Immediate results and one-year clinical outcome after percutaneous coronary interventions in chronic total occlusions: data from a multicenter, prospective, observational study (TOAST-GISE)

Surgery for myocardial salvage in acute myocardial infarction and acute coronary syndromes

This article addresses the pathophysiology, the treatment options, and their rationale in the setting of life-threatening acute myocardial infarction and acute on chronic ischemia. Although biases may exist between cardiologists and surgeons, with this review, we hope to provide the reader with information that will shed light on the options that best suit the individual patient in a given set of circumstances.

Chronic total occlusion treatment in post-CABG patients: saphenous vein graft versus native vessel recanalization-long-term follow-up in the drug-eluting stent era

OBJECTIVE

To compare the postprocedural and long-term clinical outcomes of two groups of patients, all presenting with chronic saphenous vein graft (SVG) occlusion, who underwent either SVG or native vessel reopening.

BACKGROUND

Chronic total occlusions (CTO) treatment in patients who underwent previous surgical revascularization is a dilemma and the choice of performing native vessel or SVG recanalization is not always easy.

METHODS

Between July 2002 and October 2004, a total of 260 patients were successfully treated for a CTO. Of them, we selected all patients (n = 24) who had previous bypass surgery with graft occlusion. Of this final group, 13 patients underwent a percutaneous graft recanalization while 11 underwent native vessel reopening.

RESULTS

Primary end points were in-hospital and 3-year rates of death, myocardial infarction, target lesion revascularization, and target vessel revascularization. No events occurred in either group during the in-hospital period. Cumulative 3-year event-free survival in the native vessel and SVG group was 81.8% and 83.9% respectively (P = NS). One death and one TVR occurred in each group.

CONCLUSION

In selected cases, SVG reopening instead of the native vessel is feasible. In such a high-risk population, drug-eluting stent implantation in both SVG and native CTO lesions is associated with good long-term outcomes.

Percutaneous coronary intervention for chronic total occlusions: improved survival for patients with successful revascularization compared to a failed procedure

BACKGROUND

There are limited data on the impact of successful chronic total occlusion (CTO) revascularization by percutaneous coronary intervention (PCI) on survival. We performed a retrospective study comparing the survival between patients with a successful and a failed CTO revascularization by PCI.

METHODS

Between January 1, 2000 and June 30, 2004, 543 of 5803 (9.4%) patients underwent PCI for a CTO at our center. A CTO was defined as an occlusion of the artery present for at least 3 months with Thrombolysis in Myocardial Infarction flow grade 0 or 1. Patient records were linked to a national database to monitor all deaths during follow up. Propensity matching was used to balance out case mix differences.

RESULTS

Technical success for CTO was 377 of 543 (69.4%). In-hospital mortality was 0.3% and 1.2% for the CTO success and CTO failure patients, respectively. During a mean (SD) follow up of 1.7 (0.5) years, the mortality rate was 2.5% in the CTO success patients and 7.3% in the CTO failure patients. The crude hazard ratio for death with CTO failure was 3.92 (95% confidence intervals 1.56-10.07; P = 0.004). The rates of coronary artery bypass were 3.2% vs. 21.7% (P < 0.001) for the CTO success and CTO failure patients, respectively. Our propensity matched 157 CTO success to CTO failure patients and the associated hazard ratio for death with CTO failure was 4.63 (95% confidence interval 1.01-12.61; P = 0.049). Multivariate analysis showed that CTO failure was an independent predictor of death.

CONCLUSION

Patients with a successful revascularization of a CTO by PCI have an increased survival rate compared to patients with a failed CTO procedure.

Improvement of the primary success rate of recanalization of chronic total coronary occlusions with the Safe-Cross system after failed conventional wire attempts

BACKGROUND

In view of the improved long-term patency with drug-eluting stents, the challenge with chronic total coronary occlusion (CTO) remains the low primary success rate. Improved guide wires have increased this rate, but alternative devices may be of additional value. The goal of the present study was to determine the additional benefit of a new penetration device in CTOs after an extensive conventional wire approach.

METHODS AND RESULTS

In 148 consecutive patients the recanalization of a CTO of >3 months was attempted. A conventional wire approach was used with recent dedicated recanalization wires, which was successful in 104 patients (70%). If after at least 20 min of fluoroscopic time no crossing of the wire was achieved, the Safe-Cross wire (SC) (Intralumina) was used which enables verification of the intraluminal wire position via optical reflectometry, and crossing of resistent occlusion caps by radiofrequency ablation. Due to severe dissections after the conventional approach, the SC was not used in 10 patients. In 34 patients the SC wire was applied, leading to successful lesion crossing in 14 patients (41%). Thus, the primary success rate was improved from 70.2% to 79.7%. No periprocedural major adverse events were observed with the SC wire. The successful attempts with the SC wire were predominantly in blunt occlusions. All patients with successful wire passage could be treated with one or more stents.

CONCLUSIONS

In a real world cohort of patients with CTO, the SC wire could increase the primary success rate after failed extensive conventional wire attempt. In these worst case patients the SC success rate was 41%. This new wire appears to have additional potential in failures of a conventional wire approach.

Trends in outcomes after percutaneous coronary intervention for chronic total occlusions: a 25-year experience from the Mayo Clinic

OBJECTIVES

The aim of our study was to examine the trends in procedural success, in-hospital, and long-term outcomes after percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) over the last 25 years from a single PCI registry and to examine the impact of drug-eluting stents.

BACKGROUND

The percutaneous treatment of CTO remains a major challenge. Past studies have used variable definitions of CTO, and there are limited data available from contemporary practice.

METHODS

We evaluated the outcomes of 1,262 patients from the Mayo Clinic registry who required PCI for a CTO. The patients were divided into 4 groups according to the time of their intervention: group 1 (percutaneous transluminal coronary angioplasty era), group 2 (early stent era), group 3 (bare-metal stent era), and group 4 (drug-eluting stent era).

RESULTS

Procedural success rates were 51%, 72%, 73%, and 70% (p < 0.001), respectively, in the 4 groups. In-hospital mortality (2%, 1%, 0.4%, and 0%, p = 0.009), emergency coronary artery bypass grafting (15%, 3%, 2%, and 0.7%, p < 0.001), and rates of major adverse cardiac events (8%, 5%, 3%, and 4%, p = 0.052) decreased over time. During follow-up, the combined end point of death, myocardial infarction, or target lesion revascularization, was significantly lower in the 2 most recent cohorts compared with those patients treated before (p = 0.001 for trend). Technical failure to treat the CTO was not an independent predictor of long-term mortality (hazard ratio 1.16 [95% confidence interval 0.90 to 1.5], p = 0.25).

CONCLUSIONS

Procedural success rates for CTO have not improved over time in the stent era, highlighting the need to develop new techniques and devices. Compared with the prestent era, in-hospital major adverse cardiac events and 1-year target vessel revascularization rates have declined by approximately 50%.

