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Objectives: To evaluate clinical and angiographic outcomes after successful recanalization of chronic total coronary occlusion (CTO) with implantation of a long total stent length (SL)., Background: Routine follow-up angiogram (RFUA) data after successful recanalization of CTO with a long SL are lacking., Methods: RFUAs were performed at 6 months after successful recanalization of 106 CTOs using drug-eluting stents (DESs) with a long SL (≥ 20 mm) in 102 consecutive patients., Results: Mean number of stents was 3.9 ± 1.8 and mean total SL was 78 ± 32 mm (range, 23-174 mm). Sirolimus-eluting stents (SESs) were used in 100 lesions. In-stent total reocclusion occurred in 2 cases (1 SES and 1 non-SES DES). Restenosis rate was 18% in the 100 SES subgroup (total SL, 79 ± 33 mm; range, 23-174 mm; mean number of stents, 3.9 ± 1.8); younger age and longer total SL were found to be independent predictors of restenosis (longer age: hazard ratio, 0.939; 95% confidence interval, 0.885-0.996; P=.035; longer total SL: hazard ratio, 1.017; 95% confidence interval, 1.00-1.03; P=.045). Restenosis type was diffuse in only 11% and 89% were successfully treated by repeat percutaneous coronary intervention. During a median follow-up of 2 years (interquartile range, 1-4.3 years), major cardiac events other than those angiographically driven at RFUA occurred in 2 patients., Conclusion: Angiographic restenosis rate remains acceptable in patients with complex CTO successfully treated by DES despite a long SL.

Objectives: We propose a modified simultaneous kissing stenting technique (MSKS) based on systematic implantation of a protective stent in the proximal main vessel (PMV) proximally to the bifurcation before simultaneous kissing stenting (SKS)., Background: SKS has been proposed in large-size coronary vessel bifurcation lesions (BLs) when the PMV can accommodate two stents. SKS implies, however, low-pressure simultaneous final balloon inflations to avoid retrograde PMV dissection or rupture and therefore may not ensure optimal final stent apposition., Methods: From January 2005 to May 2008, a total of 97 patients with 100 BLs (true bifurcation in 92%) who underwent MSKS were enrolled in a prospective registry. Drug-eluting stents were used for distal main vessel and side branch. Drug-eluting or large-size bare-metal stents were used as proximal protective stents., Results: Immediate procedural success rate was 100%. Global restenosis rate was 10% (5% in the main vessel and 8% in the side branch) at follow-up angiogram performed at 7 months in all patients (100%). No patient had early or late stent thrombosis. Two cases of non-fatal very late stent thrombosis occurred at 46 and 64 months. Over a mean 4.5-year follow-up period, target lesion revascularization rate was 11%, with only 3% driven by clinical ischemia., Conclusion: Protective stent systematic implantation in the PMV represents a newly modified SKS technique that allows safe finalization of the procedure by high-pressure kissing balloon final inflation, ensuring optimal stent apposition with high immediate procedural success and low rates of long-term events.

Background and Aim of the Study: Experimental investigations and invasive studies conducted in small series of patients using specially designed high-fidelity micromanometer tip catheters have suggested that downstream pressure recovery (PR) within the aorta may significantly affect transvalvular pressure gradient (PG) measurement. The study aims were to evaluate in a large cohort of patients the extent of PR when transvalvular PGs are routinely measured by fluid-filled pigtail side-hole catheters (FPC) using pullback from the left ventricle to the ascending aorta (AO), and to analyze factors influencing PR. The influence of PR on the correlation between catheter and Doppler PG measurements was also assessed in a subset of patients., Methods: Transvalvular PG were measured in 91 patients with aortic stenosis using FPC pullback with the catheter positioned at different sites within the ascending aorta. In 71 patients, Doppler echocardiography was obtained within 24 h of catheterization., Results: Mean PR ranged from 0 to 20 mmHg, corresponding to a PR index (percent of maximal PG) ranging from 0 to 31%. PG was < 50 mmHg in nine of 61 patients (15%) with a PG > 50 mmHg at the origin of the aorta when further measurements were conducted with the catheter positioned more distally in the ascending aorta. PR index better correlated with the ratio of valve area to ascending AO cross-sectional area (r = 0.61, p = 0.001) than with valve area (r = 0.37, p = 0.001) and ascending AO cross-sectional area (0.27, p = 0.02) alone. Differences between Doppler- and catheter-predicted PG were minimized when correcting Doppler by non-invasively calculated PR (p < 0.0001)., Conclusion: The magnitude of PR recorded in aortic stenosis by FPC, as used in most clinical catheterization laboratories, is low in the vast majority of patients. As predicted from fluid mechanics theory, the ratio of valve area to ascending AO cross-sectional area is the central determinant of PR. PR may affect the Doppler-catheter correlation in some patients.