Showing papers in "Interventional Cardiology in 2014"
TL;DR: In this paper, the authors explore and describe studies of mobile health applications in cardiac care, including the implications for interventional cardiology, with a focus on clinical outcomes, and explore the potential of mobile applications in providing effective, efficient and appropriately personalized care; however, further studies are required to confirm this.
Abstract: Rapid advances in mobile health technologies and their ubiquitous communication capacity have invigorated remote healthcare delivery. Mobile health applications can help counter the mounting pressure on cardiac services. Patients are increasingly using health and well-being applications, including those for chronic disease monitoring. Population-screening applications are becoming widely used and can have a significant impact on early detection in future. Studies show that cardiology services are using mobile technologies to provide earlier diagnosis through remote transmission and interpretation of ECG, leading to more accurate triage and shorter door-to-balloon time in myocardial infarction. Arrhythmias can be monitored in real time, supported by automated detection algorithms, and implantable device status checks can efficiently and safely be carried out remotely. Ongoing monitoring for and early detection of deterioration in heart failure can also be achieved through mobile applications. Cardiac rehabilitation has been delivered remotely utilizing mobile technologies. Mobile health offers significant potential in providing effective, efficient and appropriately personalized care; however, further studies are required to confirm this. The objective of this review is to explore and describe studies of mobile health applications in cardiac care, including the implications for interventional cardiology, with a focus on clinical outcomes.
21 citations
TL;DR: A 10-year experience of solely MRI-guided and XMR catheterization in patients at this institution is reported, and the developments in clinical MRI- guided and X MR catheterizations are reviewed and future perspectives are discussed.
Abstract: MRI- or combined x-ray and MRI (XMR)-guided catheterization was introduced as an alternative to x-ray-guided catheterization to reduce radiation exposure and offer more comprehensive anatomical, hemodynamic and physiological data. However, developments have been slow to come into routine clinical practice. We report a 10-year experience of solely MRI-guided and XMR catheterization in patients at our institution, review the developments in clinical MRI-guided and XMR catheterization and discuss future perspectives. This includes further results from our clinical trial on MRI-guided cardiac interventions.
14 citations
TL;DR: Treatment options are described and an algorithm for appropriate, safe and effective patient management is suggested for venous TOS and an approach for diagnostic workup and treatment is suggested.
Abstract: Venous thoracic outlet syndrome (TOS) is a less common presentation than neurogenic TOS. It is caused by venous obstruction due to axillosubclavian venous thrombosis or, less frequently, nonthrombotic external compression. Thrombotic venous TOS is commonly known as Paget–Schroetter syndrome and primarily involves axillosubclavian vein thrombosis. Patients with nonthrombotic forms of venous TOS typically have normal venography at rest, but arm abduction generates a positional venous compression resulting in arm swelling and pain. This paper reviews the anatomy and pathophysiology associated with venous TOS and suggests an approach for diagnostic workup and treatment. Controversies exist as to the most appropriate treatment and, in particular, the timing of treatment during the natural course of the disease. Here we describe treatment options and suggest an algorithm for appropriate, safe and effective patient management.
12 citations
TL;DR: Second-generation drug-eluting stents with biocompatible and biodegradable polymers promised a better safety outcome and studies on novel antiproliferative and polymer-free drug-Eluting stenting demonstrated at least comparable angiographic late loss.
Abstract: Coronary stent implantation is the standard of care in percutaneous coronary interventions, offering a better outcome in the short and long term. The main limitation of bare-metal stents is in-stent restenosis resulting from neointimal hyperplasia, associated with a substantial rate of target lesion revascularization. Drug-eluting stents reduced in-stent restenosis and repeat revascularization; however, late stent thrombosis has been the main concern with regards to this technology. Chronic inflammatory and hypersensitivity reactions to the polymer of drug-eluting stents were implicated in the predisposition to stent thrombosis. Second-generation drug-eluting stents with biocompatible and biodegradable polymers promised a better safety outcome. Moreover, studies on novel antiproliferative and polymer-free drug-eluting stents demonstrated at least comparable angiographic late loss. Early-phase studies on bioabsorbable vascular scaffolds demonstrated substantial late loss: a combination of neointimal hyperp...
8 citations
TL;DR: The two septal reduction procedures are described, the available comparative data for clinical outcomes are examined, and clinical considerations when selecting myectomy or ablation are discussed.
