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Burr entrapment is a rare but serious complication during rotational atherectomy (RA). The Japanese have termed this the Kokeshi phenomenon named after a wooden doll found in northern Japan consisted of a simple trunk but a large head akin to the Rotablator (Mechery et al., 2016; Kaneda et al., 2000). The reason underlying this complication is the lack of diamond dust on the back end of the burr (Lin et al., 2013). The burr is olive-shaped and has diamond coating at its distal surface for antegrade ablation. The proximal part is smooth without diamonds, which prevents backward ablation of tissues when retracted (Lin et al., 2013; Dahdouh et al., 2013). Rota entrapment usually needs surgical management with coronary artery bypass grafting (CABG) surgery. To date, only few cases of successful non-traumatic retrieval using nonsurgical bailout techniques have been published (Grise et al., 2002). We report a case of burr entrapment within the left anterior descending (LAD) artery which was successfully retrieved by combination of multiple maneuvers and the patient underwent routine PCI following the retrieval.

The 15th European Bifurcation Club (EBC) meeting was held in Barcelona in October 2019. It facilitated a renewed consensus on coronary bifurcation lesions (CBL) and unprotected left main (LM) percutaneous interventions. Bifurcation stenting techniques continue to be refined, developed and tested. It remains evident that a provisional approach with optional side branch treatment utilising T, T and small protrusion (TAP) or culotte continues to provide flexible options for the majority of CBL patients. Debate persists regarding the optimal treatment of side branches, including assessment of clinical significance and thresholds for bail-out treatment. In more complex CBL, especially those involving the LM, adoption of dedicated two-stent techniques should be considered. Operators using such techniques have to be fully familiar with their procedural steps and should acknowledge associated limitations and challenges. When using two-stent techniques, failure to perform a final kissing inflation is regarded as a technical failure, since it may jeopardise clinical outcome. The development of novel technical tools and drug regimens deserves attention. In particular, intracoronary imaging, bifurcation simulation, drug-eluting balloon technology and tailored antiplatelet therapy have been identified as promising tools to enhance clinical outcomes. In conclusion, the evolution of a broad spectrum of bifurcation PCI components has resulted from studies extending from bench testing to randomised controlled trials. However, further advances are still needed to achieve the ambitious goal of optimising the clinical outcomes for every patient undergoing PCI on a CBL.

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

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) in coronary bifurcation lesions (CBL) is undergoing substantial technical progress and standardization, paralleling the evolution of dedicated devices, tools, and techniques. A standard consensus to classify CTO-CBL might be instrumental to homogenize data collection and description of procedures for scientific and educational purposes. The Medina-CTO classification replicates the classical three digits in Medina classification for bifurcations, representing the proximal main vessel, distal main vessel, and side branch, respectively. Each digit can take a value of 1 if it concerns atherosclerosis and is anatomically stenosed, or 0 if it is not. In addition, the occluded segment(s) of the bifurcation are noted by a subscript, which describes key interventional features of the cap: t (tapered), b (blunt), or a (ambiguous). This approach results in 56 basic categories that can be grouped by means of different elements, depending on the specific needs of each study. Medina-CTO classification, consisting of adding a subscript describing the basic cap characteristics to the totally occluded segment(s) of the standard Medina triplet, might be a useful methodological tool to standardize percutaneous intervention of bifurcational CTO lesions, with interesting scientific and educational applications.

