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Several novel software systems have been developed for the reconstruction of the coronary artery tree and the calculation of fractional flow reserve (FFR) from coronary artery angiography images without coronary artery instrumentation: FFR angio , Computational pressure-flow dynamics derived FFR, quantitative flow ratio, and vessel FFR. In this report, we review the current evidence on each software, their contemporary use, and future directions., Competing Interests: Declaration of competing interest Dr. Brilakis reports consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), ControlRad, CSI, Ebix, Elsevier, GE Healthcare (Little Chalfont, United Kingdom), InfraRedx, Medtronic, Siemens, and Teleflex; research support from Regeneron and Siemens; ownership, Hippocrates LLC; and being a shareholder in MHI Ventures and Cleerly Health. Dr. Sandoval reports consulting/speaker honoraria from Abbott Diagnostics, Roche Diagnostics, Zoll, Philips; being JACC Advances associate editor; and holding patent 20,210,401,347. The remaining authors have no competing interest to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Competing Interests: Dr Kern is a speaker for Abbott Vascular, Acist Medical Inc, Boston Scientific, CathWorks, Medtronics Inc, Opsens Inc, and Philips Inc. Dr Seto is a speaker for Janssen, Getinge, and GE Healthcare and a consultant to Acist, Terumo, Frond Medical, and Summacor.

Competing Interests: Funding Support and Author Disclosures Dr Parikh has received research support from Bayer, Infraredx, and Abbott Vascular; and consulting fees from Abbott Vascular and Infraredx. Dr Seto has received honoraria from Janssen, Terumo, Getinge, and GE Healthcare; and is a consultant to Frond Medical and Summacor. Dr Tehrani has reported that he has no relationships relevant to the contents of this paper to disclose.

Background: The learning curve for new operators performing ultrasound-guided transfemoral access (TFA) remains uncertain., Methods: We performed a pooled analysis of the FAUST (Femoral Arterial Access With Ultrasound Trial) and UNIVERSAL (Routine Ultrasound Guidance for Vascular Access for Cardiac Procedures) trials, both multicenter randomized controlled trials of 1:1 ultrasound-guided versus non-ultrasound-guided TFA for coronary procedures. Outcomes included the composite of major bleeding or vascular complications and successful common femoral artery cannulation. Participants were stratified by the operators' accrued case volume. We used adjusted repeated-measurement logistic regression, with random intercepts for operator clustering, for comparison against the non-ultrasound-guided TFA group and to model the learning curve., Results: The FAUST and UNIVERSAL trials randomized a total of 1624 patients, of which 810 were randomized to non-ultrasound-guided TFA and 814 to ultrasound-guided TFA (cases 1-10, 391; 11-20, 183; and >20, 240). Participants who had operators who performed >20 ultrasound-guided TFAs had a decreased risk for the primary end point (5/240 [2.1%] versus 64/810 [7.9%]; adjusted odds ratio, 0.26 [95% CI, 0.09-0.61]) compared with non-ultrasound-guided TFA. Operators who performed >20 ultrasound-guided procedures had increased odds of successfully cannulating the common femoral artery (224/246 [91.1%] versus 327/382 [85.6%]; adjusted odds ratio, 1.76 [95% CI, 1.08-2.89]) compared with non-ultrasound-guided TFA. The learning curve plots demonstrated growing competence with increasing accrued cases., Conclusions: New operators should perform at least 20 ultrasound-guided TFA to decrease access site complications and increase proper cannulation compared with non-ultrasound-guided TFA. Additional accrued cases may lead to increased proficiency. Training programs should consider these findings in the transradial era., Competing Interests: Dr d’Entremont is a Canadian Institutes of Health Research Canada Graduate Scholarship awardee. Dr Jolly reports receiving grants or contracts from Boston Scientific and payment or honoraria for lectures, presentations, speaker’s bureaus, article writing, or educational events from Penumbra, Teleflex, and Abiomed. Dr Seto reports receiving grants or contracts from Arena Medical, Philips, and ACIST; payment or honoraria for speaker’s bureaus from Janssen, Terumo, Gettinge, and GE Healthcare; consulting fees from Medtronic and Medicure; and reports having equity in Frond Medical. The other authors report no conflicts.