Abstract: Left ventricular outflow tract obstruction, either resting or labile, occurs in approximately 70% of patients with hypertrophic cardiomyopathy and is a major cause of symptoms. In patients with obstructive physiology and medically refractory symptoms, septal myectomy and alcohol septal ablation reduce the left ventricular outflow tract gradient and improve symptoms. Myectomy is more effective at gradient reduction compared with ablation, with lower need for subsequent pacemaker implantation. However, cohort studies and meta-analyses have shown short-term mortality and post-procedural functional classes are similar between procedures. In many centers alcohol septal ablation case volumes have surpassed myectomy. There remains significant controversy regarding choice of myectomy or ablation. This review describes the two septal reduction procedures, examines the available comparative data for clinical outcomes and discusses clinical considerations when selecting myectomy or ablation.
7 citations
TL;DR: As the field of medicine and indeed cardiology move forward with innovations which are effective but often expensive, it becomes imperative to employ these cost-effectiveness analytic tools, not with the intention of denying vital health services but to ascertain what the society willing to pay for.
Abstract: Health care is a vital good for which there is an infinite demand. However, societal resources are finite and need to be distributed efficiently to avoid waste. Thus, the relative value of an intervention - cost compared to its effectiveness- needs to be taken into consideration when deciding which interventions to adopt. Cost-effectiveness analysis provides the crucial information which guides these decisions. As the field of medicine and indeed cardiology move forward with innovations which are effective but often expensive, it becomes imperative to employ these cost-effectiveness analytic tools, not with the intention of denying vital health services but to ascertain what the society willing to pay for.
7 citations
6 citations
TL;DR: A comprehensive review of all reports of infection related to percutaneous cardiac procedures since 1994 is covered as are the current infection control guidelines.
Abstract: Percutaneous coronary intervention (PCI) and interventional structural heart disease procedures have steadily increased worldwide over the last two decades. Patient infection is a potential complication of percutaneous cardiac procedures, but the incidence is very low due to the use of sterile techniques and percutaneous arterial puncture. Infection can be categorized as occurring at the access site, which includes vascular closure devices, or locally within the implanted device or a cardiac structure. Although rare, endovascular and cardiac infection can be challenging to diagnose and may have catastrophic consequences. In most cases, treatment requires prolonged parenteral antibiotics and surgical intervention. A comprehensive review of all reports of infection related to percutaneous cardiac procedures since 1994 is covered as are the current infection control guidelines.
6 citations
TL;DR: Transradial approach reduces access site bleeding and vascular complications in coronary interventional procedures and may offer a more direct and safer approach in cases involving a complex arch in patients with significant carotid disease.
Abstract: Carotid artery stenting with embolic protection has been shown to be a proven alternative to carotid endarterectomy in patients with significant carotid disease. The transfemoral approach is the conventional access site for carotid stenting. Access site complications are the most common adverse event after carotid stenting from the femoral access and most technical failures are related to a complex aortic arch. As demonstrated in multiple studies, transradial approach reduces access site bleeding and vascular complications in coronary interventional procedures. It may offer a more direct and safer approach in cases involving a complex arch. Previous feasibility studies and case reports have demonstrated that transradial access may be a viable alternative strategy in these patients.
5 citations
TL;DR: This review will focus on contemporary evidence supporting the utility of renal denervation, review current and emerging devices, consider potential future treatment indications, and discuss unresolved issues that need to be addressed before renal Denervation can be embraced as mainstream therapy.
Abstract: Hypertension has a considerable worldwide burden and is a major risk factor for cardiovascular disease. Despite the use of lifestyle measures and medical therapy, a large proportion of patients remain treatment ‘resistant’ and fail to have adequate control of blood pressure. This may adversely affect both future cardiovascular events and mortality. Catheter-based renal denervation is a promising contemporary evolution of a historical treatment for hypertension and aims to achieve a reduction in renal sympathetic activation. This has been shown previously to be important in both resistant hypertension and in other disease states including heart failure. This review will focus on contemporary evidence supporting the utility of renal denervation, review current and emerging devices, consider potential future treatment indications, and discuss unresolved issues that need to be addressed before renal denervation can be embraced as mainstream therapy.
5 citations
TL;DR: Physiologic measurements such as hyperemic/resting translesional gradients are useful to confirm the severity of renal hypoperfusion and therefore improve the selection of patients likely to respond to renal artery revascularization.