Aims Studies comparing the outcome of percutaneous coronary intervention (PCI) along with optimal medical therapy (OMT) versus OMT alone in treatment of chronic total occlusion (CTO) are limited by observational design, variable follow-up period, diverse clinical outcomes, high drop-out and cross-over rates. This study aims to conduct a meta-analysis of published data of observational as well as randomized studies comparing long term outcomes of PCI+OMT versus OMT alone. Methods and results PubMed, Embase and Cochrane databases were systematically reviewed. 15 studies meeting criteria were included in the meta-analysis. The New-castle Ottawa scale was used to appraise the overall quality of the studies. Random-effects model with inverse variance method was undertaken. Major adverse cardiovascular events (MACE) which comprises of cardiac death, myocardial infarction, stroke, and un-planned revascularization were significantly lower in the PCI+OMT group (RR:0.76; 95% CI:0.61 to 0.95; P=, In this largest meta-analysis consisting of 15 studies, comparing 6093 patients in PCI group and 4943 patients in OMT group, it has been found that, PCI of CTO has a better long term outcome in terms of MACE, cardiac death and all causes of mortality with similar unplanned revascularization. Higher age, TVD, CKD independently contribute to higher MACE in CTO patients undergoing PCI in multivariate logistic meta-regression analysis.

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.

Coronary artery disease carries a high morbidity and mortality worldwide, and exercise-based cardiac rehabilitation programmes play a large role in secondary prevention. Exercise-based rehabilitation programmes are expensive, and in certain subgroups uptake is poor. Yoga has been suggested to show improvements in cardiovascular health which would support its use in cardiac rehabilitation programmes. We carried out a review of current randomized controlled trials to determine if yoga-based cardiac rehabilitation leads to reduced cardiac risk factors, and improved physiological and psychological outcomes in patients with coronary artery disease compared to standard care. Six randomized controlled studies were identified after a medical database search, and meta-analysis was carried out for the different outcomes. Overall, the addition of yoga to standard care resulted in improved subjective feeling of cardiac health and quality of life. There was also a trend towards improvement in left ventricular systolic function. Improvement in cardiac risk factors, MACE and psychological health in this cohort has still to be proven, but was not inferior to standard or enhanced care, and the benefits became more pronounced at longer follow-up. Future studies with longer follow-up and larger patient numbers would aid in accurately assessing the long-term benefit of yoga-based rehabilitation.

Background Management of heavily calcified coronary arteries is still a major challenge in interventional cardiology. Inadequate stent expansion in calcific lesions is the single most important predictor of stent thrombosis and in-stent restenosis. Rotational atherectomy (RA) is an important tool to modify the calcium burden but is associated with limitations and requires specific skills. Intravascular lithotripsy (IVL) is a novel technique to treat calcified stenotic lesions and has been proposed as an alternative to RA with promising results. Case summary We report a case of a patient with severely calcified right coronary artery stenosis successfully treated with combination of RA and IVL. Discussion In this case, we demonstrate that the RA and IVL are complementary strategies, not sufficient on their own and not alternative to each other.

The 15(th) European Bifurcation Club (EBC) meeting was held in Barcelona in October 2019. It facilitated a renewed consensus on coronary bifurcation lesions (CBL) and unprotected left main (LM) percutaneous interventions. Bifurcation stenting techniques continue to be refined, developed and tested. It remains evident that a provisional approach with optional side branch treatment utilising T, T and small protrusion (TAP) or culotte continues to provide flexible options for the majority of CBL patients. Debate persists regarding the optimal treatment of side branches, including assessment of clinical significance and thresholds for bail-out treatment. In more complex CBL, especially those involving the LM, adoption of dedicated two-stent techniques should be considered. Operators using such techniques have to be fully familiar with their procedural steps and should acknowledge associated limitations and challenges. When using two-stent techniques, failure to perform a final kissing inflation is regarded as a technical failure, since it may jeopardise clinical outcome. The development of novel technical tools and drug regimens deserves attention. In particular, intracoronary imaging, bifurcation simulation, drug-eluting balloon technology and tailored antiplatelet therapy have been identified as promising tools to enhance clinical outcomes. In conclusion, the evolution of a broad spectrum of bifurcation PCI components has resulted from studies extending from bench testing to randomised controlled trials. However, further advances are still needed to achieve the ambitious goal of optimising the clinical outcomes for every patient undergoing PCI on a CBL.