Percutaneous revascularization of chronic total occlusions: Review of the role of invasive and non-invasive imaging modalities

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) has a lower success rate than PCI of non-occluded coronary stenosis. Failure to cross the occlusive lesion with a guide wire is the main cause of unsuccessful PCI of a CTO. Multi-imaging modalities may provide valuable information for PCI of CTO. This paper reviews the role of invasive and non-invasive imaging modalities such as intravascular ultrasound, optical coherent reflectometry, CT coronary angiography and cardiac magnetic resonance imaging in facilitating percutaneous coronary intervention of CTO.

Endovascular recanalization of basilar artery occlusion 80 days after symptom onset

BACKGROUND AND PURPOSE

Acute basilar artery occlusion portends high risk of stroke and death. Thrombolysis or endovascular therapy has been limited to patients who present within hours of symptom onset. Without recanalization, acute basilar artery occlusion almost always results in death or severe disability.

SUMMARY OF CASE

We report a case of basilar artery occlusion and successful endovascular recanalization 80 days after symptom onset.

CONCLUSIONS

Endovascular therapy can be feasible and safe for symptomatic basilar artery occlusion at chronic stage.

Angiographic Fate of Collateral Vessels After Surgical Revascularization of the Totally Occluded Left Anterior Descending Artery

BACKGROUND

Coronary artery bypass grafting (CABG) is best indicated for chronic total occlusion of the left anterior descending artery (LAD) with collaterals. We investigated angiographic changes in the collateral circulation after CABG.

METHODS

Preoperative and postoperative angiograms were reviewed in 42 patients who underwent grafting onto occluded LADs. We described the type, location, and size of collaterals, the Rentrop grading, and collateral frame count (CFC). Regional wall motion of the LAD area was also evaluated with the centerline method. Postoperatively, we measured the lengths of LAD proximal (Lp) and distal (Ld) to the graft anastomotic site.

RESULTS

Preoperative collaterals comprised 78 pathways (septal 42%, branch-branch 20%, atrial 19%, bridging 18%). After CABG, residual collaterals were identified, mainly through the septal pathways, in 6 patients (14%), most of whom were diabetic. The residual collaterals were a part of those which had been opacified in earlier phases of the preoperative angiograms (CFC: 17 +/- 3 vs 25 +/- 15, p = 0.01). Also, the Ld was shorter in these patients so that Lp/Ld was greater than in patients without residual collaterals (0.80 +/- 0.24 vs 0.53 +/- 0.28, p = 0.04). We found no association of residual collaterals with the improvement of LAD regional wall motion after CABG.

CONCLUSIONS

Even after successful CABG, some collaterals with earlier filling of the LAD remain, mainly through the septum. Although the clinical significance remains to be clarified, complex and diffuse atherosclerosis associated with more distal graft anastomoses may contribute to maintaining collaterals after CABG to the occluded LAD, especially in diabetic patients.

Coronary septal collaterals as an access for the retrograde approach in the percutaneous treatment of coronary chronic total occlusions

OBJECTIVES

To investigate the feasibility and safety of the percutaneous dilatation of coronary septal collaterals and to allow its use as an access for retrograde approach to percutaneous coronary intervention (PCI) of coronary chronic total occlusions (CTOs).

BACKGROUND

Despite improvements in percutaneous techniques and materials, CTO recanalization success rate is still suboptimal. The retrograde approach allows to significantly increase this success rate. However, its application via a bypass graft or epicardial collateral can potentially result in severe complications. A safer retrograde access is desired and would allow broadening the application of the retrograde approach in the percutaneous treatment of CTOs.

METHODS

After a failed antegrade CTO recanalization attempt, a retrograde approach via septal collaterals was tried in 21 patients (19 males, 2 females). The septal collateral was accessed via the contralateral patent coronary artery and was crossed with a hydrophilic floppy wire. After successful wire crossing of the septal collateral, sequential low pressure dilatation was performed with a 1.25 or 1.5 mm balloon to allow the delivery of a balloon catheter up to the distal CTO site.

RESULTS

Successful wire crossing and balloon dilatation of septal collaterals was achieved in 19 cases and in 17 cases, respectively. Postdilatation septal collateral diameter increased significantly reaching a mean diameter of 1.46 +/- 0.38 mm. Retrograde CTO recanalization was successfully performed in 71% of the cases. No major complications occurred.

CONCLUSIONS

Coronary septal collaterals can be used as an access for the retrograde approach in the percutaneous treatment of CTOs.

Percutaneous transluminal angioplasty and stenting for chronic total occlusion of intracranial carotid artery: a case report

SUMMARY

Chronic total occlusion of cerebrovascular lesions is regarded as a contraindication to revascularization. We describe a case of chronic total occlusion of intracranial internal carotid artery that iwass successfully recanalized by endovascular treatment. A 72-year-old man who presented with slight right hemiparesis was proved to have chronic total occlusion of the left intracranial internal carotid artery. Percutaneous transluminal angioplasty/stenting was achieved using reversal of flow with the Parodi Anti-Embolic System. The present case indicates that percutaneous transluminal angioplasty/stenting can be an effective therapeutic option in selected patients with chronic total occlusion of cerebrovascular lesions.

Value of T2-weighted, first-pass and delayed enhancement, and cine CMR to differentiate between acute and chronic myocardial infarction

The aim of this study was to analyze the diagnostic accuracy of edema on T2-weighted (T2w) cardiac magnetic resonance imaging (CMR), presence of microvascular obstruction (MO) on first-pass enhancement (FPE) or on delayed enhancement (DE) CMR, and wall thinning on cine CMR to differentiate between acute (AMI) and chronic myocardial infarction (CMI) in patients with infarction on DE-CMR. Fifty patients were imaged 5 +/- 3 days (baseline) and 8 +/- 3 months (follow-up) after AMI at 1.5 T. Imaging findings were graded as present or absent in a blinded consensus reading. Edema was present at baseline in 48 (96%) patients and absent at follow-up in 49 (98%) patients. At baseline, MO was present in 29 (58%) patients on FPE-CMR and in 24 (48%) patients on DE-CMR (P = ns). At follow-up, persisting hypoenhancement was observed in ten (20%) patients on FPE-CMR, whereas two (4%) patients showed persisting hypoenhancement on DE-CMR (P<0.05). Wall thinning was present in 4 (8%) patients at baseline and in 20 (40%) patients at follow-up. Edema had high sensitivity (96%), specificity (98%), and accuracy (97%) to differentiate between AMI and CMI. Accuracy of all other imaging findings was lower compared to that of edema (P<0.001). In the presence of infarction on DE-CMR, T2w-CMR reliably differentiates between AMI and CMI.