Abstract: Patients with refractory hypertension, progressive ischemic nephropathy and cardiac destabilization syndromes (e.g., flash pulmonary edema) with obstructive atherosclerotic renal artery stenosis (RAS) are likely to benefit from renal artery stenting. Screening for RAS can be done with Doppler ultrasonography (DUS), computed tomographic angiography (CTA) and magnetic resonance angiography (MRA). There is currently a disparity between the acute procedural success of renal artery stenting (97%) and the derived clinical benefit (∼70%), leading to debate about which candidates ultimately benefit from renal revascularization. Physiologic measurements such as hyperemic/resting translesional gradients are useful to confirm the severity of renal hypoperfusion and therefore improve the selection of patients likely to respond to renal artery revascularization. Experienced operators should perform renal interventions in order to minimize complications. Primary patency exceeds 80% at 5 years and surveillance for in-st...
TL;DR: Transcatheter aortic valve implantation is increasingly being offered as a management option for patients with increasing prevalence in the elderly and imaging with echocardiography has an important role through all aspects of the procedure.
Abstract: Aortic stenosis is a common valve disease with increasing prevalence in the elderly. The presence of comorbidities in this population can make surgical aortic valve replacement challenging; therefore, transcatheter aortic valve implantation is increasingly being offered as a management option for these patients. Imaging with echocardiography has an important role through all aspects of the procedure from initial imaging and patient selection, guidance of the procedure and assessment of complications.
TL;DR: The treatment of May–Thurner syndrome and other forms of iliac vein obstruction has evolved with the advancements of endovascular surgery.
Abstract: May–Thurner syndrome most commonly refers to left-sided iliofemoral vein obstruction caused by compression of the left common iliac vein between the right common iliac artery and lumbar vertebrae. However, other forms of May–Thurner syndrome have been described, and May–Thurner syndrome is part of a larger spectrum of venous disease, iliac vein obstruction. May–Thurner syndrome and other forms of iliac vein obstruction can present with acute iliofemoral deep vein thrombosis or chronic venous symptoms of pain, swelling, skin changes and ulceration. The treatment of May–Thurner syndrome and other forms of iliac vein obstruction has evolved with the advancements of endovascular surgery.
TL;DR: A review will look at the potential targets for percutaneous RSDN-heart failure, cardiac arrhythmias and kidney disease, sleep-disordered breathing and insulin resistance.
Abstract: The human sympathetic nervous system has an important regulatory role. In its dysfunctional hyperexcitatory state, it can lead to multiple pathologies. The renal sympathetic nerves play a significant role in these pathological states. Percutaneous renal sympathetic denervation (RSDN) allows for safe minimally invasive selective denervation of the renal sympathetic nerves. RSDN has been shown to be safe and efficacious in blood pressure reduction in earlier nonblinded SYMPLICITY HTN-1 and -2 trials. In Europe, it is approved for a select group of truly resistant severe essential hypertension. However, its real efficacy is now in doubt with the blinded SYMPLICITY HTN-3 trial that showed no significant difference in change in office and mean 24-h ambulatory systolic blood pressure between RSDN and sham-procedure arms. This review will look at the potential targets for percutaneous RSDN-heart failure, cardiac arrhythmias and kidney disease, sleep-disordered breathing and insulin resistance.
TL;DR: The various indigenously available stents, available clinical trial data for each of the stents and future perspectives are discussed.
Abstract: The availability and utilization of percutaneous coronary intervention in developing countries is limited mainly because of the expenses involved. As most of the consumables are imported, the availability of indigenously developed stents will help in bringing down the cost of the procedure, thus making these procedures available to all sections of society. Ever since the availability of the first indigenous stent in 1997, much progress has been made in developing various stents, both bare metal and drug-eluting. Data from long-term follow-up is now available for many of the indigenously developed stents. In this article, we will discuss the various indigenously available stents, available clinical trial data for each of the stents and future perspectives.
TL;DR: The wire was more likely to advance intraluminally if the chronic total occlusion had a tapered proximal cap and an abrupt distal margin.
Abstract: Aim: We assessed the wire behavior by using intravascular ultrasound when knuckle wire technique is performed for chronic total occlusion of the superficial femoral artery. We investigate the relationship between the angiogram and the wire behavior. Methods: This retrospective multicenter study enrolled 48 patients (50 limbs) in whom intravascular ultrasound could be performed successfully after knuckle wire technique. Results: The wire passed intraluminally from the proximal cap to the reentry site in nine cases (18%). Once the wire entered the subintimal space, it remained in the subintimal space through the occlusion (32/34 cases; 95%). Conclusion: The wire was more likely to advance intraluminally if the chronic total occlusion had a tapered proximal cap and an abrupt distal margin.