Coronary Artery Aneurysms (CAAs) in both symptomatic and asymptomatic patients are associated with poor long-term outcomes. The best treatment option for CAAs remains a subject of debate. The underlying pathology is not well understood, randomised controlled trials and supportive data are lacking and there is no consensus on treatment plan. The recommended therapies include medical management, percutaneous or surgical exclusion of the aneurysm or coronary artery bypass grafting surgery (CABG). Percutaneous coronary intervention (PCI) can be technically challenging even with a suitable anatomy, specifically in acute coronary syndrome (ACS). We report case series of CAAs presenting as ACS and focus on PCI treatment option.

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.

Coronary Bifurcation lesions are technically more challenging and Bifurcation percutaneous coronary intervention (PCI) remains a challenge with unpredictable and sub-optimal clinical and angiographic results. Drug-Coated Balloons (DCB) are emerging devices in the field of coronary intervention with promising results that may overcome some of drug eluting stents limitations and may have potential advantages in complex bifurcation PCI.We have performed a re-appraisal about the issues with current bifurcation PCI techniques and the use of DCB in the treatment of Bifurcation lesions. Several studies performed utilizing DCB are described and critically appraised. Over the recent years, there have been tremendous developments in the DCB technology, lesion preparation, clinical experience, and clinical data during bifurcation PCI. The current review describes the advances in the DCB technology, pharmacokinetics, role of excipients, and optimization of the technique. Special emphasis in lesion preparation and potential pathway of using DCB in bifurcation PCI is proposed.Although different proof of concept and pilot studies have shown promising results in treatment of bifurcation lesions with DCB, larger randomized trials and/or international consensus papers are required to enable worldwide translation of this idea to clinical practice.

Transradial cardiac catheterisation has been reported to be more beneficial compared to other approaches with easier and safer post-procedural haemostasis, better patient comfort, earlier ambulation and possibility of performing procedure and discharge on the same day. There is only limited data examining transradial access in the elderly population. In this review we looked at the available literature to give an insight into how the transradial approach compared to the transfemoral and other approaches in the elderly population. Elderly population is at higher risk of vascular access site bleeding and the transradial approach has shown equal efficacy to transfemoral approach. However, transradial approach significantly reduces vascular complications, hospital stay, mobilization times and adverse cardiac events. Therefore, transradial approach should be considered as the preferred vascular access site in the elderly population.

Myocardial edema is one of the characteristic features in the pathogenesis of Takotsubo syndrome. We report a middle aged man who presented with typical clinical and echocardiographic features of apical variant of Takotsubo syndrome. However, a cardiovascular magnetic resonance study performed 10 days after presentation did not show any apical 'ballooning' but revealed features of an apical hypertrophic cardiomyopathy on cine images. Tissue characterization with T2 weighted images proved severe edema as the cause of significantly increased apical wall thickness. A follow-up cardiovascular magnetic resonance study was performed 5 months later which showed that edema, wall thickening and the appearance of apical hypertrophic cardiomyopathy all resolved, confirming Takotsubo syndrome as the cause of the initial appearance. As the affected myocardium most commonly involves the apical segments, an edema induced increase in apical wall thickness may lead to appearances of an apical hypertrophic cardiomyopathy rather than apical ballooning in the acute to subacute phase of Takotsubo syndrome.

Background Chronic total occlusion (CTO) is common, being reported in 18% to 30% of patients undergoing coronary angiography. Percutaneous coronary intervention (PCI) is usually performed to relieve anginal symptoms, but data are emerging to suggest that there may also be a mortality benefit. Objectives This study aimed to compare outcomes of patients with successful versus unsuccessful PCI to a CTO. Methods We analyzed the U.K. Central Cardiac Audit Database for all CTO PCI cases carried out in England and Wales between January 1, 2005, and December 31, 2009. Vital status in September 2010 was obtained from the Medical Research Information Service. Results A total of 13,443 patients (78.8% male) had a mean age of 63.5 years and underwent 14,439 CTO procedures. CTO PCI was successful in 10,199 cases (70.6%). During follow-up of 2.65 years (interquartile range: 1.59 to 3.83 years), successful PCI of at least 1 CTO was associated with improved survival (hazard ratio [HR]: 0.72; 95% CI: 0.62 to 0.83; p Conclusions Successful CTO PCI was associated with improved long-term survival. The improvement was greatest in patients when complete revascularization was achieved. The identity of the successfully treated occluded vessel was not associated with differences in outcome.

