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Background: Although drug-eluting stents (DES) have reduced the rates of in-stent restenosis (ISR) compared with bare-metal stents (BMS), DES related ISR (DES-ISR) still occurs and outcomes of DES-ISR remain unclear. The objective of this meta-analysis was to investigate the long-term clinical outcomes of patients with DES-ISR compared with patients with BMS related ISR (BMS-ISR) after the treatment of DES or drug-eluting balloon (DEB). Methods and results . We searched the literature in the main electronic databases including PUBMED, EMBASE, Cochrane Library, and Web of Science. The primary endpoints were target lesion revascularization (TLR) and target vessel revascularization (TVR). The secondary endpoints included all cause death (ACD), cardiac death (CD), myocardial infarction (MI), stent thrombosis or re-in-stent restenosis (ST/RE-ISR), and major adverse cardiovascular events (MACEs). A total of 19 studies with 6256 participants were finally included in this meta-analysis. Results showed that the rates of TLR ( P < 0.00001), TVR ( P < 0.00001), CD ( P =0.02), ST/RE-ISR ( P < 0.00001), and MACEs ( P < 0.00001) were significantly higher in the DES-ISR group than in the BMS-ISR group. No significant differences were found between the two groups in the rates of MI ( P =0.05) and ACD ( P =0.21)., Conclusions: Our study demonstrated that patients with DES-ISR had worse clinical outcomes at the long-term follow-up than patients with BMS-ISR after the treatment of DES or DEB, suggesting that DES and DEB may be more effective for BMS-ISR than that for DES-ISR. Positive prevention of DES-ISR is indispensable and further studies concentrating on detecting the predictors of outcomes of DES-ISR are required., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2020 Yi-Xing Yang et al.)

Background: Chronic total occlusion revascularization remains a challenging problem because of its complexity. We present a case of a patient with chronic total occlusion who was successfully revascularized with the use of a new device called a real-time intravascular ultrasound double-lumen microcatheter., Case Presentation: A 58-year-old East Asians woman presented to our hospital with a complaint of recurrent chest pain of 5 months' duration. Angiography revealed chronic total occlusion of the right coronary artery from the right coronary artery ostium to the ostia of the posterolateral and posterior descending branches. A guidewire was passed to the distal right coronary artery but went into the false lumens at the posterior descending and posterolateral ostia after use of the antegrade and retrograde approaches. Hence, we used the new device to pass through the subintimal right coronary artery space with reentry into the true lumen before the posterior descending and posterolateral ostia. A stent was successfully deployed at the posterior descending and posterolateral ostia, and the final result was excellent., Conclusions: This device was useful for finding the entry point and for reentry into the true lumen of a chronic total occlusion. It may be a valuable tool for recanalization of complex chronic total occlusion lesions.

Objective: The positive impact of minimally invasive extracorporeal circuits (MiECC) on patient outcome is expected to be most evident in patients with limited physiologic reserves. Nevertheless, most studies have limited their use to low-risk patients undergoing myocardial revascularization. As such, there is little evidence to their benefit outside this patient population. We, therefore, set out to explore their potential benefit in octogenarians undergoing aortic valve replacement (AVR) with or without concomitant myocardial revascularization., Methods: Based on the type of the utilized ECC, we performed a retrospective propensity score-matched comparison among all octogenarians (n = 218) who received a primary AVR with or without concomitant coronary artery bypass grafting in our institution between 2003 and 2010., Results: A MiECC was utilized in 32% of the patients. The propensity score matching yielded 52 matched pairs. The 30-day postoperative mortality (2% vs. 10%; p=0.2), the incidence of low cardiac output (0% vs. 6%; p=0.2) and the Intensive Care Unit (ICU) stay (2.5 ± 2.6 vs. 3.8 ± 4.7 days; p=0.06) were all in favour of the MiECC group, but failed to reach statistical significance while the 90-day postoperative mortality did (2% vs. 16%; p=0.02)., Conclusion: MiECCs have a positive influence on the outcome of octogenarians undergoing AVR with or without concomitant coronary artery bypass grafting. Their use should, therefore, be extended beyond isolated coronary artery bypass graft (CABG) surgery.

There are many underlying mechanisms for cocaine-associated myocardial infarction, and the culprit must be elucidated for appropriate therapeutic management. Optical coherence tomography provides unique insights when angiography alone has limited diagnostic value; it also aids in the decision between conservative management and revascularization strategy and guides coronary interventions.

