Oost-Limburg’, ‘Comité d’éthique CHU-Charleroi-ISPPC’, ‘Commission cantonale d'éthique de la recherche CCER-Republique et Canton de Geneve’, ‘Ethik Kommission de Ärztekammer Nordrhein’ and ‘Riverside Research Ethics Committee’). The trial outcomes will be published in peer-reviewed journals of the concerned literature.Trial registration numberNCT03846752.

Aim: Chronic total occlusions (CTO) in patients with history of coronary artery bypass graft (CABG) show more advanced and complex atherosclerotic pathology. Aim of our study is to compare outcomes in patients undergoing CTO percutaneous coronary intervention (PCI) with previous CABG versus those without in the REgistry of Crossboss and Hybrid procedures in FrAnce the NetheRlands, BelGium and UnitEd Kingdom (RECHARGE). Methods & results: The RECHARGE cohort (1,252 patients) was divided in two groups according to the presence of previous CABG (217) or not. We also focused, in the post-CABG group, on a comparison between CTO in previously grafted vessels versus non-grafted vessels. The CTO complexity scores were higher and the success rate (71.9% vs. 88.7%, p

Chronic total occlusions (CTO) in patients with history of coronary artery bypass graft (CABG) show more advanced and complex atherosclerotic pathology. Aim of our study is to compare outcomes in patients undergoing CTO percutaneous coronary intervention (PCI) with previous CABG versus those without in the REgistry of Crossboss and Hybrid procedures in FrAnce the NetheRlands, BelGium and UnitEd Kingdom (RECHARGE).The RECHARGE cohort (1,252 patients) was divided in two groups according to the presence of previous CABG (217) or not. We also focused, in the post-CABG group, on a comparison between CTO in previously grafted vessels versus non-grafted vessels. The CTO complexity scores were higher and the success rate (71.9% vs. 88.7%, p .001) was lower in the CABG group, this difference was driven by higher failure rates in high-complexity-score CTO. The rate of in-hospital complications was similar. In the post-CABG group, the procedural success of CTO located in previously grafted vessels versus those in vessels not previously grafted, was comparably suboptimal (73.1% vs. 68%, p = .47).Patients undergoing CTO PCI with prior CABG have a higher prevalence of comorbidities and more complex lesion characteristics. In the post-CABG population the success rate was significantly lower, particularly in high CTO complexity scores, though complication rates were comparable. In the post-CABG population, the CTO success rate was independent of the presence of a previous graft on the CTO vessel.

Dr Azzalini received honoraria from Guerbet, Terumo, and Sahajanand Medical Technologies; and research support from ACIST Medical Systems, Guerbet, and Terumo. Dr Pan received honoraria from Abbott Vascular. The other authors report no conflicts of interest.

We aimed to evaluate the impact of incomplete revascularization (ICR) on long-term outcomes of patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Consecutive patients undergoing CTO PCI at 4 centers were included. Baseline SYNTAX score (bSS: low [≤ 22], intermediate [22 and33], high [≥33]), residual SYNTAX score (rSS: 0,0 and ≤8,8), and SYNTAX revascularization index (SRI: 100 × (bSS-rSS)/bSS: 100%, 50% to 99%,50%) were calculated. The primary end point was major adverse cardiac events (MACEs; cardiac death, any myocardial infarction, any revascularization) on follow-up. Multivariable Cox regression analysis was conducted to identify predictors of MACEs. Overall, 686 patients were included (low bSS: n = 437; intermediate bSS: n = 187; high bSS: n = 62). Occlusion complexity, crossing strategies, and procedural success rates were similar across groups. The degree of ICR increased with higher bSS categories (rSS was 2.5 ± 4.7 in low vs 6.2 ± 9.3 in intermediate vs 9.1 ± 12.2 in high bSS, p0.001). The SRI followed a similar pattern. Median follow-up was 781 (369 to 1,217) days. Three-year MACE rates increased with higher bSS and rSS, and decreasing SRI categories (bSS: low 19.4% vs intermediate 25.9% vs high 33.3%, p = 0.02), which was driven by a higher incidence of repeat revascularization. Compared with an rSS = 0, both an rSS0 and ≤8 (hazard ratio 2.06, p = 0.004) and an rSS8 (hazard ratio 3.19, p0.001) were independent predictors of MACEs. Similar findings were observed when the SRI was entered in a separate model. In conclusion, even a mild degree of ICR is associated with a higher incidence of MACEs on long-term follow-up after CTO PCI.

