Faculty Bibliography

Technological innovations have enabled higher success rates with percutaneous coronary intervention (PCI) of complex coronary lesions via the transradial approach. The orbital atherectomy system (OAS; Cardiovascular Systems, Inc) is the most recent innovation that abrades plaque using a rotation device for the facilitation of stent placement in heavily calcified lesions. Fifty patients with classic anginal symptoms and an abnormal stress test demonstrating ischemia underwent PCI using the coronary OAS. In all, 46 out of 50 patients received stents in the target lesion after orbital atherectomy. At follow-up, there were no major adverse cardiovascular events, including cardiac death, myocardial infarction, and need for target-vessel revascularization. Radial artery occlusion rate was 6% at 30 days. The use of the OAS via the radial approach may be a safe and feasible option to assist in the treatment of heavily calcified coronary lesions.

OBJECTIVE:To demonstrate the feasibility and safety of transpedal arterial access for lower-extremity angiography and intervention. BACKGROUND:Traditionally, the femoral artery is chosen for the initial access site in symptomatic peripheral artery disease (PAD), but this approach carries a substantial portion of the entire procedural complication risk. METHODS:80 patients were prospectively evaluated for the treatment of PAD between May and July 2014. All patients underwent peripheral angiography, and intervention if necessary. A pedal artery was the initial access site for all patients. Under ultrasound guidance, one of the pedal arteries was visualized and accessed, and a 4 Fr Glidesheath was inserted. Retrograde orbital atherectomy and balloon angioplasty were performed with a 4 Fr sheath or upsizing to a 6 Fr Glidesheath Slender (Terumo) for stenting as needed. Clinical and ultrasound assessment of the pedal arteries were performed before the procedure and at 1-month follow-up. RESULTS:Diagnostic transpedal peripheral angiography was performed in all 80 patients. 43 out of 51 patients (84%) who required intervention were successful using a pedal artery as the sole access site. No immediate or delayed access-site complications were detected. Clinical follow-up was achieved in 77 patients (96%) and access artery patency was demonstrated by ultrasound at 1 month in 100% of patients. CONCLUSION/CONCLUSIONS:The routine use of a transpedal approach for the treatment of PAD may be feasible and safe. Pedal artery access may also avoid many of the complications associated with the traditional femoral approach, but further study is needed.

OBJECTIVES: To provide new strategies and techniques for the successful recanalization of chronic total occlusions (CTOs) with the sole use of the CrossBoss catheter. In addition, some common CTO scenarios are illustrated in detail. BACKGROUND: CTOs are one of the most challenging complex coronary lesion subsets to intervene upon. Even with the innovation of specialized catheters, the success rate of antegrade recanalization remains low. METHODS: Between June and December 2013, a retrospective analysis of 50 consecutive patients who presented with a planned percutaneous intervention (PCI) of a CTO was performed. In all patients, the CrossBoss catheter was used. No additional reentry devices were necessary. Procedural success was defined as <20% residual stenosis and TIMI-3 distal blood flow of the treated vessel at the end of the procedure. RESULTS: The majority of the patients were male (72%), with an average age of 68 years. Thirty percent of patients presented with prior CTO-PCI failure. The average fluoroscopy time was 45.9 minutes and the average amount of contrast use was 273.8 mL. No patient suffered a coronary perforation from the CrossBoss catheter. CONCLUSIONS: With increased experience using the CrossBoss catheter, the antegrade success rate of CTOs can be improved. Some tips include identifying the likely course of the artery with the aid of retrograde injection, proper guidewire selection and manipulation, and redirecting the CrossBoss catheter if there is substantial deviation from the original path.