Outcome of diabetic and non-diabetic patients undergoing successful coronary angioplasty with bare stent of chronic total occlusion

BACKGROUND

The prognosis of patients with diabetes mellitus and chronic coronary total occlusion (CTO) treated with percutaneous coronary angioplasty (PTCA) is poorly investigated.

METHODS

To compare the long-term outcome of patients with CTO, with and without diabetes mellitus and undergoing successful PTCA with bare stent implantation performed in a single centre, 170 consecutive patients (mean age 62 +/- 10 years) with CTO aged > 1 month were analysed. Death, myocardial infarction, repeat angioplasty and coronary artery by-pass were considered as hard events in 167 patients with available long-term follow-up (mean 25 +/- 15 months).

RESULTS

Vessel mean luminal diameter after the procedure and stent length were 2.5 +/- 0.4 mm and 21.9 +/- 9.4 mm, respectively. No differences were found in baseline clinical, angiographic and procedural variables between the groups, categorized on the basis of presence or absence of diabetes. There were 13 (27%) and 25 (21%) events in diabetic and non-diabetic groups, respectively (P = not significant). Multivariate analysis identified final mean luminal diameter (odds ratio = 4.7192, P = 0.0013) and stent length (odds ratio = 1.0655, P = 0.0003) but not diabetes (P = 0.78) as predictors of events at long-term follow-up.

CONCLUSIONS

Patients with and without diabetes undergoing CTO re-opening with stent implantation do not differ at long-term follow-up in terms of death, myocardial infarction and target lesion revascularizations. Final mean luminal diameter and stent length are significant predictors of events during long-term follow-up.

Advanced wiring technique for chronic coronary total occlusions

Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) is one of the greatest challenges in interventional cardiology. The procedural success rate is relatively low, mainly due to guidewire failure to cross the occlusion. An effective wiring technique is the key to the success of CTO-PCIs. However, success or failure of wire crossing is mostly dependent on an operator's experience and skill. To improve the success rate of CTO-PCI in current interventional cardiology, several techniques were introduced in the Japanese CTO club. In this article, some advanced wiring techniques developed by the Japanese CTO club will be explored.

Off-Pump Revascularization of Chronically Occluded Left Anterior Descending Artery Through Left Anterior Small Thoracotomy: Early and Late Angiographic and Clinical Follow-Up

BACKGROUND

The aim of this retrospective study was to evaluate the safety and efficacy of left anterior small thoracotomy for treatment of isolated chronic total occlusion of the left anterior descending artery.

METHODS

From November 21, 1994, to December 31, 2002, 143 patients with isolated left anterior descending artery chronic occlusion underwent off-pump surgery through left anterior small thoracotomy. Safety was evaluated analyzing 30-day mortality, major adverse cardiac events, and major complications; efficacy was evaluated analyzing 6-month angiographic results and 12-month survival, freedom from cardiac death, freedom from acute myocardial infarction, either in all areas or in the grafted one, freedom from redo or percutaneous coronary intervention, freedom from target vessel revascularization, and freedom from major adverse cardiac events and from any event. Eight-year outcome was reported as well.

RESULTS

Thirty-day mortality was 0.7% (1 patient). No patient experienced acute myocardial infarction, cerebrovascular accident, or urgent repeat revascularization. One-year survival was 98.6% +/- 0.7%; freedom from cardiac death was 99.3% +/- 0.7%; freedom from acute myocardial infarction in either all areas or in the grafted one was 100%; freedom from redo or percutaneous coronary intervention or from target vessel revascularization was 99.3% +/- 0.7%, and freedom from major adverse cardiac events or any event was 97.9% +/- 1.2%. Eight-year survival was 94.9% +/- 1.9%; freedom from cardiac death was 96.3% +/- 1.6%, from acute myocardial infarction in all or in the grafted area 99.2% +/- 0.8%, from redo or percutaneous coronary intervention 94.4% +/- 2.1, from target vessel revascularization 97.8% +/- 1.3%, from major adverse cardiac events 92.8% +/- 2.2%, and from any event 89.5% +/- 2.7%. Six months after surgery, 56% of survivors underwent angiographic control, showing a patency rate of 98.2%.

CONCLUSIONS

In our experience, left anterior small thoracotomy operation can be considered a suitable choice for treatment of left anterior descending artery chronic occlusion.

Recent trends in the percutaneous treatment of chronic total coronary occlusions

Percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has a lower success rate than PCI for non-CTO lesions. We sought to determine trends in the treatment of CTOs within the current interventional era. Using 4 sequential recruitment waves of the National Heart, Lung, and Blood Institute Dynamic Registry, we assessed the relative prevalence and success rates in treating CTO (n=371) versus non-CTO (n=4,802) lesions over a 7-year period (1997 to 2004). Characteristics of attempted lesions and factors associated with PCI outcome were evaluated. CTO lesion attempts decreased by 41% over time, from 9.6% (1997 to 1998) to 5.7% (2004, p<0.0001 for trend). More contemporary CTO lesions were longer (22.4 vs 17.0 mm, p=0.006 for trend), had thrombus less often (21.3% vs 35.4%, p=0.03 for trend), and were more often treated with stents (69.8% vs 45.4% p=0.02). The rate of successful intervention for CTO lesions decreased nonsignificantly during this time, from 79.7% to 71.4% (p=0.18). Using multivariable analysis, female gender (adjusted odds ratio 0.42, 95% confidence interval 0.20 to 0.88, p=0.02), and thrombus (adjusted odds ratio 0.31, 95% confidence interval 0.15 to 0.61, p=0.0008) were associated with higher success rates, whereas the presence of severe noncardiac disease (adjusted odds ratio 1.91, 95% confidence interval 1.05 to 3.45, p=0.03) was associated with a higher risk for PCI failure. Recruitment wave and patient age were not independently related to lesion success. In conclusion, during the PCI period of 1997 to 2004, CTO lesions were attempted less frequently and success rates did not increase, indicating a need for new operator techniques or device technologies to treat this important lesion subset by a percutaneous approach.

Procedural implications of intravascular ultrasound morphologic features of chronic total coronary occlusions

Although the success rates of percutaneous coronary intervention of chronic total occlusions (CTOs) have improved, morphologic features are not well known. We analyzed experience at 4 centers where intravascular ultrasound (IVUS) was performed in 67 native artery CTO lesions (mean CTO duration 6.3 months) just after the lesion was crossed with a guidewire (n = 7) or after dilatation with a 1.5-mm (n = 46) or 2.0-mm (n = 14) balloon. IVUS detected calcium somewhere in the CTO in 96%; however, only 68% had mild calcium. IVUS identified a proximal end of the CTO in all lesions, but a distal end of the CTO in only 50%. An intramural hematoma was observed in 34% of CTOs, suggesting that the guidewire frequently entered the medial space during successful recanalization. CTOs were longer, vessel area was smaller, and total calcium index was greater in lesions with hematomas (p = 0.003, 0.05, and 0.03, respectively). Inadequate reflow after the procedure was observed in 9% and was associated with longer lesions and intralesional calcium. CTO length as measured with angiography was shorter than the length as measured with IVUS (p = 0.02). Calcium was detected on the angiogram in 61% (p = 0.054 vs IVUS). Most typical angiographic findings associated with a low rate of procedural success were not associated with different IVUS morphologies. In conclusion, CTO lesions had multiple small calcium deposits, intramural hematomas were common and were indicative of guidewire penetration into the medial space during the CTO procedure, especially in long calcified lesions in smaller vessels, and inadequate reflow after the procedure was correlated with more complex CTO morphology.