Retrograde chronic total occlusion (CTO) percutaneous coronary intervention PCI has become the cornerstone of CTO PCI. Interventional collateral channel (CC) selection and crossing remain the essential component for retrograde CTO PCI. There is limited data on how to select the CC and the

Conflicting data have been reported about the association between plaque composition and remodelling index (RI). The aim of this study is to evaluate the relationship between plaque morphology obtained by optical coherence tomography (OCT) and arterial remodelling.OCT and intravascular ultrasound imaging pull back was performed at corresponding sites on 94 lesions in 47 patients. OCT plaque characteristics for lipid content, fibrous cap thickness, thin-cap fibroatheroma (TCFA), plaque rupture, thrombus, calcification and erosion were derived using validated criteria. Compared with intermediate/negative remodelling (RI1.0), positive remodelling (RI1.0) was associated with presence of higher lipid pool (2.86 ± 0.42 vs. 2.20 ± 0.78; p0.001), thin fibrous cap (47.86 ± 25.43 μm vs. 74.41 ± 32.41 μm; p0.001), TCFA3mm (82.1% vs. 22.7%; p0.0001), plaque rupture and thrombus (42.8% vs. 19.7%; p = 0.024), and higher plaque burden (73.70 vs. 70.70; p = 0.048). No difference was observed in the presence of calcification and plaque erosions.Coronary lesions with positive remodelling show higher incidences of vulnerable plaque and plaque rupture across the lesion length. This potentially explains the correlation between unstable coronary syndromes and positive remodelling.

ObjectivesThe aim of this prospective, randomized study was to evaluate the effects of telmisartan, compared with the calcium-channel blocker amlodipine, on endothelial function after coronary drug-eluting stent (DES) implantation in hypertensive patients.BackgroundDES implantation impairs local endothelial function, which may be associated with future cardiovascular events. Telmisartan, which has unique peroxisome proliferator-activated-receptor-gamma–mediated effects in addition to its renin-angiotensin system–inhibition effects, has favorable effects on endothelial function.MethodsFifty-one hypertensive patients with coronary artery stenosis but without coronary artery spasm, treated with a sirolimus-eluting stent, were randomly assigned to either the telmisartan (25 cases) or amlodipine (26 cases) treatment groups. At baseline and at 3 months after DES implantation, endothelium-dependent and -independent vasomotion were evaluated by quantitative coronary angiography under the condition of medication withdrawal. The mean luminal diameter of a 20-mm coronary segment, beginning 5 mm distal to the stent, was measured before and after infusion of intracoronary acetylcholine (10−7, 10−6 mol/l) and then again after infusion of nitroglycerin.ResultsBlood pressure was comparable between groups at baseline and after 3 months. Vasoconstriction after acetylcholine infusion at 3 months (impaired endothelial function) was less pronounced in the telmisartan group than in the amlodipine group (p < 0.0001), although there was no significant difference between the 2 groups before DES implantation. The response to nitroglycerin did not differ between groups before or at 3 months after DES implantation.ConclusionsTelmisartan, compared with amlodipine, significantly ameliorated endothelial dysfunction after DES implantation in terms of vasoconstriction induced by acetylcholine.