OBJECTIVES/OBJECTIVE:To evaluate the use of extension catheters in transradial intervention of complex coronary lesions. BACKGROUND:Complex percutaneous coronary intervention (PCI) via transradial approach remains a challenge for many interventionalists, primarily due to the difficulty in obtaining adequate guide catheter support. METHODS:A retrospective case series identified 54 patients who presented for PCI of complex coronary lesions. A lesion was defined as complex if it contained severe calcification, proximal tortuosity, chronic total occlusion, or was located distal to a previously implanted stent. After identifying the complex lesions, a conversion to femoral approach was considered, but an attempt via the transradial approach with the use of an extension catheter was chosen as the initial strategy. Specific cases highlighting this approach are illustrated in detail. RESULTS:The average age of the patients was 72 years old, with male predominance (55%). The success rate of completing the transradial intervention with the help of an extension catheter was 96%. Stent delivery failed due to severe tortuosity and calcification in only 2 cases. The coronary artery involved was either the left anterior descending (n = 25), the left circumflex (n = 10), the right coronary artery (n = 14), or a saphenous vein graft (n = 5). There were no coronary dissections evident from use of the extension catheter. CONCLUSION/CONCLUSIONS:In the treatment of complex coronary lesions via the transradial approach, the use of an extension catheter may assist in improving successful intervention and decrease the frequency of crossover to a femoral approach.

OBJECTIVE: To examine the use and outcomes of balloon-assisted tracking (BAT) technique for dealing with complexities of arm and chest vasculature during transradial approach (TRA) at a single high volume radial center. BACKGROUND: TRA has been used for coronary angiography and percutaneous coronary interventions (PCI) around the world. Different techniques have been described to address the anatomical issues and tortuosities for successful completion of coronary angiography and PCI. This study describes the use of BAT technique and associated outcomes during real world clinical practice. METHODS: Subjects comprised 63 patients, (out of total 8,245 patients between January 2011 and December 2012) in whom we encountered significantly complex anatomical course in radial, brachial, or subclavian region, leading to difficult advancement of a diagnostic or a guide catheter despite trying all standard maneuvers. In all of them BAT technique was used and they were retrospectively analyzed for the purpose of this study. RESULTS: About 63 (0.76%) of 8,245 patients met the study criteria. Twenty-five (39.7%) patients had very small RA. Twenty-two (34.9%) had severe RA tortuosity. Four (6.3%) had complex RA loops. Six (9.5%) had severe RA spasm and six (9.5%) had severe subclavian tortuosity and/or stenosis. We encountered technical failure in three (4.8%) patients (two had very small RA and one had 360 degree RA loop). CONCLUSION: BAT technique was useful to address the anatomical issues and tortuosities of radial, brachial, and subclavian vasculature during TRA. (c) 2013 Wiley Periodicals, Inc.

OBJECTIVES: To report the incidence and predictors of moderate/severe radial artery spasm (RAS) in patients undergoing cardiovascular percutaneous procedures through a transradial approach (TRA) in centers with TRA expertise. BACKGROUND: Data regarding the actual rate of clinically meaningful RAS are limited due to difference in study designs and operator expertise. METHODS: The RAS registry, an international (14 centers from Argentina, Chile, India, Indonesia, Macedonia, The Netherlands and United States of America) registry that included 1,868 patients undergoing TRA cardiovascular procedures (63.5% diagnostic and 56.5% therapeutic).All selected centers used TRA as default strategy in the cardiac catheterization laboratory. Throughout 2012, each center included all consecutive TRA cases (during a 2-month period) into a dedicated database covering clinical characteristics as well as procedural topics related to TRA patterns and RAS occurrence. RESULTS: The incidence of moderate/severe RAS was 2.7%. Only 0.7% of patients required crossover (8 to transfemoral and 5 to contralateral TRA). Patients with moderately/severe spasm were more frequently females, had a history of dyslipidemia, received more often a 7F sheath and more puncture attempts than patients without spasm. By multivariate analysis, the need for more than one attempt and the use of a 7 F sheath were independent predictors of the development of moderate/severe RAS. CONCLUSIONS: The incidence of moderate/severe RAS is low in centers with a default TRA. Its development appears to be strongly related to the numbers of puncture attempts and the use of large sheaths. (c) 2013 Wiley Periodicals, Inc.