We aimed to investigate the procedural and long-term outcomes of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in patients who had undergone previous coronary artery bypass grafting (CABG) vs those who had not, and to evaluate the role of the Registry of CrossBoss and Hybrid procedures in France, the Netherlands, Belgium, and United Kingdom (RECHARGE) score in predicting acute and long-term outcomes.We compiled a multicentre registry of consecutive patients undergoing CTO PCI at 7 centres between January 2009 and April 2017. The primary end point was target-vessel failure (TVF), a composite of cardiac death, target-vessel myocardial infarction, and target-vessel revascularization on follow-up.Overall, 2058 patients were included (patients who underwent CABG, n = 401; CABG-naïve patients, n = 1657). Patients who had undergone CABG were older and had a higher prevalence of comorbidities and higher occlusion complexity (RECHARGE score, 3.6 ± 1.3 vs 1.8 ± 1.2; P0.001). Antegrade dissection/re-entry techniques and the retrograde approach were used more frequently in patients who had undergone CABG. Procedural metrics were worse, and technical (82% vs 88%; P = 0.001) and procedural (81% vs 87%; P = 0.001) success was lower in patients who had undergone CABG. They also experienced a higher rate of major complications (3.7% vs 1.5%; P = 0.004). The RECHARGE score was inversely associated with technical success (P0.001). Median follow-up was 377 days (interquartile range, 277-766 days). The 24-month TVF rate was higher in patients who had undergone CABG than in CABG-naïve patients (16.1% vs 9.0%; P0.001). On multivariable analysis, the RECHARGE score (hazard ratio, 1.61; P0.001) remained an independent predictor of TVF, together with longer total stent length and not using a drug-eluting stent.Compared with CABG-naïve patients, CTO PCI in patients who had undergone CABG shows higher procedural complexity, worse success rates, and higher adjusted risk of TVF on follow-up.

Objectives The authors sought to evaluate the final 5-year safety and effectiveness of the platinum-chromium everolimus-eluting stent (PtCr-EES) in the randomized trial, as well as in 2 single-arm substudies that evaluated PtCr-EES in small vessels (diameter Background In the multicenter, randomized PLATINUM (PLATINUM Clinical Trial to Assess the PROMUS Element Stent System for Treatment of De Novo Coronary Artery Lesions), the PtCr-EES was noninferior to the cobalt-chromium everolimus-eluting stent (CoCr-EES) at 1 year in 1,530 patients undergoing percutaneous coronary intervention. Methods Patients with 1 or 2 de novo coronary artery lesions (reference vessel diameter 2.50 to 4.25 mm, length ≤24 mm) were randomized 1:1 to PtCr-EES versus CoCr-EES. All patients in the substudies received PtCr-EES. The primary endpoint was target lesion failure (TLF), a composite of target vessel-related cardiac death, target vessel-related myocardial infarction, or ischemia-driven target lesion revascularization. Results In the randomized trial, the 5-year TLF rate was 9.1% for PtCr-EES and 9.3% for CoCr-EES (hazard ratio [HR]: 0.97; p = 0.87). Landmark analysis demonstrated similar TLF rates from discharge to 1 year (HR: 1.12; p = 0.70) and from 1 to 5 years (HR: 0.90; p = 0.63). There were no significant differences in the rates of cardiac death, myocardial infarction, target lesion or vessel revascularization, or stent thrombosis. PtCr-EES had 5-year TLF rates of 7.0% in small vessels and 13.6% in long lesions. Conclusions PtCr-EES demonstrated comparable safety and effectiveness to CoCr-EES through 5 years of follow-up, with low rates of stent thrombosis and other adverse events. The 5-year event rates were also acceptable in patients with small vessels and long lesions treated with PtCr-EES. (The PLATINUM Clinical Trial to Assess the PROMUS Element Stent System for Treatment of De Novo Coronary Artery Lesions [PLATINUM]; NCT00823212; The PLATINUM Clinical Trial to Assess the PROMUS Element Stent System for Treatment of De Novo Coronary Artery Lesions in Small Vessels [PLATINUM SV]; NCT01498692; The PLATINUM Clinical Trial to Assess the PROMUS Element Stent System for Treatment of Long De Novo Coronary Artery Lesions [PLATINUM LL]; NCT01500434)