OBJECTIVES The purpose of this study was to assess the prevalence and to quantify the thin-cap fibroatheroma (TCFA) and ruptured plaques in patients with coronary artery disease using optical coherence tomography (OCT). BACKGROUND TCFA lesions are the most prevalent precursors of plaque rupture, and are responsible for acute coronary syndromes (ACS). There are limited data regarding the frequency and distribution of TCFA in diseased coronary arteries. METHODS Coronary artery OCT was performed in 78 vessels in 47 patients, with stable angina (SA) or ACS. OCT plaque characteristics were derived using criteria that had been validated earlier. TCFA was defined as rich in lipid (two or more quadrants) with thin fibrous cap (

Objective This study compared the impact of pattern of sirolimus eluting stent restenosis (SES ISR) on the angiographic outcomes following conventional modalities of treatment. Methods A total of 344 consecutive patients who underwent treatment for SES ISR were included in the study. Lesions were divided into focal 10 mm, 188 (54.7%). The endpoints analysed were angiographic restenosis and target lesion revascularisation. A total of 31%, 41%, and 23% patients were treated with cutting balloon angioplasty, balloon angioplasty, and repeat stenting. Results Baseline characteristics were similar for two patterns, except for young age, more AMI and severe angina, more CTO lesions, long lesions, and more use of repeat stenting in non focal ISR group. Follow up angiography shows binary restenosis was significantly lower in the focal group (32.4% vs. 49.2; p =0.012) and target lesion revascularisation were also lower with focal pattern ISR (30.6 vs. 42.9; p =0.06). Restenosis rates are similar between balloon angioplasty and repeat stenting (28 vs. 23%) in focal ISR group, and repeat stenting showed better outcomes in the non focal group (60% vs. 36%). Conclusion The recurrent ISR remains high with available treatments and the pattern of SES ISR predicted the outcomes, with lower restenosis rates with focal pattern of ISR.

Objectives We performed this study to investigate with optical coherence tomography (OCT) the vascular response after sirolimus-eluting stent (SES) implantation between patients with and those without diabetes mellitus (DM). Background The difference in vascular response after SES implantation between patients with and those without DM has not been fully evaluated with OCT. Methods Optical coherence tomography was performed to examine 74 nonrestenotic SES implanted in 63 patients (32 with DM and 31 without DM) at 9 months after SES implantation. For struts showing neointimal coverage, the neointimal thickness on the luminal side of each strut section was measured, and neointimal characteristics were classified into high, low, and layered signal pattern. Results Baseline patient characteristics and lesion and procedural characteristics data were similar between the 2 groups. In total, 11,422 struts were analyzed. High signal neointima was observed in 90.2 ± 13.9%, low signal neointima in 7.3 ± 10.0%, and layered neointima in 2.7 ± 5.8%/stents. There was higher incidence of low signal neointima (10.5 ± 10.3% vs. 4.5 ± 5.6%, p = 0.003), neointimal thickness was larger (median: 106.8 μm, interquartile range: 79.3 to 130.4 μm vs. median: 83.5 μm, interquartile range: 62.3 to 89.3 μm; p Conclusions High signal neointimal pattern was predominantly observed, and low or layered signal pattern was observed in some cases. In DM patients, low signal neointima was observed with high frequency. Neointimal coverage and neointimal thickness was also higher in DM patients as compared with non-DM patients.

Objectives: The aim of this study was to assess the impact of length and hydrophilic coating of the introducer sheath on radial artery spasm, radial artery occlusion, and local vascular complicatio...

Background— The aim of this study was to compare the impact of transradial catheterization with hydrophilic-coated catheter sheaths versus uncoated sheaths on NO-mediated endothelial-dependent and -independent vasodilator function. Methods and Results— Thirty-five subjects undergoing transradial catheterization were recruited and assessed before and the day after catheterization. A subgroup was also assessed 3 to 4 months after catheterization. Subjects received hydrophilic-coated sheaths (n=15) or uncoated sheaths (n=20). Radial artery flow-mediated dilatation and endothelium- and NO-dependent arterial dilatation were assessed within the region of sheath placement. Glyceryl trinitrate endothelium-independent NO-mediated function was also assessed. The noncatheterized arm provided an internal control. Flow-mediated dilatation in the catheterized arm decreased from 10.3�3.8% to 5.3�3.3% and 8.1�2.4% to 5.2�3.7% in the coated and uncoated groups, respectively ( P P P P P Conclusions— Placement of a catheter sheath inside the radial artery disrupts vasodilator function, which recovers after 3 months. No differences were evident between hydrophilic-coated and uncoated sheaths.

