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BackgroundThere is mounting data supporting the use of drug-coated balloons (DCB) not only for treatment of in-stent restenosis (ISR), but also in native coronary artery disease. So far, paclitaxel-coated balloons represented the mainstay DCBs. The SeQuent® crystalline sirolimus-coated balloon (SCB) (B.Braun Medical Inc, Germany) represents a novel DCB, which allows a sustained release of the limus-drug. We evaluated its performance in an all-comer cohort, including complex coronary lesions.MethodsConsecutive patients treated with the SeQuent® SCB were analyzed from the prospective SIROOP registry (NCT04988685). We assessed clinical outcomes, including major adverse cardiovascular events (MACE), target lesion revascularization (TLR), target vessel myocardial infarction (TV-MI) and cardiovascular death. Angiograms and outcomes were independently adjudicated.ResultsFrom March 2021 to March 2023, we enrolled 126 patients and lesions, of which 100 (79%) treated using a “DCB-only” strategy and 26 (21%) with a hybrid approach (DES + DCB). The mean age was 68 ± 10 years, 48 (38%) patients had an acute coronary syndrome. Regarding lesion characteristics, ISR was treated in 27 (21%), 11 (9%) underwent CTO-PCI and 59 (47%) of the vessels were moderate to severe calcified. Procedural success rate was 100%. At a median follow-up time of 12.7 (IQR 12; 14.2) months, MACE occurred in 5 patients (4.3%). No acute vessel closure was observed.ConclusionsOur data indicates promising outcomes following treatment with this novel crystalline SCB in an all-comer cohort with complex coronary lesions. These results require further investigation with randomized trials.

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Despite a large body of evidence supporting the use of intravascular imaging (IVI) to guide percutaneous coronary intervention (PCI), concerns exist about its universal recommendation. The selective use of IVI to guide PCI of complex lesions and patients is perceived as a rational approach. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs). Embase, PubMed, and Cochrane were systematically searched for RCTs that compared IVI-guided PCI with angiography-guided PCI in high-risk patients and complex coronary anatomies. The primary outcome was major adverse cardiac events (MACE). A random-effects model was used to calculate the risk ratios (RRs) with 95 % confidence intervals (CIs). A total of 15 RCTs with 14,109 patients were included and followed for a weighted mean duration of 15.8 months. IVI-guided PCI was associated with a decrease in the risk of MACE (RR: 0.65; 95 % CI: 0.56–0.77; p < 0.01), target vessel failure (TVF) (RR: 0.66; 95 % CI: 0.52–0.84; p < 0.01), all-cause mortality (RR: 0.71; 95 % CI: 0.55–0.91; p < 0.01), cardiovascular mortality (RR: 0.47; 95 % CI: 0.34–0.65; p < 0.01), stent thrombosis (RR: 0.55; 95 % CI: 0.38–0.79; p < 0.01), myocardial infarction (RR: 0.81; 95 % CI: 0.67–0.98; p = 0.03), and repeated revascularizations (RR: 0.70; 95 % CI: 0.58–0.85; p < 0.01) compared with angiography. There was no significant difference in procedure-related complications (RR: 1.03; 95 % CI: 0.75–1.42; p = 0.84) between groups. Compared with angiographic guidance alone, IVI-guided PCI of complex lesions and high-risk patients significantly reduced all-cause and cardiovascular mortality, MACE, TVF, stent thrombosis, myocardial infarction, and repeat revascularization. [Display omitted] • Universal IVI guidance for PCI carries logistical and economic barriers. • The selective use of IVI for high-risk PCI is perceived as a rational approach. • Systematic review and meta-analysis of 15 RCTs and 14,109 patients. • IVI versus angiography for PCI in patients with high anatomical and clinical risk. • IVI reduced mortality, MACE, TVF, stent thrombosis, MI, and revascularization. [ABSTRACT FROM AUTHOR]