Objective: The da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) cannot give tactile feedback to surgeons. This shortcoming may increase the risk of left internal thoracic artery (LITA) injury during its harvest. We utilized Firefly Fluorescence Imaging (Firefly) to assess LITA quality in robot-assisted minimally invasive direct coronary artery bypass (R-MIDCAB)., Methods: We retrospectively reviewed clinical records and intraoperative videos of 30 consecutive patients who underwent R-MIDCAB with LITA-left anterior descending (LAD) coronary bypass. All patients had post-harvest assessment of LITA blood flow by Firefly with 1 mL (2.5 mg/mL) of indocyanine green injection through a central line., Results: Twenty-seven of the patients were male, mean age was 67.7 ± 10.7 years. In post-harvest assessment performed before transection of the distal LITA, blood flow in LITA was well visualized in 28 patients. In the remaining 2 patients, 1 had dissection and the other had severe spasm of the LITA. Firefly was also useful for locating LITA and LAD and for assessing blood flow of the graft after anastomosis. Time required for each Firefly assessment was approximately 20 seconds. There were no side effects or complications due to Firefly intraoperatively and postoperatively. Twenty-six patients had postoperative coronary computed tomography; LITA patency rate was 100% (26/26)., Conclusion: Firefly is fast, simple, and effective for locating and assessing flow in LITA and LAD before and after anastomosis in R-MIDCAB.

Increasing evidence is available for the use of percutaneous coronary intervention (PCI) in selected patients with unprotected left main (LM) bifurcation coronary lesions. However, little data have been reported on recurrent in-stent restenosis (ISR) for LM bifurcation lesions. The aim of this study was to evaluate the efficacy of a drug-eluting balloon (DEB) for LM bifurcation ISR compared with that of a drug-eluting stent (DES).Between December 2011 and December 2015, 104 patients who underwent PCI for unprotected LM bifurcation ISR were enrolled. We separated the patients into 2 groups: (1) those underwent PCI with further DEB and (2) those underwent PCI with further DES. Clinical outcomes were analyzed.Patients' average age was 67.14 ± 7.65 years, and the percentage of male patients was 76.0%. A total of 75 patients were enrolled in the DEB group, and another 29 patients were enrolled in the DES group. Similar target lesion revascularization (TLR) rate and recurrent myocardial infarction (MI) rate were noted for both groups. A significantly higher cardiovascular mortality rate was found in the DES group (10.7% versus 0%, P = 0.020), and a higher all-cause mortality rate was noted in the DES group (21.4% versus 6.8%, P = 0.067).It is feasible to use DEB for LM bifurcation ISR. When comparing DEB with DES, similar TLR rates were found, but lower recurrent MI and lower cardiovascular death were noted for DEB treatment.

Introduction and Objectives: There is little evidence on the optimal strategy for bifurcation lesions in the context of a coronary chronic total occlusion (CTO). This study compared the procedural and mid-term outcomes of patients with bifurcation lesions in CTO treated with provisional stenting vs 2-stent techniques in a multicenter registry., Methods: Between January 2012 and June 2016, 922 CTO were recanalized at the 4 participating centers. Of these, 238 (25.8%) with a bifurcation lesion (side branch ≥ 2mm located proximally, distally, or within the occluded segment) were treated by a simple approach (n=201) or complex strategy (n=37). Propensity score matching was performed to account for selection bias between the 2 groups. Major adverse cardiac events (MACE) consisted of a composite of cardiac death, myocardial infarction, and clinically-driven target lesion revascularization., Results: Angiographic and procedural success were similar in the simple and complex groups (94.5% vs 97.3%; P=.48 and 85.6% vs 81.1%; P=.49). However, contrast volume, radiation dose, and fluoroscopy time were lower with the simple approach. At follow-up (25 months), the MACE rate was 8% in the simple and 10.8% in the complex group (P=.58). There was a trend toward a lower MACE-free survival in the complex group (80.1% vs 69.8%; P=.08). After propensity analysis, there were no differences between the groups regarding immediate and follow-up results., Conclusions: Bifurcation lesions in CTO can be approached similarly to regular bifurcation lesions, for which provisional stenting is considered the technique of choice. After propensity score matching, there were no differences in procedural or mid-term clinical outcomes between the simple and complex strategies., (Copyright © 2017 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Coronary artery disease in patients with diabetes mellitus (DM) is characterized by extensive atherosclerosis, longer lesions, and diffuse distal disease. Consequently, these patients have worse outcomes after coronary revascularization, regardless of the modality used. Traditionally, coronary artery bypass grafting (CABG) has been regarded as more effective than percutaneous coronary intervention (PCI) in patients with DM, likely because of more complete revascularization and protection against disease progression in the bypass segment. Revascularization with balloon angioplasty, bare-metal stents, and first-generation drug-eluting stents have all been shown to be inferior to CABG in patients with DM. Current professional society guidelines reflect these findings, strongly recommending CABG over PCI in this setting. Newer stent platforms, however, have challenged this notion. The use of thinner struts, biocompatible polymer coating, and newer antiproliferative agents have improved the rates of cardiovascular events in patients with DM revascularized percutaneously. Since the publication of current guidelines, new studies suggested acceptable outcomes in patients with DM revascularized with second-generation drug-eluting stents, even though these conclusions are drawn from small subgroup analyses or nonrandomized studies. Robust registry data suggest similar mortality with lower rates of stroke after PCI compared with surgery, at the expense of increased rates of repeat revascularization. If complete revascularization can be achieved, similar rates of myocardial infarction are also observed. Therefore, contemporary revascularization in patients with DM with multivessel coronary artery disease should involve a multidisciplinary approach, in which interventional cardiologists and cardiac surgeons involve their patients to individualize treatment choices, and balance the risks and effectiveness of each modality., (Copyright © 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

A novel GuideLiner-sleeve technique to enable use of atherectomy in calcific ostial lesions of the LAD and LCX is described.