Fractional flow reserve (FFR) and nonhyperemic pressure ratios (NHPRs) provide an important clinical tool to evaluate the hemodynamic significance of coronary lesions. However, these indices have major limitations. As these indices are meant to be surrogates of coronary flow, clinical scenarios such as aortic stenosis (with increased end-systolic and end-diastolic pressures) or atrial fibrillation (with significant beat-to-beat cardiac output variability) can have significant effect on the accuracy and reliability of these hemodynamic indices. Here, we provide a comprehensive evaluation of the pitfalls, limitations, and strengths of FFR and NHPRs in common clinical scenarios paired with coronary artery disease., Competing Interests: Disclosure Dr D.M. Tehrani reports no disclosures. Dr A.H. Seto has received research grants from Philips and Acist, consulting fees from Medtronic and Medicure, and is a speaker for Terumo, General Electric, and Janssen, (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Randomised controlled trials of ultrasound (US)-guided transfemoral access (TFA) for coronary procedures have shown mixed results., Aims: We aimed to compare US-guided versus non-US-guided TFA from randomised data in an individual participant-level data (IPD) meta-analysis., Methods: We completed a systematic review and an IPD meta-analysis of all randomised controlled trials comparing US-guided versus non-US-guided TFA for coronary procedures. We performed a one-stage mixed-model meta-analysis using the intention-to-treat population from included trials. The primary outcome was a composite of major vascular complications or major bleeding within 30 days., Results: A total of 2,441 participants (1,208 US-guided, 1,233 non-US-guided) from 4 randomised clinical trials were included. The mean age was 65.5 years, 27.0% were female, and 34.5% underwent a percutaneous coronary intervention. The incidence of major vascular complications or major bleeding (34/1,208 [2.8%] vs 55/1,233 [4.5%]; odds ratio [OR] 0.61, 95% confidence interval [CI]: 0.39-0.94; p=0.026) was lower in the US-guided TFA group. In the prespecified subgroup of participants who received a vascular closure device, those randomised to US-guided TFA experienced a reduction in the primary outcome (2.1% vs 5.6%; OR 0.36, 95% CI: 0.19-0.69), while no benefit for US guidance was observed in the subgroup without vascular closure devices (4.1% vs 3.3%; OR 1.21, 95% CI: 0.65-2.26; interaction p=0.009)., Conclusions: In participants undergoing coronary procedures by TFA, US guidance decreased the composite outcome of major vascular complications or bleeding and may be especially helpful when using vascular closure devices.

Background: Anatomical vessel location affects post-percutaneous coronary intervention (PCI) physiology., Aims: We aimed to compare the post-PCI instantaneous wave-free ratio (iFR) in left anterior descending (LAD) versus non-LAD vessels and to identify the factors associated with a suboptimal post-PCI iFR., Methods: DEFINE PCI was a multicentre, prospective, observational study in which a blinded post-PCI iFR pullback was used to assess residual ischaemia following angiographically successful PCI., Results: Pre- and post-PCI iFR recordings of 311 LAD and 195 non-LAD vessels were compared. Though pre-PCI iFR in the LAD vessels (median 0.82 [0.63, 0.86]) were higher compared with those in non-LAD vessels (median 0.72 [0.49, 0.84]; p<0.0001), post-PCI iFR were lower in the LAD vessels (median 0.92 [0.88, 0.94] vs 0.98 [0.95, 1.00]; p<0.0001). The prevalence of a suboptimal post-PCI iFR of <0.95 was higher in the LAD vessels (77.8% vs 22.6%; p<0.0001). While the overall frequency of residual physiological diffuse disease (31.4% vs 38.6%; p=0.26) and residual focal disease in the non-stented segment (49.6% vs 50.0%; p=0.99) were similar in both groups, residual focal disease within the stented segment was more common in LAD versus non-LAD vessels (53.7% vs 27.3%; p=0.0009). Improvement in iFR from pre- to post-PCI was associated with angina relief regardless of vessel location., Conclusions: After angiographically successful PCI, post-PCI iFR is lower in the LAD compared with non-LAD vessels, resulting in a higher prevalence of suboptimal post-PCI iFR in LAD vessels. This difference is, in part, due to a greater frequency of a residual focal pressure gradient within the stented segment which may be amenable to more aggressive PCI.