Objectives High platelet reactivity (HPR) was studied in patients presenting with ST-segment elevation myocardial infarction (STEMI) due to stent thrombosis (ST) undergoing immediate percutaneous coronary intervention (PCI). Background HPR on P2Y 12 inhibitors (HPR-ADP) is frequently observed in stable patients who have experienced ST. The HPR rates in patients presenting with ST for immediate PCI are unknown. Methods Consecutive patients presenting with definite ST were included in a multicenter ST registry. Platelet reactivity was measured before immediate PCI with the VerifyNow P2Y 12 or Aspirin assay. Results Platelet reactivity was measured in 129 ST patients presenting with STEMI undergoing immediate PCI. HPR-ADP was observed in 76% of the patients, and HPR on aspirin (HPR-AA) was observed in 13% of the patients. HPR rates were similar in patients who were on maintenance P2Y 12 inhibitor or aspirin since stent placement versus those without these medications. In addition, HPR-ADP was similar in patients loaded with a P2Y 12 inhibitor shortly before immediate PCI versus those who were not. In contrast, HPR-AA trended to be lower in patients loaded with aspirin as compared with those not loaded. Conclusions Approximately 3 out of 4 ST patients with STEMI undergoing immediate PCI had HPR-ADP, and 13% had HPR-AA. Whether patients were on maintenance antiplatelet therapy while developing ST or loaded with P2Y 12 inhibitors shortly before undergoing immediate PCI had no influence on the HPR rates. This raises concerns that the majority of patients with ST have suboptimal platelet inhibition undergoing immediate PCI.

Case series Patient: Male, 81 • Female, 72 • Male, 58 Final Diagnosis: CTO Symptoms: Angina pectoris Medication: — Clinical Procedure: PCI Specialty: Cardiology Objective: Unusual setting of medical care Background: Retrograde advancement of microcatheters through septal/epicardial connectors can be challenging. Although several tricks might help to do so (e.g., balloon trap of retro wire in second guiding, balloon trap of retro wire in native coronary artery, and use of antegrade extension to approximate the antegrade conduit to the retrograde gear), these tricks cannot always be applied, especially in patients with poor access. Also, puncturing, knuckling, and crossing of the distal CTO cap (or the aorta as described in 1 of the cases) sometimes needs a lot of backup of the microcatheter. Case Report: We describe 3 cases in which we used a novel telescopic technique with 5F Guidion (IMDS®) supported retrograde Corsair (Asahi®) advancement in complex CTO lesions. Conclusions: The telescopic Corsair in 5F Guidion may offer the support needed to end successfully in these situations.

© American Heart Association, Inc., Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI. 1. Ischemic symptom improvement is the primary indication for CTO-PCI. 2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI. 3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges. 4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs. 5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use. 6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation. 7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training.