Abstract Background Although patients with familial heterozygous hypercholesterolemia (FH) have a high risk of early myocardial infarction (MI), the coronary artery disease (CAD) burden in FH patients with acute MI remains to be investigated. Methods The data for all consecutive patients hospitalized in 2012–2019 for an acute MI and who underwent coronary angiography were collected from a multicenter database (RICO database). FH (n = 120) was diagnosed using Dutch Lipid Clinic Network criteria (score ≥ 6). We compared the angiographic features of MI patients with and without FH (score 0–2) (n = 234) after matching for age, sex, and diabetes (1:2). Results Although LDL-cholesterol was high (208 [174–239] mg/dl), less than half of FH patients had chronic statin treatment. When compared with non-FH patients, FH increased the extent of CAD (as assessed by SYNTAX score; P = 0.005), and was associated with more frequent multivessel disease (P = 0.004), multiple complex lesions (P = 0.022) and significant stenosis location on left circumflex and right coronary arteries. Moreover, FH patients had more multiple lesions, with an increased rate of bifurcation lesions or calcifications (P = 0.021 and P = 0.036, respectively). In multivariate analysis, LDL-cholesterol levels (OR 1.948; 95% CI 1.090–3.480, P = 0.024) remained an independent estimator of anatomical complexity of coronary lesions, in addition to age (OR 1.035; 95% CI 1.014–1.057, P = 0.001). Conclusions FH patients with acute MI had more severe CAD, characterized by complex anatomical features that are mainly dependent on the LDL-cholesterol burden. Our findings reinforce the need for more aggressive preventive strategies in these high-risk patients, and for intensive lipid-lowering therapy as secondary prevention.

BackgroundPercutaneous coronary intervention (PCI) is the preferred treatment method for coronary artery diseases (CAD). This study aimed to evaluate the effectiveness and complications of the Guidezilla™ guide extension catheter I (GGEC I) in transradial coronary intervention (TRI).MethodsThis case series study included patients with CAD who underwent TRI using the GGEC I between August 2016 and January 2019 at the First Affiliated Hospital of Xi’an Jiaotong University.ResultsA total of 221 patients aged 65.1 ± 9.26 years were included. Coronary angiography results indicated that most patients (77.8%) had triple-vessel lesions, including 47.5% with chronic total occlusion (CTO). A total of 237 target lesions were treated, most being type C lesions (95.8%). The most common indication for GGEC I use was heavy calcification (67%), followed by extreme tortuosity (12.2%), extreme tortuosity and heavy calcification (10.9%), distally located lesion (4.5%), picking up the retrograde wire (3.2%), anomalous vessel origin (1.8%), and releasing the burr incarceration (0.4%). The mean operation time was 58 min, and the overall success rate was 94.1%. Four patients received a drug-coated balloon. No significant differences were found in operation time and success rate among the low (32) CAD groups based on SYNTAX score stratification (P > 0.05). Two subacute thrombosis cases each were reported perioperatively, during hospitalization, and at the 1-month follow-up.ConclusionThe GGEC I might have advantages for TRI and is unaffected by SYNTAX score stratification.

Drug eluting stents (DES) have revolutionised interventional cardiology and currently represent the standard for percutaneous coronary interventions (PCI). However, due to several limitations, new strategies are required, especially in very complex lesions. Drug-coated balloons (DCB) offer an attractive therapeutic alternative, and have already obtained a Class I recommendation for the treatment of in stent restenosis (ISR) with Level A of evidence. Moreover, the role of DCB has been tested in several other settings, such as de novo large vessel disease, multivessel disease or very complex lesions, with promising results regarding safety and effectiveness. In this context, a hybrid strategy consisting in the use of a DES and DCB with the aim of reducing the amount of metal implanted and minimising the risk of ISR and stent thrombosis could become the solution for very complex lesions. Several important studies already demonstrated very good angiographic results in terms of late lumen loss and restenosis for this approach in bifurcation lesions. Moreover, for long diffuse coronary disease similar rates of MACE, TVR, and TLR at 2-year follow-up in comparison to a DES-alone strategy were found. What is more, the use of this strategy in high-bleeding risk patients could safely permit the practitioners to reduce the DAPT duration, as data is suggesting. As our daily practice already strongly incorporated this strategy and with more data expected from important trials, it is our strong believe that the hybrid approach can become a standard treatment choice in the near future. [ABSTRACT FROM AUTHOR]