Novel double catheter technique in complex percutaneous coronary interventions

We present a novel double catheter technique for successful complex intervention of a very old proximal left circumflex chronic total occlusion (>10 years old). Prior attempts of guide wire passage using bare wire alone, over-the wire balloon or microcatheter support techniques were unsuccessful.

Chronic Total Coronary Occlusions

Chronic total coronary occlusions (CTO) occur in up to one-third of patients undergoing coronary angiography. Indications for opening CTOs include relief of angina, improving left ventricular function, decreasing the need for coronary artery bypass surgery, and improved long-term survival. Newer technology, wire-based and non-wired-based, has improved the ability to cross these previously uncrossable lesions, thereby improving the acute success rates of opening these lesions. Also, the advent of drug-eluting stents has markedly increased the long-term patency of these complex lesions. Therefore, the clinical demand for opening these chronically occluded arteries has increased.

Success rates of percutaneous coronary intervention of chronic total occlusions and long-term survival in patients with diabetes mellitus

The objectives of this study were to evaluate angiographic and clinical outcomes among patients with diabetes mellitus (DM) who underwent percutaneous coronary intervention (PCI) for a chronic total occlusion (CTO). We compared them with matched patients undergoing PCI of a non-CTO lesion. All patients had documented DM. Matching was performed using a propensity score for CTO. There were 506 patients with DM and CTO who were matched with a non-CTO group. Results showed that angiographic success rates were lower with CTO (75% vs. 93%, p<0.001). In-hospital major adverse cardiac event (MACE - death, urgent bypass surgery, Q-wave myocardial infarction or target vessel revascularisation) rates were equivalent (CTO 3.2% vs. non-CTO 2.6%, p=0.57). Survival was not different five years after revascularisation of CTO (75%) vs. non-CTO (79%) (p=0.20). In addition, when DM patients with CTO were analysed according to angiographic success of PCI, there were no significant differences in either in-hospital (success 1.6% vs. failure 2.4%, p=0.7) or 1-year mortality (success 22.2% vs. failure 26.8%, p=0.3). We conclude that PCI of CTO is safe in patients with DM. Angiographic failure is not associated with an increase in MACE rates or mortality as compared to matched non-CTO patients. However, there is not a measurable improvement in survival in this DM-CTO population.

Effect of percutaneous coronary intervention of nonacute total coronary artery occlusions on QT dispersion

BACKGROUND

Myocardial ischemia is one of several potential causes of increased QT dispersion (QTd) in patients with nonacute total coronary artery occlusions (TCOs). We sought to assess the effect of percutaneous revascularization (PCI) of TCO on QTd and the relationship between QTd and long-term vessel patency.

METHODS

Seventy patients enrolled in the TOSCA were analyzed. Patients were undergoing PCI of a TCO > 72 hours' duration. Two independent reviewers measured QTd from electrocardiograms done immediately before PCI (PRE), 12 to 18 hours after PCI (POST), and then at 6 months (6M). Follow-up angiography was performed at 6 months.

RESULTS

Mean QTd decreased from PRE (77 +/- 29 milliseconds) to POST (66 +/- 26 milliseconds, P < .001) and 6M (65 +/- 25 milliseconds, P < .001). Patients with the same or longer QTd at 6 months compared with POST (POST < or = 6M) had significantly higher risk of failed target-vessel patency (odds ratio 10.3, 95% CI 1.24-84.8) than patients with QTd reduction at 6M versus POST values.

CONCLUSION

Revascularization of TCO resulted in a decrease in QTd, which was sustained at 6M. This suggests that PCI to a TCO has a beneficial effect on stabilization of the underlying ischemic substrate. Furthermore, absence of QTd reduction at 6M versus POST was associated with increased risk of failed target-vessel patency.

Percutaneous coronary intervention: recommendations for good practice and training

Cardiologists undertaking percutaneous coronary intervention (PCI) are excited by the combination of patient and physician satisfaction and technological advance occurring on the background of the necessary manual dexterity. Progress and applicability of percutaneous techniques since their inception in 1977 have been remarkable; a sound evidence base coupled with the enthusiasm and ingenuity of the medical device industry has resulted in a sea change in the treatment of coronary heart disease (CHD), which continues to evolve at breakneck speed. This is the third set of guidelines produced by the British Cardiovascular Intervention Society and the British Cardiac Society. Following the last set of guidelines published in 2000, we have seen PCI activity in the UK increase from 33,652 to 62,780 (87% in four years) such that the PCI to coronary artery bypass grafting ratio has increased to 2.5:1. The impact of drug eluting stents has been profound, and the Department of Health is investigating the feasibility of primary PCI for acute myocardial infarction. Nevertheless, the changes in the structure of National Health Service funding are likely to focus our attention on cost effective treatments and will require physician engagement and sensitive handling if we are to continue the rapid and appropriate growth in our chosen field. It is important with this burgeoning development now occurring on a broad front (in both regional centres and district general hospitals) that we maintain our vigilance on audit and outcome measures so that standards are maintained for both operators and institutions alike. This set of guidelines includes new sections on training, informed consent, and a core evidence base, which we hope you will find useful and informative.

Comparison between multivessel stenting with drug eluting to the LAD and bilateral internal thoracic artery grafting

BACKGROUND

Reduction of restenosis and reinterventions was reported with drug-eluting stents (Cypher). This study compares results of multivessel Cypher stenting with bilateral internal thoracic artery (BITA) grafting.

METHODS

From January 2002 to June 2004, 725 consecutive patients underwent multivessel myocardial revascularization, 95 by 2 or more Cypher stents and 630 by BITA. After matching for age, sex, and extent of coronary artery disease, 2 groups (87 patients each) were used to compare the 2 revascularization modalities.