Aims: We aimed to compare healing responses with optical coherence tomography, and clinical and angiographic outcome after treatment of coronary bifurcation lesions with a dedicated stent versus a conventional culotte technique. Methods and results: Forty patients with true and complex coronary bifurcation lesions were randomly assigned to treatment with the Axxess™ bifurcation stent in the proximal main vessel (MV) and additional BioMatrix™ stents in the branches (Biosensors Europe SA, Morges, Switzerland), versus a culotte technique using XIENCE™ stents (Abbott Vascular, Santa Clara, CA, USA). The primary endpoint of percentage of uncovered struts at nine months was similar with the dedicated strategy vs. culotte in the proximal MV (median 17.8 [IQR 3.3-24.7] vs. 6.8 [2.0-20.5]; p=0.19), bifurcation core (9.5 [5.7-19.5] vs. 4.0 [0.7-17.6]; p=0.17), distal MV (2.6 [2.3-18] vs. 2.2 [0.5-6.0]; p=0.09) and side branch (5.7 [1.5-11.5] vs. 1.9 [0-5.8]; p=0.14). As compared with culotte, a strategy using Axxess resulted in a significantly larger lumen in the proximal MV both acutely (minimum lumen diameter 3.03±0.51 vs. 2.71±0.44 mm, p=0.04) and at follow-up (mean lumen area 10.0±2.1 vs. 7.1±1.8 mm 2 , p

Aims Long-term data on bioabsorbable polymer-coated everolimus-eluting stents (BP-EES) are limited. The EVOLVE trial compared the safety and efficacy of two dose formulations of the SYNERGY BP-EES with the permanent polymer-coated PROMUS Element EES (PE). Methods and results The EVOLVE study was a prospective, multicentre, non-inferiority trial that randomised 291 patients with de novo coronary lesions (length: ≤28 mm; diameter: ≥2.25 to ≤3.5 mm) to receive PE (n=98), SYNERGY (n=94), or SYNERGY half-dose (n=99). At five years, there were no significant differences in the rates of TLF or individual components between groups. TLR rates trended lower in both SYNERGY arms than in the PE arm (TLR: 1.1% SYNERGY and 1.0% SYNERGY half-dose vs. 6.1% PE; p=0.07 and p=0.06, respectively). TVR was numerically lower in the SYNERGY arms compared to the PE arm (TVR: 3.3% SYNERGY and 4.2% SYNERGY half-dose vs. 10.2% PE; p=0.06 and p=0.11, respectively). No incidence of stent thrombosis was reported in any arm up to five years. Conclusions The EVOLVE trial represents the longest-term follow-up of the SYNERGY stent available to date, demonstrating its continued safety and efficacy for the treatment of selected de novo atherosclerotic lesions up to five years.

OBJECTIVES We evaluated healing responses with optical coherence tomography, and long-term clinical outcomes after treatment with a dedicated stent versus a conventional culotte technique. BACKGROUND Dedicated bifurcation stents have been proposed as an alternative treatment for coronary bifurcation lesions. The long-term performance of dedicated stents versus conventional dual-stent techniques for the treatment of complex coronary bifurcation lesions is unknown. METHODS Forty patients with true coronary bifurcation lesions were randomized to treatment with a dedicated Axxess bifurcation stent in the proximal main vessel and additional Biomatrix stents in branches versus culotte stenting using Xience stents. RESULTS The percentage of uncovered struts in each bifurcation segment at 9 months (primary endpoint) was similar between groups. Five-year clinical follow-up was available for all patients and included major adverse cardiac events [MACE; a composite of cardiac death, myocardial infarction (MI) and ischemia-driven target lesion revascularization (TLR)], target-vessel (TVR) and non-target-vessel revascularization (non-TVR), non-TLR and stent thrombosis. At 5 years, in the culotte group, one patient had undergone TLR and another suffered a clinical MI, resulting in 10% MACE versus none in the Axxess group. TVR (5% vs. 10%, P = 0.54) and non-TVR (5% vs. 20%, P = 0.39) rates were similar between the Axxess and culotte groups, respectively. There was no stent thrombosis. CONCLUSION Compared with culotte stenting with Xience, complex coronary bifurcation stenting using a dedicated strategy combining the Axxess and Biomatrix stents results in similar stent strut coverage at 9 months, and excellent clinical outcomes at 5 years.