Objective: Sternal bleeding during cardiac surgery is currently controlled using bone wax or other chemical substances that may result in adverse effects and affect wound healing and recovery. The purpose of this study was to identify a safe, cost-effective, and easy-to-use technique to reduce sternal bleeding and sternal trauma during cardiac surgery., Methods: After sternotomy, a sternal protection device was placed over each hemisternal section before insertion of the retractor and remained in situ until the end of surgery. Sternal bleeding and ease of use were assessed and recorded during surgery. Sternal trauma was assessed and recorded within 5 minutes of removal of the device, and overall satisfaction (Global Impression) and any intraoperative adverse events or device malfunction were reported at surgery completion. Patients were followed up 24 hours and 4 weeks after surgery., Results: Twelve patients completed the study. Adverse events reported were not considered related to the device. No sternal trauma was identified in any patient. In 9 of 11 patients, sternal bleeding was reduced after insertion of the device. The device was generally considered easy to use, although some difficulty was encountered when used with the Internal Mammary Artery retractor., Conclusions: Our data suggest that the device is safe and able to reduce sternal bleeding during surgery using sternal retractors. We recommend further studies in a larger population of patients with a control group to evaluate the device's ability to reduce the morbidity associated with sternal bleeding and sternal trauma.

Patients with diabetes mellitus are at increased risk of developing coronary artery disease (CAD) and have an increased incidence of recurrent events following revascularization. Choosing the most appropriate strategy to revascularize these high-risk patients is crucial for improving the clinical outcomes. Several studies, randomized trials and meta-analyses have compared short- and long-term outcomes following coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in diabetic patients suffering from CAD. The aim of this article is to review the currently available evidence on the role of PCI and CABG in the management of diabetic patients with CAD., (Copyright © 2017 Hellenic Society of Cardiology. Published by Elsevier B.V. All rights reserved.)

Despite permanent improvement in success rate and technical developments, chronic total occlusion (CTO) remains undertreated by percutaneous coronary intervention (PCI). Dedicated CTO operators from Japan, Europe and USA perform these procedures with success rate beyond 90%, but there is still huge gap between this group of specialists and broader population of PCI operators. Recently proposed CTO scores can be used for patients' selection according to the CTO operators' experience. Patients with low CTO Score values may be suitable for less experienced operators at the beginning of the CTO PCI learning curve, while more complex CTOs (higher CTO Score values) should be differed to CTO experts. As most of CTO scores better predict antegrade procedural success, at the hands of expert CTO operators, lower or intermediate CTO Score values suggest cases which could be started by anterograde techniques. In this paper we review: 1) an impact of CTO on completeness of revascularization; 2) appropriate CTO equipment setting; 3) procedure planning aspects, including the use of computed tomography angiography and CTO scores; 4) current CTO techniques classifying them into A) antegrade, B) retrograde and C) hybrid approach. Further advancements in CTO PCI should not only provide higher rate of complete revascularization, with improved clinical outcome, but also simplify procedure and make it suitable for broader spectrum of interventionalists.

The heart team, consisting of conservative cardiologists, cardiac surgeons and interventional cardiologists, is important for a balanced, multidisciplinary decision-making process for patients suffering from coronary artery disease (CAD). Standard evidence-based, interdisciplinary, institutional protocols can be used for commonly encountered case scenarios to avoid the need for a systematic case by case review. Complex cases with a SYNTAX score of more than 32, diabetes mellitus and lesions of the left main stem or three-vessel disease should in general not be treated by an ad hoc percutaneous coronary intervention (PCI) but first discussed in the heart team. Culprit lesion PCI is usually the first choice in most patients with acute coronary syndrome. If complete percutaneous revascularization is not possible, coronary artery bypass grafting (CABG) should be considered by the heart team. In patients assigned for CABG, timing of the procedure should be decided on an individual basis, depending on the symptoms, hemodynamic stability, coronary anatomy and signs of ischemia. In stabilized patients with acute coronary syndrome, the choice of revascularization modality can be made in analogy to patients with stable CAD.

Chronic occlusion of coronary arteries also known as chronic total occlusions (CTO) are found in approximately 20 % of patients undergoing percutaneous coronary interventions (PCI) and in approximately 50 % of patients after coronary artery bypass grafts (CABG). As a result of technical advancements in retrograde recanalization techniques specialized centers can now achieve success rates of over 85 %, regardless of the CTO anatomy. Given the complexity of retrograde CTO techniques, a consensus paper issued by the Euro CTO Club requires interventional cardiologists to have sufficient experience in antegrade approaches (>300 antegrade CTO cases and >50 per year) with an additional training program (25 retrograde cases each as first and second operating surgeon) before becoming a qualified independent retrograde surgeon. The increased investment in time and technical resources can only be justified if the patient has a clear clinical benefit. This technical advancement and the progressively clearer evidence that complete revascularization can be achieved in patients with multivessel coronary artery disease have attracted growing interest in recent years from interventional cardiologists in the recanalization of CTO.