The aim of this study was to determine the impact of catheter sheath insertion, a model of endothelium disruption in humans, on the conventional FMD (flow-mediated dilatation) response in vivo . Seventeen subjects undergoing transradial catheterization were recruited and assessed prior to, the day after, and 3–4 months postcatheterization. The catheter sheath's external diameter was 2.7 mm, and the average preprocedure internal radial artery diameter was 2.8 mm, indicating a high likelihood of endothelial denudation as a consequence of sheath placement. Radial artery flow-mediated and endothelium-derived NO (nitric oxide)-dependent function (FMD) was assessed within the region of sheath placement (sheath site) and also above the sheath (catheter site). GTN (glyceryl trinitrate) endothelium-independent NO-mediated function was also assessed distally. Measurements were made in both arms at all time points; the non-catheterized arm provided an internal control. Neither sheath (4.5±0.9%) nor catheter (4.4±0.9%) insertion abolished FMD, although both significantly decreased FMD from preintervention levels (9.0±0.8% sheath segment; 8.4±0.8% catheter segment; P

Aims: This paper studies in-stent restenosis (ISR) after percutaneous coronary intervention (PCI) following bare-metal stent (BMS) and drug-eluting stent (DES) in all consecutive patients between 2004 and 2007 undergoing PCI for ISR lesions at our centre. Methods and results: We compared the clinical presentation, pattern and angiographic outcomes in 838 patients with BMS ISR (487) and SES ISR (351). About 18% of the patients presented with acute coronary syndrome with 2% presenting as ST elevation myocardial infarction, similar in both groups. Angiographic pattern was predominantly focal with SES ISR (47%SES ISR vs. 19% BMS ISR; p

Objectives The study evaluates the feasibility and efficacy of the novel modification of the retrograde recanalization of the chronic total occlusion (CTO) of the coronary arteries by using intravascular ultrasound (IVUS)-guided reverse controlled antegrade and retrograde tracking (CART). Background Despite improvement in the techniques and materials, CTO recanalization is still suboptimal. The CART procedure has improved success rates, but there are certain inherent technical uncertainties and risk with this procedure. Methods This first series involves 31 patients, with 22 patients having previous failed attempts at CTO recanalization. All patients were treated with bilateral approach and using IVUS-guided reverse CART concept. Results Successful recanalization of the CTO was achieved in all cases (100%). The access route was septal collateral in 20 (70%) cases and epicardial collateral in 11 (30%) cases. IVUS guidance was used successfully in 30 cases, and the channel dilator (microcatheter) was used in 27 cases. Guidewire injury and grade 1 perforation was seen in 3 (9%) cases, which were managed conservatively. There was no death, coronary artery bypass surgery, or pericardiocentesis in this group of patients. Mean fluoroscopy time was 65.84 ± 23.16 min, ranging from 31 to 106 min and total contrast volume used 321.32 ± 137.77 ml (range 115 to 650 ml). Conclusions This first series describes a high success rate of CTO recanalization with IVUS-guided reverse CART in selected patients performed by an experienced operator.