RESULTS

The 2 groups were similar; however, left main and the use of an intra-aortic balloon pump were more prevalent in the BITA group. The number of coronary vessels treated per patient was higher in the BITA group (2.71 versus 2.24 for BITA and Cypher, respectively; P = .001). Mean follow-up was 12 months. Thirty-day mortality was 0 in both groups. There were no late deaths in the BITA group and 2 (2.3%) in the Cypher group (P value was not significant). Angina returned in 29.9% of the Cypher group and 12.6% of the BITA group (P = .005). Multivariable Cox analysis revealed percutaneous intervention (PCI) (Cypher group) to be the only independent predictor of angina recurrence (Odds Ratio 2.62, 95% Confidence Interval 1.11-6.17). There were 10 reinterventions (PCI) in the Cypher group compared to 5 in the BITA group. One-year reintervention-free survival (Kaplan-Meier) of the BITA group was 96% compared to 88% in the Cypher group (P = .015).

CONCLUSIONS

Midterm clinical outcome of surgically treated patients is still better. However, the reintervention gap between surgery and percutaneous interventions was reduced by treating 2 or more coronary vessels with Cypher stents.

Impact of 16-slice computed tomography in percutaneous coronary intervention of chronic total occlusions

The main reason for failure of percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) is because the calcified plaque prevents the guide wire crossing the occlusion. We aimed to identify the route, and characterize plaque components within CTO, using 16-slice computed tomography (MSCT). Twenty three angiographic CTO in 22 patients (mean age 69 +/- 5 years, 17 males) were included. All patients had undergone MSCT prior to PCI. Images were analyzed for lesion visibility and plaque characteristics of CTO. The presence and location of calcified plaque within the CTO were systematically assessed. Each lesion was classified as a noncalcified, moderately calcified, or exclusively calcified plaque. Procedural failure was defined as the inability to cross a guide wire through the occlusion. All coronary routes of CTO segment were visualized. MSCT revealed three markedly bent CTO segments (13.0%), which could not be identified by coronary angiography only. Calcified plaques were detected in 30 lesions of 19 CTO segments (82.6%), but were not detected in the other four. The majority of calcified plaque was located in the proximal lesion, or both proximal and distal lesions. Fifteen out of 30 calcified lesions (50.0%) were exclusively calcified plaques. Overall procedural success was obtained in 21 CTOs (91.3%). MSCT can accurately identify the route of the CTO segment and evaluate both distribution and amount of the calcified plaque within it. Even with the complicated and/or calcified lesions, PCI success rate was excellent under MSCT guidance. MSCT should become a useful tool in PCI of CTO.

Chronic total occlusion angioplasty through supplying collaterals

Chronic total occlusions are typically difficult to recannalize especially when adverse angiographic morphologies are identified. We describe a case of chronic total occlusion crossing retrograde through the supplying collaterals followed by successful angioplasty and stenting.

Drug-Eluting Coronary Stents

The introduction and widespread use of coronary stents have been the most important advancement in the percutaneous treatment of coronary artery disease since the introduction of balloon angioplasty. Coronary artery stents reduce the rate of angiographic and clinical restenosis compared to balloon angioplasty. This angiographic restenosis was further reduced with the introduction of drug-eluting stents and hence further reduction in the frequency of major adverse cardiac events. Herein we present a comprehensive and up-to-date review about the use of drug-eluting stents in the treatment of coronary artery disease.

A novel approach to chronic total occlusions: The crosser system

OBJECTIVES

To evaluate safety and efficacy of the CROSSER CTO Recanalization System (CROSSER).

BACKGROUND

The CROSSER, a novel device dedicated to recanalization of chronic total occlusions (CTO), relies on a monorail catheter delivering vibrational energy to facilitate the crossing of occluded coronary arteries.

METHODS

We included de novo or restenotic occlusions in native coronary arteries with typically unfavorable characteristics and a prior failed guidewire attempt either performed in a previous procedure or just before the usage of the CROSSER. The end points analyzed were technical success (ability to cross or facilitate a guidewire crossing into the true lumen), angiographic success (<20% residual stenosis and TIMI flow grade 3), and clinical success (angiographic success and freedom from major adverse cardiac events at 30 days).

RESULTS

Twenty-eight patients (30 lesions) were included. The morphology was blunt in 83.3% and the length of the occlusion was >20 mm in 76.6%. The median age of the CTO was 9 months (range 3-60 months). Technical success was obtained in 19 (63%) occlusions and angiographic success in 16 (53%): 26.3% in lesions with prior procedural failure and 73.7% when CROSSER was attempted after initial guidewire failure. Complications were: one guidewire perforation without consequences and one peri-procedural myocardial infarction (MI). No events occurred within 30-day follow-up after discharge.

CONCLUSIONS

In our experience, the CROSSER System is safe and increases the success of opening CTO refractory to guidewires. This novel device may represent an useful adjunct to the armamentarium of the interventional cardiologist.

Transplantation of Blood-Derived Progenitor Cells After Recanalization of Chronic Coronary Artery Occlusion

Transplantation of blood-derived circulating progenitor cells (CPC) has been shown to improve myocardial regeneration after myocardial infarction. It remains unclear whether CPC transplantation exerts beneficial effects also in patients with chronic myocardial ischemia. We initiated a randomized, double-blind, placebo-controlled study evaluating the impact of intracoronary infusion of CPCs on coronary vasomotion and left ventricular (LV) function in patients after recanalization of chronic coronary total occlusion (CTO). After recanalization of CTO, 26 patients (age, 63±2 years; LV ejection fraction, 53±2%) were randomly assigned to the treatment (intracoronary transplantation of CPCs) or control group. Coronary flow reserve in response to adenosine (2.4 mg/min) was measured in the target vessel at the beginning of the study and after 3 months. LV function and infarct size were assessed by MRI and metabolism by 18 F deoxyglucose positron emission tomography. CPC application resulted in an increase in coronary flow reserve by 43% from 2.3±0.3 to 3.3±0.5 ( P <0.05 versus beginning and control). At 3 months, the number of hibernating segments in the target region (from 2.9±0.6 to 2.0±0.6 segments, P <0.05 versus beginning and control) had declined in the treatment group, whereas no significant changes were observed in the control group. MRI revealed a reduction in infarct size by 16% and an increase in LV ejection fraction by 14% in the treatment group (from 51.7±3.7 to 58.9±3.2%; P <0.05 versus beginning and control) because of an augmented wall motion in the target region. Hence, intracoronary transplantation of CPCs after recanalization of CTO results in an improvement of macro- and microvascular function and contributes to the recruitment of hibernating myocardium.

Family history, diabetes and extension of coronary atherosclerosis are strong predictors of adverse events after PTCA: A one-year follow-up study

BACKGROUND AND AIM

In this study we addressed some open questions in patients with coronary artery disease (CAD). First, we analysed which of the traditional risk factors was associated with the spreading of coronary stenosis and second, we aimed to identify if any variable was predictive of post-percutaneous transluminal coronary angioplasty (PTCA) clinical events.