Background: Percutaneous coronary intervention (PCI) is a widely used therapeutic approach for complex coronary artery disease, especially in patients with ST-elevation myocardial infarction (STEMI). The choice of vascular access site, typically radial or femoral, can significantly impact patient outcomes due to varying complication rates associated with each approach., Objective: This study aimed to compare access site complications between radial and femoral approaches in primary PCI for complex coronary lesions, providing insights into the safety and efficacy of these approaches., Methods: A prospective cohort study was conducted from January 1, 2023, to December 31, 2023, at a tertiary care cardiovascular center. A total of 350 adult patients presenting with STEMI and requiring emergency PCI for complex coronary lesions were included and randomized equally to either radial (n = 175) or femoral (n = 175) access groups. Primary outcomes included access site complications, such as hematomas, pseudoaneurysms, arteriovenous fistulas, and major bleeding events. Secondary outcomes included procedural success, access site crossover, and hospital stay duration. Data were analyzed using chi-square tests, Student's t-tests, and multivariate logistic regression., Results: The incidence of access site complications was significantly lower in the radial group (11.4%) compared to the femoral group (22.9%) (p = 0.007). Major bleeding events were also notably reduced in the radial group (2.3% vs. 8.6%, p = 0.01). There was a significantly shorter median hospital stay for the radial group (three days vs. five days, p < 0.001), while procedural success rates were comparable between groups (97.1% vs. 94.3%, p = 0.31)., Conclusion: The radial approach for primary PCI in complex lesions is associated with fewer access site complications and shorter hospital stays compared to the femoral approach, supporting its use as the preferred access site., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Ethical Review Board of Army Cardiac Centre, CMH, Lahore, issued approval 584/IRB/ACC/2022. This is to certify that Ethical Approval has been granted to conduct a study on the project 'Comparison of Access Site Complications in Primary PCI Using Radial Versus Femoral Approach for Complex Lesions: A Prospective Study,' conducted from January 1, 2023, to December 31, 2023. Consent was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Ahmad et al.)

Objective: This study evaluates the safety and efficacy of percutaneous coronary intervention in moderately and severely calcified coronary lesions, which are either not crossed or dilated using a Scoreflex balloon at nominal pressure, using single-burr rotational atherectomy (burr--artery ratio, ≤0.6) followed by scoring balloon dilatation (balloon--artery ratio, 0.9). Methods: We retrospectively identified 144 patients with severely and moderately calcified native coronary lesions, which were either not crossed or fully opened using an appropriately sized Scoreflex balloon at nominal pressure, from a tertiary care center in India. All patients underwent rotational atherectomy. The primary endpoint was angiographic and procedural success and in-hospital clinical outcomes. The secondary endpoint was the incidence of major adverse cardiac events (MACE) at one-year clinical follow-up. Results: The mean age of the patients was 68.75±8.37 years, and 83.33% of them were over 60 years old. Moderate calcification was present in 21.53%, and the remaining 78.47% had severe calcification. Procedural success was achieved in 139 (96.52%) patients. In-hospital death was reported in four (2.77%) patients. Multiple regression analysis revealed that in severely calcified coronary lesions, burr rotation speed and heparin dose were significantly associated with in-hospital MACE occurrence (p=0.0337). Conclusion: A modified small-burr rotational atherectomy technique with scoring balloon angioplasty pre-dilatation is a safe and effective surgical procedure with favorable clinical outcomes for moderately and severely calcified coronary lesions. [ABSTRACT FROM AUTHOR]