The outcomes of chronic total occlusion percutaneous coronary intervention have considerably improved during the last decade with continued emphasis on improving procedural safety. Vascular access site bleeding remains one of the most frequent complications. Several procedural strategies have been implemented to reduce the rate of vascular access site complications. This state-of-the-art review summarizes and describes the current evidence on optimal vascular access strategies for chronic total occlusion percutaneous coronary intervention., Competing Interests: Disclosures Drs Aminian and Dens are consultants for Terumo Corporation. Dr Iglesias is a consultant for Biotronik, Cordis, Medtronic, and Terumo Corporation; has received unrestricted research grants to the institution from Abbott Vascular, AstraZeneca, Biotronik, Biosensors, Concept Medical, Philips Volcano, and Terumo Corporation; and has received honoraria/speaker fees for AstraZeneca, Biosensors, Biotronik, Bristol Myers Squibb/Pfizer, Cordis, Concept Medical, Medalliance, Medtronic, Novartis, Terumo Corporation, and Philips Volcano. Dr Brilakis has received consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), Cardiovascular Systems, Inc, Elsevier, GE Healthcare, Interventional Medical Device Solutions (IMDS), Medicure, Medtronic, Siemens, Teleflex, and Terumo Corporation; has received research support from Boston Scientific and GE Healthcare; is the owner at Hippocrates LLC; and is a shareholder at MHI Ventures, Cleerly Health, and Stallion Medical. Dr Gasparini reports consulting/speaker honoraria from Abbott Vascular, Cordis, Terumo Corporation, Asahi Intecc, IMDS, Boston Scientific, and Medtronic. Dr Valgimigli reports personal fees from AstraZeneca, grants and personal fees from Terumo Corporation, personal fees from Alvimedica/Carbostent and Implantable Devices, personal fees from Abbott Vascular, personal fees from Daiichi Sankyo, personal fees from Bayer, personal fees from Abiomed, personal fees from CoreFLOW, personal fees from Idorsia Pharmaceuticals, Ltd, personal fees from Universität Basel, Deptartment Klinische Forschung, personal fees from Bristol Myers Squib SA, personal fees from Medscape, personal fees from Biotronik, and personal fees from Novartis, outside the submitted work. Dr van Royen received research grants from Philips, Abbott, Biotronik, and Medtronic and personal fees from Abbott, Microport, and Rainmed. Dr van Leeuwen received speaker/consulting services honoraria from Terumo Corporation, Daiichi Sankyo, and Abbott and research grants from AstraZeneca, Top Sector Life Sciences & Health, Terumo Corporation, Top Medical B.V., and Abbott. The other authors report no conflicts.

Competing Interests: Funding Support and Author Disclosures Dr Seto has received speaker fees from Terumo and is a consultant for Medtronic. Dr Velagapudi has received travel funding from Boston Scientific and Medtronic; and has received speaker fees from Medtronic. Dr Carr holds equity in an ASC OBL and is a consultant for Abbott. Dr Blankenship is a principal investigator for research on supersaturated oxygen infusion after anterior MI funded by Zoll. Dr Abbott is a consultant for Boston Scientific. Dr Mamas has received speaker fees from Terumo; and is a principal investigator for registry-based research on complex PCI outcomes funded by Abbott. Dr Vidovich holds equity of intellectual property related to catheter technology and is a principal investigator for research on optical coherence tomography in left main funded by Boston Scientific. Dr Kent is a consultant for Medtronic; and is an adviser to Abbott. Dr Curzen is a chief investigator for the RIPCORD 2 (A Randomised Controlled Trial to Compare Routine Pressure Wire Assessment With Conventional Angiography in the Management of Patients With Coronary Artery Disease) trial, funded by Boston Scientific, and the FORECAST (Fractional Flow Reserve Derived From Computed Tomography Coronary Angiography in the Assessment and Management of Stable Chest Pain) trial, funded by HeartFlow; has received research grants from Boston Scientific and Beckmann Coulter; has received speaker fees from Abbott, Boston Scientific, and Edwards Lifesciences; has received travel funds from Biosensors, Medtronic, Edwards Lifesciences, and Boston Scientific; and is a consultant for Abbott, Boston Scientific, and Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Fractional flow reserve (FFR) and nonhyperemic pressure ratios (NHPRs) provide an important clinical tool to evaluate the hemodynamic significance of coronary lesions. However, these indices have major limitations. As these indices are meant to be surrogates of coronary flow, clinical scenarios such as aortic stenosis (with increased end-systolic and end-diastolic pressures) or atrial fibrillation (with significant beat-to-beat cardiac output variability) can have significant effect on the accuracy and reliability of these hemodynamic indices. Here, we provide a comprehensive evaluation of the pitfalls, limitations, and strengths of FFR and NHPRs in common clinical scenarios paired with coronary artery disease., Competing Interests: Disclosure Dr D.M. Tehrani reports no disclosures. Dr A.H. Seto has received research grants from Philips and Acist, consulting fees from Medtronic and Medicure, and is a speaker for Terumo, General Electric, and Janssen, (Copyright © 2022 Elsevier Inc. All rights reserved.)