METHODS AND RESULTS

We collected a consecutive series of patients with CAD (n=301) and in the subgroup of patients undergoing PTCA (n=135) we performed a prospective one-year follow-up study recording cardiovascular morbidity and total mortality. According to the extension of coronary atherosclerosis, we found a significant relationship with the prevalence of diabetes in men and with plasma HDL-cholesterol concentrations in women. The follow-up was completed in 95% of patients; we did not document any death whereas clinical events were registered in 16% of patients. At univariate analysis, we found that patients with clinical events had a higher prevalence of family history of CAD (43% vs 14%, p<0.005), diabetes (52% vs 21%, p<0.005) and multivessel disease (52% vs 35%, p<0.05). Multivariate analysis (logistic regression) confirmed that family history of CAD (OR 4.6, 95% CI 1.7-12.8, p<0.005), diabetes (OR 4.0, 95% CI 1.5-10.6, p<0.01) and multivessel disease (OR 2.8, 95% CI 1.1-7.4, p<0.05) were the only variables predictive of clinical events.

CONCLUSIONS

In this study, factors associated with the spreading of coronary stenosis were different according to the gender. Moreover, the presence of diabetes and multivessel disease had a negative impact on the long-term prognosis of patients undergoing PTCA. In addition, the family history of CAD represented in our study a strong predictor of clinical events. We suggest that in the management of post-PTCA patients, the role of individual baseline clinical characteristics must be taken into account and that subjects with a family history of premature CAD, diabetes and a wide extension of coronary disease represent those with the highest risk.

Intracoronary Fibrin-Specific Thrombolytic Infusion Facilitates Percutaneous Recanalization of Chronic Total Occlusion

OBJECTIVES

We sought to investigate the benefit, predictors of procedural success, and safety of pre-procedural intra-coronary fibrin-specific lytic infusion (ICL) in patients with failed prior percutaneous coronary intervention (PCI) for chronic total occlusions (CTO).

BACKGROUND

Percutaneous coronary intervention for CTO remains a challenge with a high incidence of procedural failure secondary to inability to cross the occlusion with the guidewire.

METHODS

Eighty-five patients who underwent unsuccessful PCI procedures of CTO (more than three months' duration) had a repeat attempt of recanalization with the use of pre-procedural ICL. Patients received a weight-adjusted dose of either alteplase (tPA) (2 to 5 mg/h) or tenecteplase (TNK) (0.5 mg/h) for a total of 8 h. The total dose of ICL therapy was infused split between the guiding catheter and an intracoronary infusion catheter. A step-down multivariate logistic regression analysis was completed to determine the best predictors of procedural success. In-hospital major adverse cardiac events (MACE) including myocardial infarction, acute reocclusion, stroke, and death, as well as bleeding complications, were also examined.

RESULTS

The procedure was successful in 46 of 85 cases (54%). Four of 85 (5%) contained dissections that did not result in perforations, tamponade, or MACE. The incidence of groin complications was 7 of 85 (8%) and of bleeding complications requiring transfusions was 3 of 85 (3.5%). On multivariate analysis, predictors of success were tapering morphology (odds ratio, 15.5; 95% confidence interval, 3.73 to 63; p = 0.0002) and lack of bridging collaterals (odds ratio, 5.08; 95% confidence interval, 1.53 to 17; p = 0.008).

CONCLUSIONS

Intracoronary infusion of fibrin-specific thrombolytic therapy may provide a valuable and safe option for facilitating percutaneous revascularization of CTO.

Success, safety, and mechanisms of failure of percutaneous coronary intervention for occlusive non-drug-eluting in-stent restenosis versus native artery total occlusion

We compared the procedural success, mechanism of failure, and safety of percutaneous coronary intervention in 235 procedures for de novo chronic total occlusions with 78 procedures for chronic occlusive in-stent restenosis. Despite similar rates of procedural success and safety profile, angiographic predictors of successful percutaneous coronary intervention for de novo chronic total occlusions played a limited role in patients who had chronic occlusive in-stent restenosis, and the mechanisms of failure were different.

Late reopening of an occluded infarct related artery improves left ventricular function and long term clinical outcome

OBJECTIVE

To assess effects on left ventricular (LV) function and on long term clinical outcome of late percutaneous transluminal coronary angioplasty (PTCA) of a chronically occluded infarct related artery.

METHODS

65 patients who underwent PTCA a mean (SD) of 6.0 (1.2) months after a previous myocardial infarction were divided in two groups according to dilated artery patency status after PTCA: group 1 (35 patients with TIMI (thrombolysis in myocardial infarction) grade 3 flow) and group 2 (30 patients with TIMI grade 0-2 flow). Echocardiography was performed at admission and at six months' follow up. A three year follow up was conducted with major adverse cardiac events (MACE) as end points.

RESULTS

At follow up, group 1 had improved global LV ejection fraction (48.7% v 43.6%, p < 0.001) and LV indexed end diastolic and end systolic volumes (75 v 86 ml/m(2) and 40 v 53 ml/m(2), respectively, p = 0.011) compared with group 2. Kaplan-Meier analysis showed a higher incidence of cardiac death (p = 0.02) and MACE (p < 0.0001) in group 2. TIMI 3 after PTCA was an independent predictor of event-free survival at follow up.

CONCLUSION

Late PTCA of a chronically occluded infarct related artery improves LV function, reduces cardiac death, and improves long term clinical outcome.

Immediate and mid-term outcomes of sirolimus-eluting stent implantation for chronic total occlusions

AIMS

To evaluate the outcomes of sirolimus-eluting stent (SES) implantation for the treatment of chronic total occlusion (CTO).

METHODS AND RESULTS

We identified 122 patients who underwent revascularization in CTO lesions with SES from April 2002 to April 2004 (SES group). A control group was composed of 259 consecutive patients with CTO lesions treated with bare metal stents (BMS) in the 24 months immediately before the introduction of SES (BMS group). At 6-month follow-up, the cumulative rate of major adverse cardiac events (MACE) was 16.4% in the SES group and 35.1% in the BMS group (P<0.001). The incidence of restenosis was 9.2% in the SES group and 33.3% in the BMS group (P<0.001). The need for revascularization in the SES group was significantly lower, both target lesion revascularization (7.4 vs. 26.3%, P<0.001) and target vessel revascularization (9.0 vs. 29.0%, P<0.001). BMS implantation (HR: 2.97; 95% CI: 1.80-4.89; P<0.001), lesion length (>20 mm) (HR: 2.02; 95% CI: 1.37-2.99; P=0.0004), and baseline reference vessel diameter (>2.8 mm) (HR: 0.62; 95% CI: 0.42-0.92; P=0.02) were identified as predictors of MACE during 6-month follow-up.

CONCLUSION

Compared with BMS, SES implantation in CTO lesions appears to be effective in reducing the incidence of restenosis and the need for revascularization at 6 months.