Background: Although patients with familial heterozygous hypercholesterolemia (FH) have a high risk of early myocardial infarction (MI), the coronary artery disease (CAD) burden in FH patients with acute MI remains to be investigated. Methods: The data for all consecutive patients hospitalized in 2012–2019 for an acute MI and who underwent coronary angiography were collected from a multicenter database (RICO database). FH (n = 120) was diagnosed using Dutch Lipid Clinic Network criteria (score ≥ 6). We compared the angiographic features of MI patients with and without FH (score 0–2) (n = 234) after matching for age, sex, and diabetes (1:2). Results: Although LDL-cholesterol was high (208 [174–239] mg/dl), less than half of FH patients had chronic statin treatment. When compared with non-FH patients, FH increased the extent of CAD (as assessed by SYNTAX score; P = 0.005), and was associated with more frequent multivessel disease (P = 0.004), multiple complex lesions (P = 0.022) and significant stenosis location on left circumflex and right coronary arteries. Moreover, FH patients had more multiple lesions, with an increased rate of bifurcation lesions or calcifications (P = 0.021 and P = 0.036, respectively). In multivariate analysis, LDL-cholesterol levels (OR 1.948; 95% CI 1.090–3.480, P = 0.024) remained an independent estimator of anatomical complexity of coronary lesions, in addition to age (OR 1.035; 95% CI 1.014–1.057, P = 0.001). Conclusions: FH patients with acute MI had more severe CAD, characterized by complex anatomical features that are mainly dependent on the LDL-cholesterol burden. Our findings reinforce the need for more aggressive preventive strategies in these high-risk patients, and for intensive lipid-lowering therapy as secondary prevention. [ABSTRACT FROM AUTHOR]

Background: The treatment of resistant coronary lesions (RCL) is a great challenge for interventional cardiologists. The excimer laser coronary atherectomy (ELCA) is a plaque modification tool based on a main mechanism of photomechanical effect leading to mechanical disruption of the plaque. Contrast dye injection during laser delivery has demonstrated to enhance its power., Aim: To evaluate the effectiveness and safety of the contrast-enhanced ELCA by a stepwise approach in the treatment of RCLs., Methods: We retrospectively examined consecutive patients undergoing contrast-enhanced ELCA-assisted PCI between 2018 and 2021 at two Italian sites. RCLs were defined as novo or in-stent undilatable/uncrossable with conventional balloons (SC/NC balloon). The primary endpoint was ELCA technical success defined as the laser catheter crossing the entire length of the target lesion established by angiographic evidence of the catheter tip in the artery distal to the stenosis., Results: We enrolled 114 patients who underwent contrast-enhanced ELCA-assisted PCI: 58% of the patients had acute coronary syndrome while the left anterior descending artery was the target vessel in 42.1% of cases. The target lesion was most commonly in-stent (56.2%). The 0.9 mm ELCA catheter tip was employed in 89.5% of cases. The most used frequency/fluency profile was 70/70 (39.5%). The use of contrast-enhanced ELCA was associated with high technical, procedural, and clinical success rates (97.4%, 93.7%, and 90.1%, respectively)., Conclusions: The contrast-enhanced ELCA seems to be a safe and effective treatment option for the management of both de novo and in-stent-resistant coronary lesions., (© 2024 Wiley Periodicals LLC.)

Drug eluting stents (DES) have revolutionised interventional cardiology and currently represent the standard for percutaneous coronary interventions (PCI). However, due to several limitations, new strategies are required, especially in very complex lesions. Drug-coated balloons (DCB) offer an attractive therapeutic alternative, and have already obtained a Class I recommendation for the treatment of in stent restenosis (ISR) with Level A of evidence. Moreover, the role of DCB has been tested in several other settings, such as de novo large vessel disease, multivessel disease or very complex lesions, with promising results regarding safety and effectiveness. In this context, a hybrid strategy consisting in the use of a DES and DCB with the aim of reducing the amount of metal implanted and minimising the risk of ISR and stent thrombosis could become the solution for very complex lesions. Several important studies already demonstrated very good angiographic results in terms of late lumen loss and restenosis for this approach in bifurcation lesions. Moreover, for long diffuse coronary disease similar rates of MACE, TVR, and TLR at 2-year follow-up in comparison to a DES-alone strategy were found. What is more, the use of this strategy in high-bleeding risk patients could safely permit the practitioners to reduce the DAPT duration, as data is suggesting. As our daily practice already strongly incorporated this strategy and with more data expected from important trials, it is our strong believe that the hybrid approach can become a standard treatment choice in the near future.