Coronary complications are increasingly rare but remain fatal if not managed promptly and effectively. We review the incidence, management, and prevention of the most serious coronary complications including acute vessel closure from dissection, no-reflow, thrombosis, and air embolism as well as mechanical complications including perforation, stent dislodgment, and atherectomy burr entrapment., Competing Interests: Disclosure Dr D.M. Tehrani has no disclosures. Dr A.H. Seto has research grants from Philips and Acist, honoraria from Janssen, Acist, Terumo, and consulting fees from Medicare and Medtronic., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Physiologic assessment has become an essential tool to guide revascularization decisions due to the multiple limitations of angiographic and anatomic measures of physiologic significance. However, in certain cases the apparent physiologic measurement may not accurately reflect the severity of coronary disease compared with anatomical measurements. This article will review how anatomy trumps physiology in cases of acute coronary syndromes, left main disease, saphenous vein graft lesions, and myocardial bridging, and how to overcome the limitations of physiologic measurement in these clinical situations., Competing Interests: The authors declare no conflict of interest. Arnold H. Seto is serving as one of the Guest editors of this journal. We declare that Arnold H. Seto had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to Jerome L. Fleg. Dr. Seto received research grants from Acist Medical and Philips/Volcano, and is a speaker for Terumo, General Electric, and Janssen, and has received consulting fees from Medtronic and Medicure. Dr. Kern is a consultant and speaker for Abbott/St. Jude, Philips/Volcano, Acist Medical Inc., Opsens Inc. Dr. Premyodhin has no disclosures., (Copyright: © 2022 The Author(s). Published by IMR Press.)

Purpose of Review: Multivessel coronary artery disease, defined as significant stenosis in two or more major coronary arteries, is associated with high morbidity and mortality. The diagnosis and treatment of multivessel disease have evolved in the PCI era from solely a visual estimation of ischemic risk to a functional evaluation during angiography. This review summarizes the evidence and discusses the commonly used methods of multivessel coronary artery stenosis physiologic assessment., Recent Findings: While FFR remains the gold standard in coronary physiologic assessment, several pressure-wire-based non-hyperemic indices of functional stenosis have been developed and validated as well as wire-free angiographically derived quantitative flow ratio. Identifying and treating functionally significant coronary atherosclerotic lesions reduce symptoms and major adverse cardiovascular events. Coronary physiologic assessment in multivessel disease minimizes the observer bias in visual estimates of stenosis, changes clinical management, and improves patient outcomes., (© 2022. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Objectives: The aim of this trial was to test whether the potassium ferrate hemostatic patch (PFHP) as an adjunct to the TR Band (TRB) facilitated an early deflation protocol., Background: Shorter TRB compression times may reduce the rate of radial artery occlusion (RAO) and reduce observation time after transradial access., Methods: A total of 443 patients were randomized to the TRB or PFHP + TRB, with complete TRB deflation attempted 60 minutes postprocedure. The primary outcome was the time to successful full deflation of the TRB without bleeding, with secondary outcomes of time to discharge and complications including hematoma, RAO, or bleeding requiring intervention beyond TRB reinflation., Results: Time to complete TRB deflation was 66 ± 14 minutes with the PFHP vs 113 ± 56 minutes for the TRB alone (P < 0.001). Minor rebleeding requiring TRB reinflation was much more frequent without the PFHP (0% vs 67.7%; P < 0.001) with 2.3 ± 1.3 additional reinflation and deflation attempts needed for hemostasis. Hematomas developed in 4.0% of the PFHP group and 6.8% of the TRB group (P = 0.20). RAO was rare (<1%), although 41% of patients received <5,000 U heparin. Among percutaneous coronary intervention patients, time to TRB deflation (68 ± 15 minutes vs 138 ± 62 minutes; P < 0.001) and composite complications (10.0% vs 24.2%; P = 0.04) were reduced with the PFHP., Conclusions: Compared with the TRB alone, the PFHP facilitated early 60-minute TRB deflation following transradial catheterization, with a numeric reduction in vascular complications. RAO occurs rarely with early deflation regardless of heparin dose. (Comparing TR Band to StatSeal in Conjunction With TR Band II [StatSeal II]; NCT04046952)., Competing Interests: Funding Support and Author Disclosures Dr Seto is a speaker for Terumo, General Electric, Acist, and Janssen Pharmaceuticals; has received research grants from Philips and Acist; and has received consulting fees from Medicure and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Published by Elsevier Inc.)

Axillary artery access has become increasingly widespread as an alternative to the femoral route for large-bore transcatheter aortic valve replacement (TAVR), endovascular aortic repair (EVAR), and mechanical circulatory support (MCS) procedures. Advantages of percutaneous access include avoidance of a surgical incision, general anesthesia, and conduit graft infection. This statement aims to review the anatomic considerations and risks for percutaneous axillary artery access, suggest best practices for access techniques, hemostasis/closure strategies, and complication management, and recommend options for training and privileging., (© 2022 The Author(s).)