Impact of sirolimus-eluting stent on the outcome of patients with chronic total occlusions

Several randomized trials have demonstrated that stent implantation after successful recanalization of long-term total occlusions decreases restenosis and reocclusion rates. The sirolimus-eluting stent (SES) has recently proved its efficacy to decrease restenosis in selected patients. However, the efficacy of SES implantation in patients who have chronic total occlusions is currently unknown. Therefore, we investigated procedural and 6- and 12-month angiographic outcomes (analyzed by quantitative coronary angiography) and left ventricular function in 60 patients who received SESs and 120 patients who received bare metal stents (BMSs). Minimum luminal diameter did not differ immediately after recanalization (SES group 3.04 +/- 0.50 mm vs BMS group 3.12 +/- 0.48 mm). After 6 months, the SES group still had significantly larger luminal diameters (3.04 +/- 0.44 mm vs 1.94 +/- 0.98 mm) and significantly lower restenosis and reocclusion rates (2% and 0%, respectively) than did the BMS group (32% and 6%, respectively). Late loss was significantly smaller in the SES group than in the BMS group. At follow-up, the SES group had fewer cardiac events, including target lesion revascularization (p <0.001), than did the BMS group. In conclusion, SES implantation after recanalization of chronic total occlusion provides a better clinical outcome with less restenosis and target lesion revascularization after 6 months than does BMSs.

Treating chronic total occlusions using subintimal tracking and reentry: The STAR Technique

Successful recanalization of coronary total occlusions (CTOs) remains an area where improvements are needed. We propose an approach similar to the one utilized in treating some peripheral artery occlusions and aimed to create a subintimal dissection with distal reentry. A 0.014' hydrophilic wire with a J-configuration is utilized for this purpose. We applied this technique to CTO of native coronaries in 31 patients where previous attempts failed in 21 of them (67%). The right coronary artery (RCA) was the index vessel in 87% of patients. Recanalization of the vessel and of most of distal branches was achieved in 21 patients; patency of at least one major distal branch was achieved in 9 patients. Drug-eluting stents (DESs) were implanted in 53% of patients. Three patients had intraprocedural vessel perforation without consequences. Five patients (16%) had in-hospital non-Q-wave myocardial infarction. No other adverse events occurred at a mean follow-up of 5.1 +/- 3.7 months except for one noncardiac death. Angiographic follow-up was performed in 21 (67%) patients and 53% of them developed restenosis. Reintervention on the target vessel was performed in 11 patients (52%). Complete success with the procedure was originally obtained in 8 of the 10 patients who did not develop restenosis and in 8 of them DESs were originally implanted. This technique appears a promising approach to recanalize difficult total occlusions, particularly the ones localize on the RCA, which has the most important side branches located distally.

Preliminary experience with the frontrunner coronary catheter: Novel device dedicated to mechanical revascularization of chronic total occlusions

The novel device Frontrunner coronary catheter (FCC), dedicated to recanalization of chronic total occlusions (CTOs), relies on blunt microdissections inside the plaque, allowing passage of guidewire through the lesion and adjunctive angioplasty. In order to evaluate efficacy and safety of recanalization using the FCC device, we included patients with de novo or restenotic CTOs in a native coronary artery with prior failure using a guidewire or considered unsuitable for guidewire attempt in which the FCC was attempted first. Between October 2000 and June 2003, 50 patients with 50 CTOs were included in the study. Thirty-two patients had prior failure with a mechanical wire. Device and angiographic success were obtained in 25 (50%) occlusions: 53% in lesions with prior guidewire failure and 44% when FCCs were attempted first (P = 0.8). During the first year of experience, angiographic success was 42% (5 occlusions) and in the third year 75% (12 occlusions; P = 0.12). Coronary perforation occurred in nine (18.0%) patients, leading to tamponade in two (4%) patients. Perforations occurred in 5 out of 12 attempted patients during the first year and in 4 out of 38 patients in the following period (41.7% vs. 10.5%; P = 0.04). Serious adverse events occurred in five (10%) patients within 30-day follow-up. Four non-Q-wave myocardial infarctions occurred in hospital (clinical success 42%) and one death 7 days after the index procedure. The use of FCC increases the success to open chronic total occlusions refractory to mechanical guidewires or that were considered unsuitable for an attempt with a guidewire. The risk of coronary perforation due to FCC use is relatively high and it can decrease with experience.

A “Grapple Hook” technique using a deflectable tip catheter to facilitate complex proximal circumflex interventions

We present two patients with angulated, proximal left circumflex lesions, one a chronic total occlusion and one an acute subtotal occlusion. In both cases, use of the deflectable tip Venture Catheter (Velocimed, Minneapolis, MN) facilitated guide wire passage and successful percutaneous coronary intervention (PCI) after prior attempts at guide wire passage with standard wires were unsuccessful.

Collaterals and the recovery of left ventricular function after recanalization of a chronic total coronary occlusion

BACKGROUND

A good collateral function in patients with regional myocardial dysfunction may indicate viability with the potential for left ventricular (LV) recovery after revascularization of a chronic total coronary occlusion (CTO).

METHODS

A CTO (duration > 2 weeks) was successfully recanalized in 126 patients. During this procedure, the collateral function was assessed before the first balloon inflation by intracoronary Doppler and pressure wires. Collateral function indexes were calculated. Left ventricular function was assessed by the LV ejection fraction (LVEF) and the wall motion severity index (WMSI [SD/chords]). A repeat angiography was available in 119 patients after 4.9 +/- 1.4 m. An improvement of WMSI > or =1 SD/chord was considered significant.

RESULTS

Left ventricular function was normal in 42%, regional dysfunction with LVEF > or = 0.60 was observed in 16%, and regional dysfunction with LVEF < 0.60 in 42%. The former had a better collateral function than patients with LV dysfunction. In 39% of patients with LV dysfunction, a significant myocardial recovery was observed at follow-up. The collateral function was similar in patients with and without recovery. However, patients with recovery had a lower peripheral resistance as an indicator of a better preserved microvascular integrity.

CONCLUSIONS

Recovery of impaired LV function after revascularization of a CTO is not directly related to the quality of collateral function, as collateral development does not appear to require the presence of viable myocardium. However, a preserved microvascular integrity may be of relevance for myocardial recovery.

Prevention of lesion recurrence in chronic total coronary occlusions by paclitaxel-eluting stents

OBJECTIVES

The aim of this research was to assess the efficacy of paclitaxel-eluting stents in chronic total coronary occlusions (CTO).

BACKGROUND

Percutaneous coronary interventions for CTOs are characterized by a high target vessel failure rate.

METHODS

In 48 consecutive patients, paclitaxel-eluting stents (Taxus, Boston Scientific Corp., Natick, Massachusetts) were implanted after successful recanalization of a CTO (duration >2 weeks). Patients underwent an angiography after 6 months and were followed clinically for 12 months. They were compared with 48 lesion- and risk-matched patients with CTOs treated with bare metal stents (BMS). Primary clinical end point was the one-year incidence of major adverse cardiac events (MACE) (death, myocardial infarction, repeat revascularization); secondary end points were the rate of restenosis and re-occlusion.