Objective: Intravascular ultrasound (IVUS) is not routinely performed in the real-world practice, and the benefits of IVUS-guided drug-eluting stent (DES) implantation in patients with complex coronary lesions remains unclear. This updated meta-analysis attempts to evaluate the clinical outcomes of the IVUS guidance in these patients. Methods: We searched potential eligible citations from the PubMed, EMBASE, Medline, and other internet sources. The primary endpoint were major adverse cardiovascular events (MACE), including cardiac death, myocardial infarction (MI), and target vessel revascularization (TVR). The risk of definite/probable stent thrombosis (ST) was chosen as the safety endpoint. Results: Nine randomized trials including a total of 3,612 patients with complex coronary lesions were finally analyzed. Compared to angiography guidance, IVUS-guided DES implantation was associated with significantly lower incidence of MACE [odds ratios (OR) 0.57, 95% confidence intervals (CI): 0.45-0.72, p<0.001; I2=0.0%, p=0.674], cardiac death (OR 0.42, 95% CI: 0.21-0.82, p=0.010; I2=0.0%, p=0.961), MI (OR 0.65, 95% CI: 0.44-0.95, p=0.027; I2=41.8%, p=0.089), TVR (OR 0.55, 95% CI: 0.38-0.79, p=0.001; I2=0.0%, p=0.916), target lesion revascularization (TLR) (OR 0.58, 95% CI: 0.41-0.82, p=0.002; I2=0.0%, p=0.888), and ST (OR 0.48, 95% CI: 0.24-0.93, p=0.029; I2=0.0%, p=0.733). Conclusion: The updated meta-analysis demonstrates that DES implantation under IVUS guidance leads to a significant reduction in MACE, cardiac death, MI, TVR, TLR, and ST among patients with complex coronary lesions. [ABSTRACT FROM AUTHOR]

Objectives The authors sought to investigate 1-year outcomes in patients treated with bioresorbable everolimus-eluting vascular scaffolds (BVS) for “long coronary lesions.” Background The present substudy derived from the GHOST-EU registry included 1,722 lesions in 1,468 consecutive patients, enrolled between November 2011 and September 2014 at 11 European centers. Methods The lesions were divided into 3 groups according to continuous BVS length: 1) shorter than 30 mm; 2) between 30 and 60 mm; and 3) longer than 60 mm. Primary device-oriented endpoint (target lesion failure [TLF]) was defined as a combination of cardiovascular death, target vessel myocardial infarction, or clinically driven target lesion revascularization. Results Patients with lesions ≥60 mm had more comorbidities and more complex lesion characteristics, including chronic total occlusions (37%), bifurcation lesions (40.3%), higher Syntax score (16.4 ± 7.8), and higher number of scaffolds implanted per lesion (3.3 ± 0.9 mm). The main target vessel was the left anterior coronary artery in all groups. Median follow-up was 384 (interquartile range: 359 to 459) days. One-year follow-up was completed in 70.3% of patients. TLF at 1 year was significantly higher in group C (group A 4.8%, group B 4.5%, group C 14.3%; overall p = 0.001), whereas there were no significant differences between groups A and B. Finally, a numerically higher (but not statistically significant) number of scaffold thromboses were observed in group C when compared with shorter lesions (group A 2.1%, group B 1.1%, group C 3.8%; overall p = 0.29). Conclusions In a real-world setting, treatment of long coronary lesions with BVS ≥60 mm was associated with a higher TLF rate, driven by myocardial infarction and clinically driven target lesion revascularization. [ABSTRACT FROM AUTHOR]

Background The study aimed to report the results from an all-comers registry of patients undergoing coronary angioplasty and treated with bioresorbable vascular scaffold (BVS). Methods Fifty-five consecutive patients with type B/C coronary lesions according to the AHA classification and treated with BVS were enrolled in the study. The clinical and procedural characteristics of enrolled patients were recorded. Fifty-five consecutive subjects with coronary lesions type B/C treated with everolimus eluting stent (EES) were used as control group. Results The incidence of adverse events was not statistically significant comparing subjects treated with BVS with those treated with EES. Non significant differences were also found in the follow-up considering the presence of diabetes, multivessel disease, use of more than one stent at the same time, diagnosis (STEMI vs UA/NSTEMI), use of coronary stents in overlapping. The differences were significant considering the type of lesion (Log-Rank p < 0.05), stenoses treated in correspondence of a coronary bifurcation ( p < 0.05), the SYNTAX score (cut off 22) ( p < 0.001); after multivariable correction for age and gender, however, differences remained significant only for SYNTAX score. Conclusions The use of BVS in an all-comers registry of patients undergoing coronary angioplasty on complex coronary lesions is associated with a safety profile comparable to that obtained with EES; the use of BVS in particular conditions, such as very high SYNTAX score, should be further assessed. [ABSTRACT FROM AUTHOR]