Background: Bioresorbable vascular scaffolds (BVS) could overcome drug-eluting stents (DES) drawbacks connected with their permanent presence in the vessel wall. Studies exploring the clinical use of BVS are limited to the patients presenting with noncomplex, short and stable lesions. There are no prospective and randomized studies available in all-comer patients., Methods and Results: We analyzed 31 patients, who received at least one BVS (Absorb(™)) between September 1, 2012 and November 1, 2014. Median follow-up period was 424 days. In one (3.2%) patient, we performed a target vessel revascularization (TVR). The death rate was 6.5%. One (3.2%) patient, who received both BVS and a bare metal stent (BMS), died of an acute stent thrombosis 8 days after the initial procedure. One (3.2%) patient died of a non-cardiac death. We did not encounter any target lesion revascularization (TLR) or myocardial infarction (MI). The major adverse cardiac events (MACE) rate was 3.2%., Conclusions: Implantation of BVS is a safe treatment option. Lesions should be carefully selected and prepared before BVS implantation. We need more data about the safety of BVS and BMS overlapping.

Background: Bioresorbable coronary stents might improve outcomes of patients treated with percutaneous coronary interventions. The everolimus-eluting bioresorbable vascular scaffold is the most studied of these stent platforms; however, its performance versus everolimus-eluting metallic stents remains poorly defined. We aimed to assess the efficacy and safety of everolimus-eluting bioresorbable vascular scaffolds versus everolimus-eluting metallic stents in patients with ischaemic heart disease treated with percutaneous revascularisation., Methods: We searched Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), scientific sessions abstracts, and relevant websites for randomised trials investigating everolimus-eluting bioresorbable vascular scaffolds versus everolimus-eluting metallic stents published or posted between Nov 30, 2006, and Oct 12, 2015. The primary efficacy outcome was target lesion revascularisation and the primary safety outcome was definite or probable stent (scaffold) thrombosis. Secondary outcomes were target lesion failure (the composite of cardiac death, target-vessel myocardial infarction, or ischaemia-driven target lesion revascularisation), myocardial infarction, death, and in-device late lumen loss. We derived odds ratios (ORs) and weighted mean differences with 95% CIs, and calculated the risk estimates for the main outcomes according to a random-effects model. This study is registered with PROSPERO, number CRD42015026374., Findings: We included six trials, comprising data for 3738 patients randomised to receive percutaneous coronary intervention with either an everolimus-eluting bioresorbable vascular scaffold (n=2337) or an everolimus-eluting metallic stent (n=1401). Median follow-up was 12 months (IQR 9-12). Patients treated with bioresorbable vascular scaffolds had a similar risk of target lesion revascularisation (OR 0.97 [95% CI 0.66-1.43]; p=0.87), target lesion failure (1.20 [0.90-1.60]; p=0.21), myocardial infarction (1.36 [0.98-1.89]; p=0.06), and death (0.95 [0.45-2.00]; p=0.89) as those treated with metallic stents. Patients treated with a bioresorbable vascular scaffold had a higher risk of definite or probable stent thrombosis than those treated with a metallic stent (OR 1.99 [95% CI 1.00-3.98]; p=0.05), with the highest risk between 1 and 30 days after implantation (3.11 [1.24-7.82]; p=0.02). Lesions treated with a bioresorbable vascular scaffold had greater in-device late lumen loss than those treated with a metallic stent (weighted mean difference 0.08 [95% CI 0.05-0.12]; p<0.0001)., Interpretation: Compared with everolimus-eluting metallic stents, everolimus-eluting bioresorbable vascular scaffolds had similar rates of repeat revascularisation at 1 year of follow-up, despite inferior mid-term angiographic performance. However, patients treated with a bioresorbable vascular scaffold had an increased risk of subacute stent thrombosis. Studies with extended follow-up in a larger number of patients are needed to fully assess the long-term advantages of everolimus-eluting bioresorbable vascular scaffolds., Funding: None., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

CoCr alloys, in particular MP35N and L605, are extensively used in biomedical implants, for example for coronary stents. In practice, these alloys present a moderately hydrophobic surface which leads to significant platelet adhesion and consequently to risk of early thrombosis or in-stent restenosis. Surface modification of biomedical implants is known to alter their biological performances. In this study we focused on the alteration of in vitro biological responses of human cells contacting CoCr surfaces with engineered oxide layers. XPS analysis was performed to determine the composition of the oxide layer of differently treated CoCr while the bulk properties were not modified. An extensive characterization of the surfaces was performed looking at surface roughness, wettability and charge. After static exposure to blood, strongly reduced platelet and increased polymorphonuclear neutrophil adhesion were observed on treated versus untreated surfaces. Comparisons of treated and untreated samples provide evidence for wettability being an important player for platelet adhesion, although multiple factors including surface oxide chemistry and charge might control polymorphonuclear neutrophil adhesion. The differently treated surfaces were shown to be equally suitable for endothelial cell proliferation. We herein present a novel approach to steer biological properties of CoCr alloys. By adjusting their oxide layer composition, substrates were generated which are suitable for endothelial cell growth and at the same time show an altered (reduced) blood contact activation. Such treatments are expected to lead to stents of highly reproducible quality with minimal thrombogenicity and in-stent restenosis, while maintaining rapid re-endothelialization after coronary angioplasty., (© 2014 Wiley Periodicals, Inc.)