TL;DR: Novel ‘single shot’ ablation tools with the aim of creating a circumferential lesion around the PVs with a single or a limited number of energy applications emerge.
Abstract: Pulmonary vein (PV) isolation is the cornerstone of ablation therapy for atrial fibrillation. The majority of procedures are still performed using radiofrequency (RF) energy and a point-by-point ablation approach. Novel ‘single shot’ ablation tools with the aim of creating a circumferential lesion around the PVs with a single or a limited number of energy applications emerge. The currently most widely used balloon-based device for PV isolation is the cryoballoon which has proven to be an alternative for standard point-by-point RF ablation.
TL;DR: The REBEL™ stent is made from a new platinum–chromium alloy combined with a customized stent architecture and an enhanced delivery system that allows improved performances of this stent such as high radial and axial strength and lower stent recoil.
Abstract: Coronary artery disease affects over 5,000,000 people worldwide Despite technology evolution and extension of indications of drug-eluting and bioresorbable stents, bare-metal stents play an important role to treat single lesions less than 15 mm of length and/or greater than 25 mm of diameter The REBEL™ stent is made from a new platinum–chromium alloy combined with a customized stent architecture and an enhanced delivery system that allows improved performances of this stent such as high radial and axial strength and lower stent recoil The feasibility and efficacy of percutaneous implantation has been studied worldwide with a prospective, single-arm, multicenter, clinical trial with a de novo atherosclerotic coronary artery lesion currently underway
TL;DR: PCI is clearly effective in old age, but a careful approach to patient selection is essential to obtain better outcomes, and the role and the risks of PCI in the older patients and the strategies to lower the adverse events are examined.
Abstract: With the increase of the elderly population, the number of these patients undergoing percutaneous coronary intervention (PCI) has increased considerably. The elderly are, given the presence of comorbidities and frailty, at higher risk of mortality and morbidity following PCI. However, the elderly appear to derive significant benefits in terms of quality of life and might derive greater benefits from revascularization compared with younger patients. PCI is clearly effective in old age, but a careful approach to patient selection is essential to obtain better outcomes. In this qualitative review, we sought to examine the role and the risks of PCI in the older patients and the strategies to lower the adverse events in this particular set of patients.
TL;DR: Practice guidelines are gradually moving toward recommending biological valves in the majority of young women, and there are emerging solutions for valve degeneration that will further tilt the balance in favor of these valves.
Abstract: Pregnancy is associated with hypercoagulability and hemodynamic instability. Mechanical valves pose a special problem during pregnancy. Warfarin, the most effective drug for preventing valve complications, is teratogenic and also increases fetal loss. Other anticoagulant regimens are less effective and therefore increase the risk of maternal and fetal complications. Chronic anticoagulation can also significantly affect young patient’s quality of life. Biological valves do not require maintenance of any kind and do not pose special risk during pregnancy. However, they degenerate with time, requiring reintervention. Practice guidelines are gradually moving toward recommending biological valves in the majority of young women. There are emerging solutions for valve degeneration that will further tilt the balance in favor of these valves.
TL;DR: A case where the retrograde approach was used to salvage an acute vessel occlusion during a first obtuse marginal percutaneous coronary artery is reported.
Abstract: Acute vessel closure is a percutaneous coronary artery complication with potential catastrophic consequences In this article we report a case where the retrograde approach was used to salvage an acute vessel occlusion during a first obtuse marginal percutaneous coronary artery
TL;DR: The evidence base of this decision process where risk stratification is of paramount importance is discussed, with the goal of obtaining the opt-out on the optimal timing of coronary angiography and possible intervention.
Abstract: Non-ST-elevation myocardial infarction (NSTEMI) has become the most common presentation of acute myocardial infarction. Its treatment is challenging and often less straightforward compared with ST-elevation myocardial infarction (STEMI). First, clinicians must decide whether an initial invasive or an initial conservative treatment is appropriate for their NSTEMI patient. If an invasive strategy is chosen, subsequent decisions on the optimal timing of coronary angiography and possible intervention have to be made. Both aggressive and conservative strategies have their own potential risks and benefits. Aggressive strategies may result in more procedural complications, which is especially unwanted in patients otherwise at low risk of events. By contrast, conservative strategies may be harmful in high-risk patients who benefit most from early reperfusion therapy. We aim to discuss the evidence base of this decision process where risk stratification is of paramount importance with the goal of obtaining the opt...