Patients with complex coronary lesions undergoing percutaneous coronary intervention (PCI) have more major adverse cardiac events (MACE) than do those with simpler cases. Therefore, intensive antiplatelet therapy might be needed in these patients. A total of 127 patients with complex lesions undergoing PCI in the Second Hospital of Tianjin Medical University from October 2012 to April 2014 were randomized to receive either dual (aspirin plus clopidogrel, DAPT, n = 66), or triple antiplatelet therapy (aspirin plus clopidogrel plus cilostazol; TAPT, n = 61). Patients in the TAPT group received low-dose cilostazol (100 mg loading, followed with 50 mg twice per day) for 3-6 months. The primary endpoint was composite MACE. The complex coronary target lesions were defined as at least one of the following: left main disease; severe 3-vessel disease; chronic total occlusion lesions; true bifurcation lesion; ostial lesions; severe calcified lesions; and highly thrombotic lesions. The two groups had similar baseline clinical and angiographic characteristics. One-year clinical outcomes showed that the TAPT group had significantly lower incidences of myocardial infarction (1.6% vs 13.6%, P = 0.018) and MACE (1.6% vs 16.7%, P = 0.004) than DAPT group. The DAPT group had two cases of stent thrombosis, while the TAPT group did not. Furthermore, adjunctive low-dose cilostazol didn't significantly increase the incidence of bleeding events (26.2% vs 19.7%, P = 0.381) regardless of major (4.9% vs 4.5%, P = 0.921) or minor (21.3% vs 15.2%, P = 0.368) bleeding events. In conclusion, low-dose adjunctive cilostazol seems superior to dual antiplatelet therapy in reducing recurrent ischemic events in patients with complex coronary lesions and the two test groups have a similar incidence of bleeding events. [ABSTRACT FROM AUTHOR]

Aim An innovative xenon–chlorine (excimer) pulsed laser catheter (ELCA X80) has been recently used for the treatment of complex coronary lesions, as calcified stenosis, chronic total occlusions and non-compliant plaques. Such complex lesions are difficult to adequately treat with balloon angioplasty and/or intracoronary stenting. The aim of this study was to examine the acute outcome of this approach on a cohort of patients with coronary lesions. Methods and Results Eighty patients with 100 lesions were enrolled through four centers, and excimer laser coronary angioplasty was performed on 96 lesions (96%). Safety and effectiveness data were compared between patients treated with standard laser therapy and those treated with increased laser therapy. Laser success was obtained in 90 lesions (93.7%), procedural success was reached in 88 lesions (91.7%), and clinical success in was obtained in 87 lesions (90.6%). There was no perforation, major side branch occlusion, spasm, no-reflow phenomenon, dissection nor acute vessel closure. Increased laser parameters were used successfully for 49 resistant lesions without complications. Conclusions This study suggests that laser-facilitated coronary angioplasty is a simple, safe and effective device for the management of complex coronary lesions. Furthermore, higher laser energy levels delivered by this catheter improved the device performance without increasing complications. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the safety and effectiveness of rotational atherectomy followed by drug eluting stent (DES) implantation in patients with complex coronary lesions. Methods: From August 2006 to August 2012, 253 consecutive patients with 289 lesions and who underwent rotational atherectomy in our center were enrolled in this study. Results: The overall procedure success rate was 98% with the cost of two (0.8%) coronary perforations, three (1.2%) dissections, five (2.0%) slow flows or no flows, three (1.2%) peri-procedure myocardial infarctions, and two (0.8%) in hospital deaths. During follow-up (mean three years), one (0.4%) patient died, two (0.8%) patients had acute myocardial infarction, 14 (5.5%) had restenosis, and target lesion revascularization occurred in eight patients (3.2%). Conclusions: Rotational atherectomy followed by DES implantation is a safe and effective technique for patients with complex coronary lesions, especially calcified and non-dilatable lesions. [ABSTRACT FROM AUTHOR]