RESULTS

In-hospital MACE was 4.2% with Taxus, and 2.1% with BMS (p = NS). The one-year MACE rate was 12.5% in the Taxus group, and 47.9% in the BMS group (p < 0.001), which was due to a reduced need for repeat revascularization. The angiographic restenosis rate was 8.3% with Taxus versus 51.1% with BMS (p < 0.001). There was only one late re-occlusion with Taxus (2.1%) as compared with 23.4% with BMS (p < 0.005). The late loss was reduced in the Taxus group by 84% as compared with BMS. All nonocclusive restenoses in the Taxus group were focal and successfully treated by implanting an additional Taxus stent.

CONCLUSIONS

The treatment of CTOs with a paclitaxel-eluting stent drastically reduces MACE and restenosis, and almost eliminates re-occlusion, which is typically frequent with BMS in CTOs. Chronic total coronary occlusion should be a preferred indication for drug-eluting stents.

New devices for percutaneous coronary intervention are rapidly making bypass surgery obsolete

PURPOSE OF REVIEW

This review summarizes recent and cumulative progress in the success, safety, applicability, and durability of percutaneous coronary intervention.

RECENT FINDINGS

Improvements in basic percutaneous coronary intervention (PCI) equipment and the availability of bare metal stents in the mid-1990s improved acute procedural success to 98%, reduced the emergency surgery rate to 0.2%, and reduced the incidence of recurrent symptoms due to restenosis at the treated site to 15 to 20%. The recent availability of drug-eluting stents has reduced the in-stent neointimal proliferation that causes restenosis and reduced the incidence of symptomatic recurrence to less than 5%, rivaling that of bypass surgery. The work on better antithrombotic pharmacology, distal embolic protection, and devices for crossing chronic total occlusions will further add to the armamentarium for catheter-based revascularization.

SUMMARY

Based on progress over the past decade, PCI has grown to represent about two-thirds of all coronary revascularization (800,000 PCI vs 350,000 bypass surgeries). Recent and ongoing progress will make bypass surgery largely obsolete within the next several years.

Utility of the Safe-Cross-guided radiofrequency total occlusion crossing system in chronic coronary total occlusions (results from the Guided Radio Frequency Energy Ablation of Total Occlusions Registry Study)

The Safe-Cross radiofrequency guidewire (IntraLuminal Therapeutics, Carlsbad, California) combines 3 capabilities: (1) steerability of a conventional 0.014-in intermediate-stiffness guidewire, (2) optical coherence reflectometry to warn the operator when the wire tip approaches within 1 mm of the vessel wall, and (3) delivery of radiofrequency energy pulses to the wire tip to facilitate passage through an occluded segment. The Guided Radio Frequency Energy Ablation of Total Occlusions Registry was a prospective, nonrandomized, multicenter registry that enrolled 116 patients who had long-term coronary total occlusions and in whom a >10-minute good-faith attempt to cross the occlusion using conventional guidewires had failed. The median known duration of occlusion was 22 months (32%; >1 year), and the median length of the occluded segment was 25 mm (25%; >30 mm). Device success was achieved in 63 of 116 of patients (54.3%), and major adverse events occurred in 6.9%, consisting predominantly of isolated increases in cardiac enzymes with no procedure-related deaths, Q-wave myocardial infarctions, or emergency bypass operations. Clinical perforation occurred in 2.6% of patients; of these, perforation in only 1 patient (0.9%) was adjudicated to be directly related to the Safe-Cross radiofrequency wire rather than to the stiff and/or hydrophilic wires used after an inability to advance with the Safe-Cross. Based on these data, the device has been approved in Europe and was recently (January 2004) granted 510K clearance by the Food and Drug Administration.

Significant reduction in restenosis after the use of sirolimus-eluting stents in the treatment of chronic total occlusions

OBJECTIVES

The aim of this study was to assess sirolimus-eluting stent (SES) implantation for the treatment of chronic total coronary occlusions (CTO).

BACKGROUND

Long-term results after percutaneous coronary intervention (PCI) in the treatment of CTOs is hindered by a significant rate of restenosis and reocclusion. In the treatment of relatively simple nonocclusive lesions, SESs have shown dramatically reduced restenosis rates compared with bare metal stents (BMS), but whether these results are more widely applicable is unknown.

METHODS

From April 2002, all patients at our institution were treated with SES as the device of choice during PCI. During the first six months, 563 patients were treated solely with SES, with treatment of a de novo CTO in 56 (9.9%). This CTO cohort was compared with a similar group of patients (n = 28) treated in the preceding six-month period with BMS.

RESULTS

At one year, the cumulative survival-free of major adverse cardiac events was 96.4% in the SES group versus 82.8% in the BMS group, p < 0.05. At six-month follow-up, 33 (59%) patients in the SES group underwent angiography with a binary restenosis rate (>50% diameter stenosis) of 9.1% and in-stent late loss of 0.13 +/- 0.46 mm. One patient (3.0%) at follow-up was found to have reoccluded the target vessel.

CONCLUSIONS

The use of SESs in the treatment of chronic total coronary occlusions is associated with a reduction in the rate of major adverse cardiac events and restenosis compared with BMS.

The ‘Open-Artery Hypothesis’: New Clinical and Pathophysiologic Insights

The open-artery hypothesis states that myocardial reperfusion, even if late for myocardial salvage, provides benefits and prevents adverse cardiac remodeling. While observational data in humans regarding the deleterious impact of a permanent infarct-related artery occlusion and the benefits of spontaneous reperfusion are quite consistent, the reports regarding late revascularization are inconclusive in order to prove such a hypothesis. The observational studies tend to have selection biases, while randomized trials to date are too small to be conclusive. Moreover, the pathophysiological mechanisms underlying presumed benefits of reperfusion are still unclear. However, although the open-artery hypothesis remains unproven, the current evidence suggesting benefits calls for additional studies. Limitations of ischemic left ventricular dilatation and myopathy could markedly reduce cardiovascular morbidity and mortality after acute myocardial infarction.

Novel use of a high-energy excimer laser catheter for calcified and complex coronary artery lesions

This study was designed to evaluate safety and effectiveness of the 0.9 mm excimer laser coronary catheter with increased laser parameters. We report a prospective trial of 100 calcified and/or balloon-resistant lesions where a new 0.9 mm excimer laser catheter was used at standard or higher energy level to facilitate angioplasty. Standard in-hospital clinical and angiographic parameters were collected and measured. Laser technical success was obtained in 87 lesions (92%), procedural success was reached in 88 lesions (93%), and clinical success in 82 lesions (86%). Increased laser parameters were used for 29 resistant lesions. This new 0.9 mm excimer laser coronary catheter using higher energy parameters seems to be safe and effective for management of calcified and nondilatable lesions.