Objectives To evaluate the impact of incomplete revascularisation (ICR) on long-term outcomes following chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Background ICR is associated with worse post-PCI outcomes. Methods We included consecutive patients undergoing CTO PCI at 4 centres (07/2011 to 01/2017). Baseline SYNTAX score (bSS: low [≤22], intermediate [23–32], high [≥33]), residual SYNTAX score (rSS: 0–4, 4.5–8,>8), and SYNTAX Revascularisation Index (SRI: 100×(bSS-rSS)/bSS: 100%, 50%–99%, Results We included 686 patients (low bSS: n=437; intermediate bSS: n=187; high bSS: n=62). Mean bSS was 14.0±4.7 vs 26.0±2.6 vs 39.7±6.0 (p 8 (HR 3.00, 95% CI: 1.85 to 4.86, p Conclusions Even a mild degree of ICR is associated with worse long-term outcomes following CTO PCI.

Objective: To assess midterm (3 years) clinical outcomes of transcatheter aortic valve implantation (TAVI) in Belgium using the Edwards SAPIEN valve or the Medtronic CoreValve transcatheter heart valve (THV). Background: Medium and long term follow-up data of both THVs are still relatively scarce, although of great clinical relevance for a relatively new but rapidly expanding treatment modality. Therefore, reporting mid- and long term clinical outcome data, coming from large “real world” national registries, remains contributive. Methods: Between December 2007 and March 2012, 861 “real world” patients who were not candidates for surgical aortic valve replacement as decided by the local heart teams, underwent TAVI at 23 sites. Eleven sites exclusively used SAPIEN THV (n 5460), while 12 exclusively used CoreValve THV (n 5401). Differences in clinical outcomes by valve system were assessed, according to access route and baseline EuroSCORE risk profile ( 20%: high risk). Results: Overall cumulative survival at 3 years was 51% for SAPIEN vs. 60% for CoreValve (P 50.021). In transfemorally treated patients, SAPIEN and CoreValve had similar survival at 3 years for each of the baseline EuroSCORE cohorts (low risk: 72% vs. 76%, P 50.45; intermediate risk: 62% vs. 59%, P 50.94; high risk: 48% vs. 53%, P 50.65). Conclusion: Cumulative midterm 3 year survival after transfemoral TAVI in “real world” patients refused for surgery with similar baseline EuroSCORE risk profile is not different between SAPIEN or CoreValve. V C 2015 Wiley Periodicals, Inc.

Background— Small observational studies demonstrate the feasibility of transradial approach for chronic total occlusion (CTO) percutaneous coronary intervention. The aim of the current study is to assess technical success, complication rates, and procedural efficiency in fully transradial approach (fTRA) and transfemoral approach (TFA) in a large prospective European registry adopting the hybrid algorithm for CTO percutaneous coronary intervention (Registry of CrossBoss and Hybrid Procedures in France, the Netherlands, Belgium and United Kingdom, RECHARGE registry). Methods and Results— We analyzed 1253 CTO percutaneous coronary intervention procedures performed according to the hybrid protocol in 17 European centers, comparing fTRA (single or biradial access) and TFA (single or bifemoral or combined radial and femoral access). fTRA was applied in 306 (24%) and TFA in 947 (76%) cases. The average Japanese CTO score was 2.1±1.2 in fTRA and 2.3±1.1 in TFA ( P =0.06). Technical success was achieved in 85% in fTRA and 86% in TFA ( P =0.51). Technical success was comparable for fTRA and TFA in different Japanese CTO score subgroups after multivariable analysis and after propensity adjustment. In-hospital major adverse cardiac and cerebral events occurred in 2.0% in fTRA and 2.9% in TFA ( P =0.40). Major access site bleeding occurred in 0.3% in fTRA and 0.5% in TFA ( P =0.66). fTRA compared with TFA had similar procedural duration (80 minutes [54–120 minutes] versus 90 minutes [60–121 minutes]; P =0.07), similar radiation dose (dose area product 89 Gray×cm 2 [52–163 Gray×cm 2 ] versus 101 Gray×cm 2 [59–171 Gray×cm 2 ]; P =0.06), and lower contrast agent use (200 mL [150–310 mL] versus 250 mL [200–350 mL]; P Conclusions— fTRA CTO percutaneous coronary intervention is a valid alternative to TFA with a high rate of success, low complication rates, and no decrease in procedural efficiency.