Background: Limus-eluting stents have become the mainstay for percutaneous coronary intervention (PCI). However, even with the latest generation drug-eluting stent, in-stent restenosis and very late stent thrombosis remain a concern. The Selution SLR™ drug-coated balloon (DCB) is a novel sirolimus-coated balloon that provides a controlled release of the antiproliferative drug. Herein we evaluated its performance in a real-world patient cohort with complex coronary artery lesions., Methods: Patients undergoing PCI using the Selution SLR™ DCB were analyzed from the prospective SIROOP registry. We evaluated procedural success and clinical outcomes, including major adverse cardiovascular event (MACE), cardiac death, target vessel myocardial infarction and target lesion revascularization., Results: From September 2020 to April 2021, we enrolled 78 patients (87 lesions) treated using a "DCB only" strategy. The mean age was 66.7 ± 10.4 years and 28 (36%) presented with an acute coronary syndrome. Almost all lesions were type B2/C 86 (99%) and 49 (63%) had moderate to severe calcifications. Procedural success was 100%. After a median follow-up of 11.2 months (interquartile range: 10.0-12.6), MACE occurred in 5 (6.8%) patients. No acute vessel closure was observed., Conclusions: In complex coronary lesions, a "DCB only" strategy using the Selution SLR™ DCB is not just safe and feasible, but also seems to be associated with a low rate of MACE at 1-year follow-up. Our promising results warrant further evaluation in a dedicated comparative trial.

The increasing complexity of coronary artery lesions in patients with significant co-morbidities and the need for revascularization, but with the ineligibility for surgical approach, has turned the percutaneous coronary intervention a challenging task, especially in a setting in which short- and long-term complications after drug-eluting stent implantation are high. Drug-coated balloons (DCBs) have become an important tool to replace stent placement in specific situations such as small coronary artery disease and in-stent restenosis. Although preliminary data of DCB use in complex lesions is promising, the available data are still limited. Therefore, in this article, we review the most recent and relevant literature about the use of DCB in native vessel disease and in complex anatomies/patients, and pretend to justify the necessity to develop well design trials about the use of this therapy in such settings, also thinking at DCBs as a complementary tool to drug-eluting stents., (Published on behalf of the European Society of Cardiology. © The Author(s) 2021.)

Intravascular ultrasound (IVUS) is a catheter-based coronary imaging technique. It utilises the emission & subsequent detection of reflected high frequency (30-60 MHz) sound waves to create high resolution, cross-sectional images of the coronary artery. IVUS has been the cornerstone of intracoronary imaging for more than two decades. When compared to the invasive coronary angiogram which studies only the silhouette of the contrast-filled artery lumen, IVUS also crucially images the vessel wall. Because of this capability, IVUS has greatly facilitated understanding of the coronary atherosclerosis process. Such insights from IVUS reveal how commonly and extensively plain angiography underestimates the true extent of coronary plaque, the characteristics of plaques prone to rupture and cause acute coronary syndromes (lipid rich, thin cap atheroma), and a realisation of the widespread occurrence of vessel remodelling in response to atherosclerosis. Similarly, IVUS has historically provided salutary mechanistic insights that have guided many of the incremental advances in the techniques of percutaneous coronary intervention (PCI). Examples include mechanisms of in-stent restenosis, and the importance of high-pressure post-dilatation of stents to ensure adequate stent apposition and thereby reduce the occurrence of stent thrombosis. IVUS also greatly facilitates the choice of correct diameter and length of stent to implant. Overall, a compelling body of evidence indicates that use of intravascular ultrasound in PCI helps to achieve optimal technical results and to mitigate the risk of adverse cardiac events. In this review, the role of intravascular ultrasound as an adjunct to PCI in complex coronary lesions is explored. The complex coronary situations discussed are the left main stem, ostial stenoses, bifurcation stenoses, thrombotic lesions, the chronically occluded coronary artery, and calcified coronary artery disease. By thorough review of the available evidence, we establish that the advantages of IVUS guidance are particularly evident in each of these complex CAD subsets. In particular, some consider the use of IVUS to be almost mandatory in left main PCI. A comparison with other intracoronary imaging techniques is also explored., Competing Interests: Conflicts of Interest: The authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/cdt-20-189). The series “Intracoronary Imaging” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare., (2020 Cardiovascular Diagnosis and Therapy. All rights reserved.)