The aim of this study was to examine the procedural success and in-hospital outcomes after percutaneous coronary intervention (PCI) for chronic total occlusions in the current era during contemporary practice. The technique of PCI has improved over time with the introduction of novel equipment and guidewire crossing techniques. However, there is limited data available from contemporary practice in the recent years. We evaluated the procedural and in-hospital outcomes in a consecutive series of 904 procedures performed at Toyohashi Heart Center for PCI of chronic total occlusions of >3 months in duration. Technical and procedural success was achieved in 87.5% and 86.2%, respectively. In-hospital major adverse cardiac events occurred in only 1.9% of the patients. Single antegrade wire was the predominant strategy for guidewire crossing; however, retrograde guidewire crossing was used in 7.2% of the cases and controlled antegrade and retrograde subintimal tracking in 9.9% of the cases as the final strategy. Logistic regression analysis identified severe tortuosity and moderate-to-severe calcification as significant predictors of procedural failure. This is the first reported large series of patients undergoing PCI for chronic total occlusion with improved wire crossing techniques. We have reported high success rates in recent years and very low complication rates despite the use of more aggressive devices and techniques.

Background— Retrograde approach through collaterals has been introduced for percutaneous recanalization of chronic total occlusion (CTO) of the coronary arteries. We investigated the safety and efficacy of retrograde approaches used for percutaneous recanalization of CTO in a consecutive series of patients. Methods and Results— We studied 157 consecutive patients who underwent retrograde CTO recanalization between 2003 and 2008 at a single center. A total of 118 (75.2%) of these patients have had previously failed antegrade attempts. Septal, epicardial, and saphenous vein graft collaterals were used in 67.5%, 24.8%, and 7.6% of cases, respectively. Collateral channel was crossed by guide wire successfully in 115 (73.2%) cases, and the procedure was successful by retrograde approach in 103 (65.6%) cases. Collateral channels (CCs) were graded as follows: CC0, no continuous connection; CC1, continuous thread-like connection; and CC2, continuous, small sidebranch-like connection. CC1, collateral tortuosity P P =0.01), CC0, corkscrew channel ( P 90� ( P =0.0007), and nonvisibility of connection with recipient vessel were found to be significant predictors of procedural failure. The CC dissection was observed in 6 patients, with 1 needing coil embolization and others who were managed conservatively. The major adverse cardiac events were low, with 1 coronary artery bypass graft, 1 Q-wave myocardial infarction, 5 non–Q-wave myocardial infarctions, and no deaths in this group of patients. Conclusions— The retrograde approach in CTO percutaneous coronary intervention is effective in recanalizing CTO. The success rate by retrograde approach was 65.6%, and final success was 85% in this group with acceptable overall adverse events. We have identified predictors of failure related to collateral morphology.

The benefits of the transradial approach have clearly been demonstrated over the years in various studies. The reduced incidence of access site complications and early mobilization are some of the benefits making this technique popular with interventional cardiologists worldwide. With increasing experience and availability of dedicated equipment this technique is now been increasingly used for complex catheter interventions. However, there still remain some potential problems and complications with the transradial approach and it needs further research. The main purpose of this review is to highlight the benefits, complications, and potential problems with the transradial approach.

Cardiac catheterization through the radial artery approach (RA) has been shown to significantly reduce access-site complications compared with the femoral artery approach (FA) in many clinical settings. However, in the subset of patients with previous coronary artery bypass grafting (CABG), optimal vascular access site for coronary angiography and intervention is still a matter of debate. We aimed to perform a systematic review and meta-analysis of available studies comparing RA with FA in patients with previous CABG. Data were extracted by two independent reviewers; weighted mean differences and 95% confidence interval (CI) were calculated for continuous outcomes, whereas odds ratio (OR) and 95% CI were calculated for dichotomous outcomes. Summary statistics were calculated by random-effects model using Review Manager 5.3 software. The meta-analysis included 1 randomized and 8 nonrandomized studies, with a total of 2,763 patients. Compared with FA, RA required similar procedural time (mean difference 3.24 minutes, 95% CI -1.76 to 8.25, p = 0.20), fluoroscopy time (mean difference 0.62 minutes, 95% CI -0.83 to 2.07, p = 0.40), and contrast volume (mean difference -2.58 ml, 95% CI -18.36 to 13.20, p = 0.75) and was associated with similar rate of procedural failure (OR 1.32, 95% CI 0.63 to 2.80, p = 0.46), higher rate of crossover to another vascular access (OR 7.0, 95% CI 2.74 to 17.87, p0.0001), and lower risk of access-site complications (OR 0.46, 95%CI 0.26 to 0.80, p = 0.006). In conclusion, the present meta-analysis suggests that in patients with previous CABG undergoing coronary procedures, RA, compared with FA, is associated with increased crossover rate but may reduce access-site complications.