The aim of this study was to describe the procedural aspects and outcomes of retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) through ipsilateral collateral channels (ILCs).Retrograde CTO PCI via ILCs is rarely performed, usually when no other retrograde options exist, and available evidence derives mostly from case reports.A large retrospective multinational registry was compiled, including all consecutive patients undergoing retrograde CTO PCI through ILCs at 6 centers between September 2011 and October 2016. Success rates, as well as procedural complications and in-hospital outcomes, were studied.A total of 126 patients (17% of all retrograde CTO PCIs) were included. The mean age was 65.7 ± 11.2 years, and the mean J-CTO (Multicenter CTO Registry in Japan) score was 2.36 ± 1.13. The target vessel was the circumflex coronary artery in 42%, the left anterior descending coronary artery in 39%, and the right coronary artery in 19%. The ILCs used were epicardial in 76% and septal in 24%. ILC anatomy was very heterogeneous. One guiding catheter was used in 80%, whereas the ping-pong technique was used in 20%. A retrograde wire could be advanced to the distal cap in 81%. Technical and procedural success rates were 87% and 82%, respectively. ILC perforation with need for intervention was observed in 5.6% and tamponade due to ILC perforation in 2.4%. One patient (0.8%) died.Retrograde CTO PCI through ILCs is a challenging intervention that can be performed in difficult occlusions with high success rates and reasonable rates of complications by experienced operators.

In a ranking of the gross domestic product per capita in 2015, Belgium ranked 19th in the world according to the International Monetary Fun1d and the World Bank. It has a Human Development Index of 0.890, in which it is preceded by only 20 other countries in the world. This is, at least in part, due to a well-developed social security system on which all citizens can rely. Over the last 5-10 years, however, this system has come under increasing pressure. This has resulted in insufficient, incomplete and late reimbursement of all technologies that were introduced over the last ten years in the cathlab: intracoronary imaging techniques are not reimbursed at all, and FFR only to a vastly insufficient degree. For several structural heart interventions, a system of limited and incomplete reimbursement has recently been set up, with a requirement to organise these procedures within the frames of hospital networks. Numbers of PCIs have risen by 15% over the last four years, coinciding with an increase in the number of cathlabs by 50%, aiming at better access to primary PCI for STEMI patients. This has also resulted in a decrease in the average procedure volume per centre. Two thirds of PCIs are performed via the radial access. DES penetration has increased to 74%, approaching 100% in some centres, while the uptake of BRS has been very limited so far.

[Verbrugge, Frederik H.; Dupont, Matthias; Bertrand, Philippe B.; Nijst, Petra; Grieten, Lars; Dens, Joseph; Verhaert, David; Mullens, Wilfried] Ziekenhuis Oost Limburg, Genk, Limburg, Belgium. [Verbrugge, Frederik H.; Bertrand, Philippe B.; Nijst, Petra; Grieten, Lars; Mullens, Wilfried] Hasselt Univ, Hasselt, Limburg, Belgium. [Janssens, Stefan] Univ Ziekenhuis Leuven, Leuven, Vlaams Brabant, Belgium. [Tang, W. H. Wilson] Cleveland Clin, Cleveland, OH 44106 USA.