Monitoring erosion progress of biodegradable drug carrying polymer coated on coronary drug eluting stents (DES) is largely hindered because of the small amount of coating material as well as the irregular profile of coating, both of which make the monitoring using traditional methods highly challenging. In our study, electrochemical impedance spectroscopy (EIS), a widely used method in the study of metal corrosion, was used to address the challenges traditional methods face. In vitro, remained mass and molecular weight drop data of film-like poly(lactide-co-glycolide) (PLGA) samples due to degradation were monitored using traditional mass loss measurement and size exclusion chromatography (SEC) methods. The obtained data were compared to the changes of capacitance and impedance measured by EIS from PLGA-coated stainless slices with an equivalent electrical circuit model. The results showed that the changes of the resistance and capacitance obtained by EIS, which indicates transformations of PLGA coating, can be correlated to the degradation measured by traditional methods, such as SEC. Furthermore, EIS method was applied to monitor and evaluate the erosion progress of a real stent with PLGA coating. Our results suggested that EIS method can accurately monitor real-time erosion process of thin polymer coatings on DES in situ., (© 2014 Wiley Periodicals, Inc.)

Background: Many patients with coronary artery disease who are not candidates for revascularization have refractory angina despite standard medical therapy. The balloon-expandable, stainless steel, hourglass-shaped, coronary-sinus reducing device creates a focal narrowing and increases pressure in the coronary sinus, thus redistributing blood into ischemic myocardium., Methods: We randomly assigned 104 patients with Canadian Cardiovascular Society (CCS) class III or IV angina (on a scale from I to IV, with higher classes indicating greater limitations on physical activity owing to angina) and myocardial ischemia, who were not candidates for revascularization, to implantation of the device (treatment group) or to a sham procedure (control group). The primary end point was the proportion of patients with an improvement of at least two CCS angina classes at 6 months., Results: A total of 35% of the patients in the treatment group (18 of 52 patients), as compared with 15% of those in the control group (8 of 52), had an improvement of at least two CCS angina classes at 6 months (P=0.02). The device was also associated with improvement of at least one CCS angina class in 71% of the patients in the treatment group (37 of 52 patients), as compared with 42% of those in the control group (22 of 52) (P=0.003). Quality of life as assessed with the use of the Seattle Angina Questionnaire was significantly improved in the treatment group, as compared with the control group (improvement on a 100-point scale, 17.6 vs. 7.6 points; P=0.03). There were no significant between-group differences in improvement in exercise time or in the mean change in the wall-motion index as assessed by means of dobutamine echocardiography. At 6 months, 1 patient in the treatment group had had a myocardial infarction; in the control group, 1 patient had died and 3 had had a myocardial infarction., Conclusions: In this small clinical trial, implantation of the coronary-sinus reducing device was associated with significant improvement in symptoms and quality of life in patients with refractory angina who were not candidates for revascularization. (Funded by Neovasc; COSIRA ClinicalTrials.gov number, NCT01205893.).

Bioresorbable scaffolds represent a novel approach in the treatment of coronary artery disease which allows for vessel wall support without leaving a permanent foreign body in the coronary artery. This technology has the potential to reduce some of the shortcomings of current standard treatment with metallic drug-eluting stents, such as late in-stent restenosis, impaired vasomotion of the stented segment and hindrance of surgical revascularizations. Currently, several bioresorbable scaffolds are available and undergoing clinical or preclinical evaluation. This review will present the current status of development of bioresorbable scaffolds, describe the degradation/resorption process of each device and the clinical data available to date.