Thermography depends upon the infrared thermograms which records temperature variations in desired region of interest. Thermal imaging or thermography is one of the alternative to the existing diagnosis methods for analyzing human body dysfunctions. Thermography provides information about temperature variations in human skin of different body parts. Inflammation in any part of human body causes temperature changes at surrounding area, thermography can be used as a tool for monitoring dysfunctions. But some limitations and disadvantages are still present when thermography is used in bio-medical applications, so the accuracy of thermographic system need to be improved to make it a powerful diagnosis tool. Rheumatoid arthritis (RA) is an auto-immune disease that attacks healthy tissues of joints of fingers, wrist, shoulders and feet, causing pain and inflammation over these areas. Modern computer technology can be used for developing a system for auto analysis and diagnosis of RA using Artificial Neural Network. In this paper a Windows CE based portable intelligent system on Friendly ARM Mini 2440 has been implemented for detection of Rheumatoid Arthritis with the aid of fuzzy c-means segmentation algorithm and artificial neural network.

Recent improvement in clinical skills, technology and hardware has resulted in improved success rates with chronic total occlusion angioplasty. We sought to perform pooled analysis of procedural characteristics, procedural outcomes and complications following contemporary chronic toatal occlusion

Small vessel (3 mm) coronary artery disease is common and has been identified as independent predictor of restenosis after percutaneous coronary intervention. It remains controversial whether bare metal stent (BMS) implantation in small vessels has an advantage over balloon angioplasty in terms of angiographic and clinical outcomes. Introduction of drug-eluting stent (DES) has resulted in significant reduction in restenosis and the need for repeat revascularisation. Several DESs have been introduced resulting in varying reduction in outcomes as compared to BMS. However, their impact on outcomes in small vessels is not clearly known. It is expected that DES could substantially reduce restenosis in smaller vessels. Large, randomised studies are warranted to assess the impact of different DES on outcomes in patients with small coronary arteries.

Background— Radial artery catheterization is associated with endothelial denudation and impaired vasodilator function, while postcatheterization exercise training may enhance artery function. The impact of catheterization and subsequent exercise training on low-flow mediated vasoconstriction (L-FMC) has not previously been studied. The aim of this study was to examine whether radial artery L-FMC is impaired by catheterization and consequent endothelial denudation. A further aim was to examine the effect of local handgrip exercise training on radial artery L-FMC and flow-mediated dilation (FMD) after transradial catheterization. Methods and Results— Thirty-two subjects undergoing transradial catheterization underwent assessment of L-FMC and FMD in the catheterized and contralateral radial artery before, and the day after, catheterization. A further 18 patients were recruited and randomly assigned to either a 6-week handgrip exercise training program (N=9) or a nonexercise control period (N=9). L-FMC was attenuated 1 day postcatheterization in the catheterized arm (−2.07±0.84 to 0.35±0.83), but unchanged in the noncatheterized arm (−0.93±0.86 to −0.90±0.92; P P =0.06; L-FMC-pre, −3.26±1.19; L-FMC-post, −1.34±1.27%; P Conclusions— Catheterization, and associated endothelial denudation, decreases L-FMC in the radial artery, suggesting that it is endothelium-dependent. Moreover, we demonstrate for the first time that exercise training has beneficial impacts on radial artery vasodilator and constrictor function.