BACKGROUND: The transradial approach to percutaneous coronary intervention (PCI) has recently gained popularity among interventionalists. However, radial artery occlusion (RAO) limits the ability for repeat catheterization. In current practice, transulnar catheterization is thought to be a contraindication in patients with ipsilateral RAO. METHODS: Seventeen consecutive patients undergoing transulnar catheterization and PCI were reviewed. Each of the patients had clinical follow-up post-procedure at days 1, 7, and 30. RESULTS: We successfully performed 17 ulnar catheterizations in patients with ipsilateral RAO. All patents were subsequently found to have adequate collaterals from the anterior interosseous branch. One patient developed ulnar artery spasm and another patient developed a forearm hematoma. Overall, no patient suffered any ulnar nerve injury. The ulnar artery was patent both by palpation and by the presence of an adequate plethysmographic signal during follow-up at days 1, 7, and 30. No patients developed with any signs or symptoms of hand ischemia during follow-up. CONCLUSION: In patients with RAO, ipsilateral transulnar catheterization may not be an absolute contraindication. Our results suggest that extensive collaterals from the anterior interosseous artery may be the reason for protection against hand ischemia in the setting of RAO.

OBJECTIVES: The current study aimed at determining the best cutoff value of angiographic and intravascular ultrasound (IVUS) parameters for defining fractional flow reserve (FFR) <0.8 in patients with single coronary artery lesion. BACKGROUND: The correlation between angiographic or IVUS variables and FFR in patients with single coronary artery lesions has not been studied yet. METHODS: Quantitative coronary analysis and IVUS and FFR measurements were used in 323 patients with a single lesion. The best angiographic and IVUS cutoff values and their predictive value for FFR<0.8 were compared using area under the receiver-operator characteristic curve (AUC). RESULTS: FFR<0.8 was in 54.2%. Minimal lumen area (MLA), plaque burden (PB), lesion length (LL) and lesion at left anterior descending artery (LAD) were four predictors of FFR<0.8. LL had less value in predicting FFR<0.8. The cutoff values of PB and MLA for FFR<0.8 were 72.7% and 2.97 mm(2). MLA and PB had similar high diagnostic value for vessel size >/= 3 mm (cutoff values: 3.02 mm(2) and 80.7%), proximal LAD lesion (cutoff values: 3.04 mm(2) and 76.5%) and unstable angina (2.82 mm(2) and 71.9%). Combination of MLA (2.82 mm(2)) and PB (80.6%) had increased diagnostic value for distal LAD lesion. Only PB (71%) had higher diagnostic value for diabetic patients. MLA and PB could not predict FFR<0.8 for vessel size<3mm, and non-LAD lesion. CONCLUSION: Best cutoff value of MLA and PB for FFR<0.8 in patients with a single lesion is patient-, vessel size- and lesion location-oriented. PB has strengthened diagnostic accuracy for diabetic patients.

OBJECTIVE: We sought to study the clinical outcomes of bifurcation stenting in patients who presented with stent thrombosis segment elevation myocardial infarction (STEMI). BACKGROUND: Patients with STEMI are usually excluded from randomized bifurcation studies. There is limited information for bifurcation stenting in this population. METHODS: All STEMI patients who were randomized were retrospectively reviewed from DKCRUSH II (double kissing, double crush) database. DKCRUSH II is a multicenter, randomized study of provisional stenting (PS) versus the DK crush stenting techniques. A total of 370 patients with bifurcation lesions were randomized and of this group a total of 63 patients with STEMI were found. This group of STEMI included 30 patients in the PS group and 33 patients in the DK crush stenting group. RESULTS: There were no differences in terms of contrast used, procedure time, and fluoroscopy time. Procedural success rates were 97% in all patients with STEMI, with 100% in the PS group and 94% in the DK crush stenting group. During the procedure, there were two patients with less than TIMI 3 (thrombolysis in myocardial infarction) flow in the main vessel of the DK crush group However, TIMI 3 flow was 100% in the side branch for both groups. Cumulative 12-month major adverse cardiac event (MACE) was 22% in the whole STEMI group, whereas PS and DK crush groups were 23% versus 21%, respectively (P = NS). There were no differences in in-hospital, 6-month, and 12-month MACE in these two groups. At 6 and 12 months, there were two cardiac deaths in the PS group but without statistical significance when compared with the DK crush stenting group (7% vs. 0%, P = NS). CONCLUSION: Bifurcation stenting in patients with STEMI is safe and feasible. The immediate and midterm clinical outcomes were comparable between PS and DK crush stenting. (c) 2013 Wiley Periodicals, Inc.