Objectives: This study sought to determine whether adding myocardial computed tomography perfusion (CTP) to computed tomography angiography (CTA) improves diagnostic performance for coronary stents., Background: CTA of coronary stents has been limited by nondiagnostic studies caused by metallic stent material and coronary motion., Methods: CTA and CTP were performed in 91 consecutive patients with stents before quantitative coronary angiography, the reference standard for obstructive stenosis (≥50%). If a coronary stent or vessel was nondiagnostic on CTA, adenosine stress CTP in the corresponding myocardial territory was read for combined CTA/CTP., Results: Patients had an average of 2.5 ± 1.8 coronary stents (1 to 10), with a diameter of 3.0 ± 0.5 mm. Significantly more patients were nondiagnostic for stent assessment by CTA (22%; mainly due to metal artifacts [75%] or motion [25%]) versus CTP (1%; p < 0.001; severe angina precluded CTP in 1 case). The per-patient diagnostic accuracy of CTA/CTP for stents (87%, 95% confidence interval [CI]: 78% to 93%) was significantly higher than that of CTA alone (71%, 95% CI: 61% to 80%; p < 0.001), mainly because nondiagnostic examinations were significantly reduced (p < 0.001). In the analysis of any coronary artery disease, diagnostic accuracy and nondiagnostic rate were also significantly improved by the addition of CTP (p < 0.001). CTA/CTP (7.9 ± 2.8 mSv) had a significantly lower effective radiation dose than angiography (9.5 ± 5.1 mSv; p = 0.005). The area under the receiver-operating characteristic curve for CTA/CTP (0.82, 95% CI: 0.69 to 0.95) was superior to that for CTA (0.69, 95% CI: 0.57 to 0.82; p < 0.001) in identifying patients requiring stent revascularization., Conclusions: Combined coronary CTA and myocardial CTP improves diagnosis of CAD and in-stent restenosis in patients with stents compared with CTA alone. (Coronary Artery Stent Evaluation With 320-Slice Computed Tomography-The CArS 320 Study [CARS-320]; NCT00967876)., (Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Currently, recanalization of chronic total occlusions (CTOs) in peripheral arteries remains a challenging obstacle encountered by clinical practitioners. Percutaneous CTO interventions are associated with low rates of procedural success using standard guidewires and catheters. When guidewires cannot cross the occluded segment or fail to reenter the true lumen after subintimal crossing of the occlusion, successful recanalization may be unachievable. In the last few years, the emergence of novel devices and new techniques has dramatically improved the success rates of the revascularization for CTOs. This paper reviews the published data of current devices and specialized techniques of percutaneous intervention to relieve CTOs., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: New generation drug-eluting stents (DES) incorporate thinner struts and novel alloys to improve clinical performance. Nevertheless, the impact of novel stent materials and designs on human vascular response to DES remains elusive. We sought to evaluate the in-vivo coronary artery response to platinum-chromium (PtCr) versus cobalt-chromium (CoCr) stents featuring the same durable polymer and antiproliferative drug by optical coherence tomography (OCT)., Methods and Results: A total of 42 patients with de novo lesions in native coronary vessels was treated with PtCr-everolimus eluting stent (EES; n = 21) or CoCr-EES (n = 21). Angiography, intravascular ultrasound, and OCT were performed at the index procedure and 6-month follow-up. PtCr-EES and CoCr-EES had similar concentric expansion (stent eccentricity index; median 0.91 vs. 0.90, respectively, P = 0.47) and very low rate of strut malapposition (median 1.15 vs. 1.80%, P = 0.92) at post implantation. Proportion of struts embedded in tissue was lower in PtCr-EES compared to CoCr-EES (median 2.67 vs. 15.23%, P < 0.001). The primary prespecified end point, the percentage of uncovered struts per patient at 6 months follow-up, was 8.46% [interquartile range (IQR) = 3.05-17.26] in PtCr-EES and 5.88% (IQR = 1.35-13.27) in CoCr-EES (P = 0.36), whereas malapposed struts were observed in 0.00% (IQR = 0.00-0.25) versus 0.48% (IQR = 0.00-1.44), respectively, (P = 0.10). Strut-level neointimal thickness did not differ between the two platforms (median 0.09 vs. 0.08 mm, P = 0.49)., Conclusions: Acute and mid-term responses to EES using PtCr or CoCr platforms were similar, with concentric stent expansion, low malapposition, similar strut coverage and limited amount of neointima. Conversely, at postprocedure, PtCr-EES had fewer embedded struts compared with CoCr-EES., (Copyright © 2012 Wiley Periodicals, Inc.)