Background: The GuidezillaTM support extension catheter is designed to provide extra back-up support and efficient device delivery during complex percutaneous coronary interventions (PCIs), such as in treatment of severe calcification, tortuous chronic total occlusions (CTOs), and coronary anomalies. The aim of this study was to describe our initial experience with the GuidezillaTM extension catheter in the treatment of complex coronary artery lesions., Methods: This study retrospectively analyzed data from 165 PCI cases that used the GuidezillaTM guide extension catheter between March 2015 and August 2017. We collected patient clinical characteristics, target lesion characteristics, and procedural details., Results: Eighty-six percent of patients had complex Type C lesions, and 13.9% had Type B lesions. Lesion length ranged from 8 mm to 130 mm (≤ 20 mm, 15.4%; 20-40 mm, 35.8%; > 40 mm, 49.1%). The right coronary artery (59.2%) was the most common intervention vessel followed by the left ascending artery (30.6%) and the left circumflex artery (10.2%). CTO accounted for 38% of all lesions, followed by distortions (28%), heavy calcification (24%), proximal stent thrombosis (9%), and coronary artery origin anomalies (1%). A total of 142 patients underwent successful PCI using the GuidezillaTM extension catheter. The success rate was 86%., Conclusion: The GuidezillaTM guide extension catheter was an effective and safe technique in the transradial treatment of complex coronary lesions. Use of the GuidezillaTM guide extension catheter can shorten the procedure time and ensure overall procedural success with a reduced complication rate in cases where adequate progress using angioplasty devices has not been achieved., (2020 Forum Multimedia Publishing, LLC)

Background: The effect of remote ischemic preconditioning (RIPC) on periprocedural myocardial damage (pMD) in patients undergoing percutaneous coronary intervention (PCI) is controversial. The aim of this study was to investigate the effect of RIPC or intravenous nicorandil on pMD following elective PCI in a subgroup of patients with complex coronary lesions from a multicenter randomized controlled trial., Methods and results: Patients with stable angina who underwent elective PCI were assigned to 3 groups: control, upper-limb RIPC or intravenous nicorandil. The major outcome was pMD incidence following PCI, with pMD defined as an elevated level of high-sensitivity cardiac troponin T or creatine kinase myocardial band at 12 or 24 h after PCI. A total of 171 patients with complex coronary lesions (ACC-AHA coronary classification type B2 or C) were analyzed. The incidence of pMD following PCI was significantly lower in the RIPC group than in the control group (44.4% vs. 66.1%; P=0.023). The adjusted odds ratio (95% confidence interval) for pMD in the RIPC vs. the controls was 0.41 (0.18-0.94). The incidence of pMD in the nicorandil group was not significantly reduced compared with the control groups., Conclusions: This substudy suggested that RIPC prior to PCI prevented pMD in patients with complex coronary lesions. Further investigation in a multicenter prospective study is needed to confirm these results.

Abstract: Excimer laser coronary atherectomy (ELCA) has been used for coronary intervention for more than 20 years. Advances in delivery systems for laser energy using the xenon-chlorine pulsed laser catheter deliver higher energy density with lower heat production. The Spectranetics CVX-300 (Spectranetics, Colorado Springs, CO, USA) excimer laser catheter system has been used for the treatment of complex coronary lesions. We report our experience with the use of this advanced system for stenoses for which were unsuitable for standard percutaneous coronary intervention; for example, balloon-resistant lesions, chronic total occlusions, and for underexpanded stents in calcified lesions. ELCA may also be valuable for thrombus-containing lesion. We find ELCA to be indispensable in the catheterization laboratory for specific complex or calcified lesions. Its role should be explored in a large randomized trial of thrombus containing lesions and saphenous vein grafts. [ABSTRACT FROM AUTHOR]