Objectives To report 1- and 2-year clinical outcomes of patients receiving platinum chromium everolimus-eluting stents (PtCr-EES) in the prospective, single-arm PLATINUM small vessel (SV) and long lesion (LL) studies. Background Small vessel diameter and long lesion length are independently associated with increased risk of adverse cardiac events after drug-eluting stent implantation. Methods The PLATINUM SV study enrolled 94 patients with coronary artery lesions in vessels ≥2.25 mm to 24 to ≤34 mm long in vessels ≥2.50 to ≤4.25 mm in diameter. The primary endpoint for both studies was target lesion failure (TLF) at 1 year compared to a prespecified performance goal based on outcomes with the TAXUS Express paclitaxel-eluting stent in small vessels and long lesions. Results One-year TLF rates with the PtCr-EES were significantly (P

In the last few years, the success rate of chronic total occlusion (CTO) percutaneous coronary interventions (PCIs) has rapidly improved. CTO lesions in patients with a history of coronary artery bypass graft (CABG) show more extensive calcification, negative remodeling, and accelerated progression

The highest benefit of revascularization is found in patients with very low fractional flow reserve (FFR). In chronic total occlusion (CTO) patients, instant wave-free ratio (iFR, Philips) may be more appropriate to evaluate ischemia as it does not require maximal microvascular vasodilation, which

Objective In the past, certain lesion characteristics of chronic total occlusions (CTOs) have been shown to have an influence on guidewire crossing and thus percutaneous coronary interventional outcome. However, a clear description of the individual impact of these characteristics on procedural outcome, procedural characteristics and treatment strategy is lacking. The purpose of this study was to give a "weight"to these individual characteristics and evaluate their influence on interventional strategy. Methods Between November 2011 and May 2013, a non-randomized, prospective study was conducted in the hospitals of Genk and Aalst, leading to the inclusion of 132 consecutive patients. Lesions were classified according to the J-CTO (Multicenter CTO Registry of Japan) score (Morino et al., 2011). Both antegrade and retrograde procedures were performed. For antegrade procedures, a step-up strategy was applied. Univariate and multivariate analyses were performed and compared with the results of Morino et al.The study end point was general procedural success, defined as successful stenting with thrombosis in myocardial infarction 3 flow. Results Overall procedural success was achieved in 74% and according to J-CTO criteria, in 92% (easy), 82% (intermediate), 77% (difficult) and 40% (very difficult), respectively. Independent predictors included bending, blunt stump, multivessel PCI and a retrograde approach with corresponding odds ratios for failure of 5.3, 2.7, 2.8 and 4.0, respectively. Conclusion Lesion characteristics of CTOs remain important in the prediction of success. In this study, bending and a blunt stump at the entry site came forth as the most important independent predictors of failure.

To improve the success rates of chronic total occlusion (CTO) intervention, a large range of CTO-dedicated guidewires (GWs), devices and techniques have been developed. However, such an abundant choice of materials confuses inexperienced operators. Therefore, the usefulness of a simple antegrade treatment algorithm with a limited set of GWs, for easy to intermediate lesions, was investigated. Between November 2011 and March 2013, 105 patients were included, who underwent CTO PCI following the algorithm. Lesions were classified according to the Multicenter CTO Registry of Japan score. Overall technical success was achieved in 77%. Study endpoint was successful GW crossing within 30 min and was reached in 57%. High success rates were achieved in easy (81%) and intermediate (64%) lesion types. In both types, a soft wire could successfully cross in 57% and 51% respectively, with the Fielder XT® (Asahi Intecc Co.) capable of crossing most commonly (90%). The proposed treatment algorithm simplifies the percutaneous treatment of easy to intermediate CTO lesions. However, it merits further evaluation, especially for operators/centers who perform a low to intermediate amount of CTO PCI.