TL;DR: It is suggested that these excuses for not attempting CTO-PCI should be avoided so that patients receive the treatment they need, not simply the treatment their provider or institution prefers.
Abstract: Chronic total occlusion percutaneous intervention (CTO-PCI) technique has evolved coincident with improvements in success rate and safety of the procedure. Despite this, many patients are not offered this treatment even after medical therapy fails to alleviate their symptoms. The frequently stated reasons for this include the absence of randomized trial data, excessive costs and the time burden of the procedures. In this article our aim is to dispel the myths surrounding the benefits, costs and time burden of CTO-PCI and suggest that these excuses for not attempting CTO-PCI should be avoided so that patients receive the treatment they need, not simply the treatment their provider or institution prefers.
TL;DR: CAS usage is declining and CEA, because of its lower stroke rate, appears to be generally considered the procedure of choice for most patients around the world with symptomatic carotid stenosis.
Abstract: Carotid artery stenting or CAS has undergone its ups and downs since it was first introduced in the late 1980s. In its early years CAS was greeted with skepticism, particularly by vascular surgeons. Despite this, CAS was increasingly embraced by interventional cardiologists as an extension of their technical skills with coronary stenting procedures. The demonstration that CAS usually produced showers of embolic particles lead to the introduction of a variety of cerebral protection devices to capture most of this debris [1]. These and other technical advances lead to improved results which in turn were followed by widespread usage of CAS to treat asymptomatic as well as symptomatic carotid stenosis. Again interventional cardiologists were foremost in this enhanced usage. Nevertheless, because carotid endarterectomy (CEA), the alternative procedure for treating these lesions could be performed with good results and low morbidity and mortality, CAS remained highly controversial. This led to several prospective randomized trials comparing the two procedures. The earlier of these trials, conducted in Europe, demonstrated lower periprocedural stroke rates for CEA in symptomatic patients, but were criticized for not employing state of the art CAS technology [2,3]. A major multicenter US trial, CREST, had its 4-year results published in 2010 [4]. Symptomatic and asymptomatic patients were included. With up to 4 years’ follow-up, there was no difference in total adverse event rates between the two procedures. However, stroke rates were significantly higher in the CAS-treated patients, while myocardial infarction rates were higher in the CEA-treated patients [4]. These data were interpreted in different ways by different specialists who were clearly influenced by their interventional or open surgical orientation and their bias. In addition, multiple society guidelines, all based on data from the same trials, also differed in their main conclusions, again based on specialty orientation and bias [5]. Nevetheless, at present, CAS usage is declining and CEA, because of its lower stroke rate, appears to be generally considered the procedure of choice for most patients around the world with symptomatic carotid stenosis. Exceptions in which CAS is chosen include some centers of excellence and some patients with unusual anatomy or surgical contraindications. This decline in CAS usage is furthered by the increasingly widespread opinion that most asymptomatic carotid stenosis patients are best treated by modern statin-based medical therapy and require neither CAS nor CEA. Increasing numbers of experts have even opined that with current medical therapy few if any patients with asymptomatic carotid stenosis should undergo invasive treatment because the annual stroke rate is so low (<1% per year) [6,7]. According to this opinion, most asymptomatic patients who have undergone CAS derive no benefit, and up to 90% of reported CAS patients have been asymptomatic. Despite this dire status for CAS, I believe its future is bright for several reasons. All the level 1 evidence indicating that CAS carries a higher stroke rate than CEA were obtained from trials using CAS technology, Outlook for carotid stenting looks bright
TL;DR: The Lotus transcatheter device represents an evolution of this technology that allows full resheathing, repositioning and retrieval, which together with features designed to minimize para-prosthetic regurgitation address a number of the limitations of first-generation devices.