Objectives: The authors sought to report the temporal stability of an untreated, nonculprit lesion phenotype in patients presenting with ST-segment elevation myocardial infarction (STEMI)., Background: The temporal stability of the untreated, nonculprit lesion phenotype has been studied using intravascular ultrasound-virtual histology (IVUS) in patients with stable ischemic heart disease, but not in STEMI patients., Methods: As part of a formal substudy of the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) trial, baseline and 13-month follow-up IVUS was performed in 99 untreated nonculprit lesions in 63 STEMI patients. Lesions were classified as pathological intimal thickening (PIT), IVUS-derived thin-cap fibroatheroma (TCFA), thick-cap fibroatheroma (ThCFA), fibrotic plaque, or fibrocalcific plaque., Results: The frequency of TCFA increased from 41% at baseline to 54% at follow-up, whereas ThCFAs decreased from 41% to 34% and PIT decreased from 16% to 8%. Among the 41 lesions classified at baseline as TCFA, at follow-up, 32 (78%) were still classified as TCFA, whereas 9 (22%) were classified as ThCFAs or fibrotic plaques. An additional 21 lesions at follow-up were newly classified as TCFA, developing from either PIT or ThCFA. TCFA at baseline that evolved into non-TCFAs trended toward a more distal location than TCFA that did not change (p = 0.12). In lesions classified as TCFA, the minimum lumen area (MLA) decreased from 8.1 (interquartile range [IQR]: 7.4 to 8.8) mm(2) at baseline to 7.8 (IQR: 7.2 to 8.4) mm(2) at follow-up, p < 0.05; this was associated with an increase in percent necrotic core at the MLA site (14% [IQR: 12 to 16] to 19% [IQR: 17 to 22], p < 0.0001) and over the entire length of the lesion (14% [IQR: 12 to 16] to 18% [IQR: 17 to 20], p < 0.0001)., Conclusions: Untreated nonculprit lesions in STEMI patients frequently have TCFA morphology that does not change during 13-month follow-up and is accompanied by a decrease in MLA and an increase in necrotic core. (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction [HORIZONS-AMI]; NCT00433966)., (Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Two independent reports documented substantially higher operative mortality associated with transmyocardial revascularization (TMR) when used in isolation than that reported in the premarket clinical trials. To clarify the state of the art, this article assesses temporal trends in the use of TMR, short-term and long-term outcomes, and outcomes stratified by procedure type (TMR only and TMR + coronary artery bypass graft [CABG]) and by the 2 specific TMR devices., Methods: The study population included all patients undergoing TMR in isolation or in combination with CABG at 435 cardiothoracic hospitals in the United States participating in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) from January 2000 through November 2006 (n = 15,386). Analysis of long-term outcomes was accomplished through linkage to Medicare claims data. Short-term and long-term (7 years) adverse outcomes were assessed and compared between the 2 TMR device types., Results: The use of TMR in conjunction with CABG surgery is increasing. This study showed modest differences in short-term morbidity and mortality between the 2 devices. In combination with CABG, after risk adjustment, patients treated with the holmium:YAG laser (experienced a higher rate of operative mortality (3.5% vs 2.5%; adjusted hazard ratio 1.39, 95% confidence level 1.03 to 1.87) but no difference in the composite short-term rate of major morbidity or mortality, compared with the Heart Laser CO2 transmyocardial revascularization system (PLC Medical Systems, Inc, Milford, MA). However, there were no clinically meaningful differences in long-term results., Conclusions: Modest differences in short-term morbidity and mortality between the 2 devices suggest the usefulness of further research., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We evaluated the clinical and angiographic outcomes of silicon carbide-coated cobalt chromium PROKinetic bare-metal stent in patients with acute ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI)., Methods: Patients with acute STEMI (2.75-5.00 mm vessels; lesion length ≤30 mm by visual estimation) were treated with PRO-Kinetic stents at 5 centers in Korea. The primary endpoint was the rate of major adverse cardiac events (MACE), defined as all-cause death, new myocardial infarction, and target lesion revascularization (TLR) at 6-month follow-up. Follow-up angiography was recommended after the completion of the 6-month clinical followup., Results: A total of 64 patients (56.6 ± 12.9 years old, 56 male) were enrolled in the study. Procedural success was achieved in 100% of the lesions. The mean stent size was 3.51 ± 0.67 mm and the mean stent length was 20.3 ± 4.4 mm. There was 1 case of in-hospital death due to cardiac tamponade. During the 6-month clinical follow-up, 4 patients (6.3%) received TLR. Therefore, the total rate of MACE was 7.8%. Angiographic follow-up data were available for 42 patients (65.6%) and the in-stent late lumen loss was 1.02 ± 0.62 mm and in-segment late lumen loss was 0.99 ± 0.64 mm. Binary restenosis occurred in 53% of reference vessel diameters (RVDs) ≤3.0 mm, 25% of RVDs between 3.0 and 3.5 mm, and 0% of RVDs >3.5 mm (P=.006)., Conclusions: The use of the PRO-Kinetic stent seems to be safe and feasible in primary PCI for acute STEMI, and shows favorable clinical and angiographic outcomes in large (>3.0 mm) coronary arteries, but not in small arteries.

Background: The purpose of this study was to evaluate the long-term safety of the Igaki-Tamai stent, the first-in-human fully biodegradable coronary stent made of poly-l-lactic acid., Methods and Results: Between September 1998 and April 2000, 50 patients with 63 lesions were treated electively with 84 Igaki-Tamai stents. Overall clinical follow-up (>10 years) of major adverse cardiac events and rates of scaffold thrombosis was analyzed together with the results of angiography and intravascular ultrasound. Major adverse cardiac events included all-cause death, nonfatal myocardial infarction, and target lesion revascularization/target vessel revascularization. During the overall clinical follow-up period (121 ± 17 months), 2 patients were lost to follow-up. There were 1 cardiac death, 6 noncardiac deaths, and 4 myocardial infarctions. Survival rates free of all-cause death, cardiac death, and major adverse cardiac events at 10 years were 87%, 98%, and 50%, respectively. The cumulative rates of target lesion revascularization (target vessel revascularization) were 16% (16%) at 1 year, 18% (22%) at 5 years, and 28% (38%) at 10 years. Two definite scaffold thromboses (1 subacute, 1 very late) were recorded. The latter case was related to a sirolimus-eluting stent, which was implanted for a lesion proximal to an Igaki-Tamai stent. From the analysis of intravascular ultrasound data, the stent struts mostly disappeared within 3 years. The external elastic membrane area and stent area did not change., Conclusion: Acceptable major adverse cardiac events and scaffold thrombosis rates without stent recoil and vessel remodeling suggested the long-term safety of the Igaki-Tamai stent.