Background: Post-cardiac arrest (CA) patients are at risk of secondary ischemic damage in the case of suboptimal brain oxygenation during an ICU stay. We hypothesized that elevated central venous pressures (CVP) would impair cerebral perfusion and oxygenation (venous cerebral congestion). The aim of the present study was to investigate the relationship between CVP, cerebral tissue oxygen saturation (SctO2) as assessed with near-infrared spectroscopy (NIRS) and outcome in post-CA patients. Methods: This was an observational study in 48 post-CA patients with continuous CVP and SctO2 monitoring during therapeutic hypothermia. Results: The relationship between CVP and mean SctO2 was best described by an S-shaped, third-degree polynomial regression curve (SctO2 = −0.002 × CVP3 + 0.08 × CVP2 – 1.07 × CVP + 69.78 %, R2 0.89, n = 1,949,108 data points) with high CVP (>20 mmHg) being associated with cerebral desaturation. Multivariate linear regression revealed CVP to be a more important determinant of SctO2 than mean arterial pressure (MAP) without important interaction between both (SctO2 = 0.01 × MAP – 0.20 × CVP + 0.001 × MAP × CVP + 65.55 %). CVP and cardiac output were independent determinants of SctO2 with some interaction between both (SctO2 = 1.86 × CO – 0.09 × CVP – 0.05 × CO × CVP + 60.04 %). Logistic regression revealed that a higher percentage of time with CVP above 5 mmHg was associated with lower chance of survival with a good neurological outcome (cerebral performance category (CPC) 1–2) at 180 days (OR 0.96, 95 % CI 0.92–1.00, p = 0.04). In a multivariate model, the negative association between CVP and outcome persisted after correction for hemodynamic variables, including ejection fraction and MAP. Conclusions: Elevated CVP results in lower brain saturation and is associated with worse outcome in post-CA patients. This pilot study provides support that venous cerebral congestion as indicated by high CVP may be detrimental for post-CA patients. The study is part of the Limburg Clinical Research Program (LRCP) UHasselt-ZOL-Jessa, supported by the foundation Limburg Sterk Merk, hasselt University, Ziekenhuis Oost-Limburg and Jessa hospital. There are no other financial disclosures.

Objectives This study sought to compare the safety and efficacy of 2 dose formulations of SYNERGY, a novel bioabsorbable polymer everolimus-eluting stent (EES) (Boston Scientific Corp., Natick, Massachusetts) compared with the durable polymer PROMUS Element EES (Boston Scientific Corp.). Background Durable polymer coatings on drug-eluting stents have been associated with chronic inflammation and impaired healing. Bioabsorbable polymer-coated drug-delivery systems may reduce the risk of late adverse events, including stent thrombosis, and thus the need for prolonged dual-antiplatelet therapy. Methods A total of 291 patients with a de novo lesion ≤28 mm in length, in a coronary artery of ≥2.25 to ≤3.5 mm diameter, were enrolled in the EVOLVE study, a prospective, randomized, single-blind, noninferiority trial. Patients were randomly assigned in a 1:1:1 ratio to PROMUS Element, SYNERGY, or SYNERGY half dose. The primary clinical endpoint was the 30-day rate of target lesion failure, defined as cardiac death or myocardial infarction related to the target vessel, or target lesion revascularization. The primary angiographic endpoint was 6-month in-stent late loss measured by quantitative coronary angiography. Results The 30-day primary clinical endpoint of target lesion failure occurred in 0%, 1.1%, and 3.1% of patients in the PROMUS Element, SYNERGY, and SYNERGY half dose groups, respectively. The 6-month in-stent late loss was 0.15 ± 0.34 mm for PROMUS Element, 0.10 ± 0.25 mm for SYNERGY, and 0.13 ± 0.26 mm for SYNERGY half dose (SYNERGY, difference −0.06, upper 95.2% confidence limit: 0.02, p for noninferiority Conclusions The EVOLVE trial confirms the effective delivery of everolimus by a unique directional bioabsorbable polymer system utilizing the SYNERGY stent. (A Prospective Randomized Multicenter Single-Blind Noninferiority Trial to Assess the Safety and Performance of the Evolution Everolimus-Eluting Monorail Coronary Stent System [Evolution Stent System] for the Treatment of a De Novo Atherosclerotic Lesion [EVOLVE]; NCT01135225 )