Abstract: Symptomatic severe aortic stenosis occurs in 2–4% of people aged over 65 years, with calcific degeneration being the predominant etiology in the developed world. Surgical valve replacement has been and remains the gold-standard treatment modality, yet a significant number of high-risk individuals are denied or refuse this potentially life-saving treatment. Transcatheter aortic valve replacement has proven efficacy in this high-risk cohort. Current-generation transcatheter aortic valve replacement devices, however, have significant limitations. The Lotus transcatheter device represents an evolution of this technology that allows full resheathing, repositioning and retrieval, which together with features designed to minimize para-prosthetic regurgitation address a number of the limitations of first-generation devices.
TL;DR: Fractional flow reserve, which is a physiologic measurement of a coronary artery stenosis, provides objective evidence of the functional significance ofA coronary lesion and has the potential to reduce variations in practice.
Abstract: Wide variations in clinical practice raise questions about the under- or over-use of expensive interventional coronary procedures. Appropriate Use Criteria (AUC) for percutaneous coronary intervention (PCI) were developed in 2009 and updated in 2012 to help guide clinicians regarding the decision to revascularize, based on a synthesis of available evidence. Despite these criteria, recent analyses have continued to show high rates of both inappropriate PCI and underutilization of PCI. Fractional flow reserve, which is a physiologic measurement of a coronary artery stenosis, provides objective evidence of the functional significance of a coronary lesion and has the potential to reduce variations in practice.
TL;DR: The concept of using a smaller guiding catheter (i.e., 4and 5-Fr) is based on the hypothesis that these catheters may further reduce access site-related complications, including radial artery occlusion, and whether further downsizing can provide meaningful benefits.
Abstract: 2014 Although 9to 10-Fr guiding catheters were used in the early years of percutaneous coronary intervention (PCI), a 6-Fr catheter has now become standard for most PCI cases. This pursuit of miniaturization illustrates the evolution of the guiding catheter in an effort to reduce the invasiveness of angioplasty [1]. The development of the 6-Fr guiding catheter not only contributed to the reduction in access site-related complications in the groin, but also allowed the radial artery to be used as the access site for coronary intervention. Shortly after Kiemeneij and his colleagues first performed PCI via the radial route in 1992 [2], they successfully demonstrated that this approach, termed transradial coronary intervention (TRI), could reduce access site-related complications when compared with transfemoral coronary intervention [3]. Although most radial artery occlusions are clinically silent, it is important to keep the radial artery open, as it is a potential site for future access. The concept of using a smaller guiding catheter (i.e., 4and 5-Fr) is based on the hypothesis that these catheters may further reduce access site-related complications, including radial artery occlusion. Despite the recent development of guiding catheters with smaller diameters, 6-Fr remains the standard size for TRI [4]. As documented in previous studies, radial artery occlusion occurs in 2–10% of the cases after TRI with a 6-Fr catheter [5–9]. Given this relatively low incidence of radial artery occlusions, it remains to be determined whether further downsizing can provide meaningful benefits. To this end, several studies compared the incidence of radial artery occlusion after TRI using 5and 6-Fr catheters. In particular, Gobeil et al. observed no significant differences between these two sizes (8 and 2% for 5and 6-Fr catheters, respectively) [7]. In agreement, Dahm et al. did not detect significant differences in the incidences of radial artery occlusion (1.1 vs 5.9%), as well as access site complications (1.1 vs 4.8%) between TRI via 5and 6-Fr catheters [8]. In contrast, in a more recent study, Uhlemann et al. used duplex ultrasonography to demonstrate a significantly lower incidence of access site complications after TRI with a 5-Fr as opposed to a 6-Fr catheter (14.4 vs 33.1%), suggesting a favorable impact of the diameter reduction [10]. In addition, the cases of radial artery occlusion also decreased by half (13.7 vs 30.5%, respectively). However, the overall incidence of radial artery occlusion in this study appears to be high when compared with those in the previous studies [5–9]. In addition, nearly half of the patients with radial artery occlusion were symptomatic. The symptoms included a painful forearm and thenar area, loss of handgrip force, and paresthesis. Although the authors stated that routine clinical radial pulse check might be inaccurate and insensitive in detecting radial artery occlusion, this high incidence of symptomatic radial occlusion could not be explained by the use of duplex ultrasound. Furthermore, with using the same technique to identify radial artery occlusion, Yokoyama et al. reported contradictory results [11]. The incidence of radial artery occlusion (6.3%) was within the range of previously reported values [5–9] despite the fact that they included patients undergoing TRI with larger 7-Fr catheters in addition to those with the conventional diameter of 6-Fr. It should also be noted that all the patients with radial occlusion were asymptomatic. Thus, it How does the catheter size affect access site-related complications in radial percutaneous coronary intervention?