Background: In November 2007, national guidelines were released recommending delay of elective noncardiac surgery after cardiac revascularization with drug eluting stents (DES) for 12 months compared with 6 weeks after implantation of bare metal stents (BMS)., Study Design: To determine the incidence of noncardiac surgery within 24 months after stent placement, national VA data on cardiac stent implantation were merged with data from the VA National Surgery Office and Medicare. Using chi-square tests and log-rank analyses, we measured the incidence of noncardiac surgery after BMS and DES in relation to guideline release and surgical characteristics., Results: From 2000 to 2010, 126,773 stent procedures were followed by 25,977 (20.5%) noncardiac operations within 24 months. Overall, 11.8% of the BMS surgery cohort had early surgery (less than 6 weeks) compared with 46.7% of the DES surgery cohort, which had early surgery (less than 12 months). The incidence of surgery differed significantly by stent type (BMS 24.1% vs DES 17.5%, p < 0.001) and in relation to guideline release (pre- 24.6% vs postguideline 13.1%, p < 0.001). Higher complexity operations (work relative value units) were more likely to occur in the early period for both BMS (p < 0.0001) and DES (p < 0.003). After guideline release, the incidence of surgery within 12 months decreased from 16.7% to 10.0% (p < 0.0001)., Conclusions: We found evidence that guidelines recommending delaying surgery appear to be effective in decreasing the incidence of early surgery; however, early surgery is still a frequent occurrence. Additional research is needed to better define the risk of cardiac and bleeding complications in patients undergoing subsequent noncardiac surgery, as well as the optimal time for surgery and method of antiplatelet management., (Published by Elsevier Inc.)

Background: Claudication is a common and disabling symptom of peripheral artery disease that can be treated with medication, supervised exercise (SE), or stent revascularization (ST)., Methods and Results: We randomly assigned 111 patients with aortoiliac peripheral artery disease to receive 1 of 3 treatments: optimal medical care (OMC), OMC plus SE, or OMC plus ST. The primary end point was the change in peak walking time on a graded treadmill test at 6 months compared with baseline. Secondary end points included free-living step activity, quality of life with the Walking Impairment Questionnaire, Peripheral Artery Questionnaire, Medical Outcomes Study 12-Item Short Form, and cardiovascular risk factors. At the 6-month follow-up, change in peak walking time (the primary end point) was greatest for SE, intermediate for ST, and least with OMC (mean change versus baseline, 5.8±4.6, 3.7±4.9, and 1.2±2.6 minutes, respectively; P<0.001 for the comparison of SE versus OMC, P=0.02 for ST versus OMC, and P=0.04 for SE versus ST). Although disease-specific quality of life as assessed by the Walking Impairment Questionnaire and Peripheral Artery Questionnaire also improved with both SE and ST compared with OMC, for most scales, the extent of improvement was greater with ST than SE. Free-living step activity increased more with ST than with either SE or OMC alone (114±274 versus 73±139 versus -6±109 steps per hour), but these differences were not statistically significant., Conclusions: SE results in superior treadmill walking performance than ST, even for those with aortoiliac peripheral artery disease. The contrast between better walking performance for SE and better patient-reported quality of life for ST warrants further study., Clinical Trial Registration: URL: http://clinicaltrials.gov/ct/show/NCT00132743?order=1. Unique identifier: NCT00132743.

This study included 171 patients with multivascular lesions in the coronary bed treated endovascularly for myocardial revascularization. The patients divided into 3 groups underwent complete, functionally adequate, and incomplete revascularization respectively. Analysis of clinical, anamnestic and angiographic characteristics of the patients revealed possible risk factors hampering the necessary extent of revascularization in case of multivascular lesions in the coronary bed such as chronic coronary occlusion, occlusion of more than 20 mm of the coronary artery, high risk of percutaneous coronary intervention based on the SYNTAX Score scale, and calcinosis of the effected segment.

Percutaneous coronary revascularization was introduced over 30 years ago by Dr Andreas Grüntzig. This event catapulted adult invasive cardiology from a diagnostic entity to a therapeutic modality, which has since become the most frequently performed coronary revascularization procedure worldwide. This success has been built on several key concepts-problem identification, targeted solutions, applied technology, populations-based testing, postmarket surveillance, and education. These concepts will continue to be of paramount importance as novel percutaneous innovations and strategies are brought to bear on an increasingly broader group of patients with cardiovascular disease. In this review, we trace the history, review current practices, and also provide insight into future potential innovations, as it pertains to percutaneous coronary revascularization., (Copyright © 2011 Mosby, Inc. All rights reserved.)