TL;DR: The background to the development of Resolute DES is reviewed, recently published observational data suggest that premature DAPT interruption is not associated with ST in patients treated with the second-generation Resolute zotarolimus-eluting stent, and recently published data on ST and D APT interruption are reviewed.
Abstract: Percutaneous coronary intervention is currently the most commonly used revascularization procedure. This success is a direct consequence of the improved medium- and long-term target vessel patency achieved with drug-eluting stents (DES). However, DES are associated with stent thrombosis (ST), a rare but potentially catastrophic complication. Early interruption of dual anti-platelet therapy (DAPT) is a major risk factor for ST and guidelines recommend a minimum duration of DAPT of 6 to 12 months post implantation. Recently published observational data suggest that premature DAPT interruption is not associated with ST in patients treated with the second-generation Resolute zotarolimus-eluting stent. This article reviews the background to the development of Resolute DES and reviews recently published data on ST and DAPT interruption.
TL;DR: “...there are certain limitations to drug-eluting balloons ... such as the relatively high rate of bail-out stenting in case of unsatisfactory angiographic results, significant heterogeneity among different drug-Eluting balloons and limited data from clinical trials.”
Abstract: “...there are certain limitations to drug-eluting balloons ... such as the relatively high rate of bail-out stenting in case of unsatisfactory angiographic results, significant heterogeneity among different drug-eluting balloons and limited data from clinical trials.”
TL;DR: Most patients with SCAD present as an acute coronary syndrome although cases presenting as sudden death or ventricular arrhythmias are also reported, and most investigators favor a management similar to that used in patients with acute coronary syndromes secondary to coronary artery disease.
Abstract: Spontaneous coronary artery dissection (SCAD) remains an elusive and challenging clinical entity of unknown etiology eight decades after its initial pathological recognition [1]. Coronary angiography has been classically used for the diagnosis of these patients [2–6]. A radiolucent intimal flap, separating the true lumen from the false lumen, has been considered as the hallmark of the disease [2–6]. Multiple case reports and small retrospective series with limited clinical followup have been published but the total number of patients with SCAD reported to date is less than 700 [2–6]. This largely explains the limited information currently available on prevalence, predisposing conditions, pathophysiology, diagnosis, management and prognosis of patients with SCAD [2–6]. Spontaneous coronary artery dissection is a rare disease with a prevalence ranging from 0.1 to 1% in most angiographic series [2–6]. A young female without coronary risk factors presenting with typical chest pain represents the classical clinical scenario. From a pathophysiological standpoint it is accepted that in most patients an intimal tear constitutes the initiating event, leading to intramural bleeding with progressive separation between the true and false lumens. Eventually, pressuredriven compression of the true lumen precipitating myocardial ischemia occurs [2–6]. Alternatively, in other cases the intima remains intact. In these patients disruption of the vasa vasorum causes an intramural hematoma that may also compress the coronary lumen [2–6]. Triggers (including exercise and cocaine, among others) and a pathological underlying anatomic substrate (cystic medial necrosis) are frequently reported in patients suffering from with SCAD [2–6]. In fact, a never-ending list of pathological conditions has been associated with SCAD. Systemic connective tissue disorders (e.g., EhlersDanlos syndrome) and the peripartum period are frequently highlighted in classical series [2–6]. Most patients with SCAD present as an acute coronary syndrome although cases presenting as sudden death or ventricular arrhythmias are also reported. The treatment of choice for patients with SCAD remains unsettled [2–6]. Most investigators favor a management similar to that used in patients with acute coronary syndromes secondary to atherosclerotic coronary artery disease. Revascularization, however, is specially challenging in this scenario and both percutaneous techniques and coronary surgery provide suboptimal results due to the friable – already disrupted – coronary vessel wall [2–6]. Therefore, a conservative approach has been advocated for stable patients with SCAD. Despite a significant acute morbidity patients tend to stabilize after the acute episode and long-term prognosis is largely favorable. All of the above summarize the ‘classical knowledge’ on this unique condition which has remained unchanged for decades [2–6]. Recently, however, major advances have occurred in our understanding of the pathophysiology of the condition [5–11]. Importantly, the widespread use of early coronary angiography in patients presenting with an acute myocardial infarction (including young females) together with an increased Novel insights on spontaneous coronary artery dissection