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Rodriguez-Arias JJ, Gomez-Lara J, Caballero-Borrego J, Ortega-Paz L, Arévalos V, Teruel L, Gil-Jimenez T, Oyarzabal L, Romaguera R, Moreno-Terribas G, Gomez-Hospital JA, Sabate M, Brugaletta S. Long-term vascular function in CTO recanalization: A randomized clinical trial of ticagrelor vs. clopidogrel. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 37:61-67. [PMID: 34238679 DOI: 10.1016/j.carrev.2021.06.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/26/2021] [Accepted: 06/28/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Coronary vascular function of a chronic coronary total occlusion (CTO) immediately after recanalization is known to be poor and to be partially improved by pre-treatment with loading dose of ticagrelor vs. clopidogrel. It is unknown if this vascular dysfunction is maintained at long-term follow-up and may be improved by 1-year dual antiplatelet therapy (DAPT). METHODS The TIGER is a prospective, open-label, two parallel-group controlled clinical trial, which 1:1 randomized 50 CTO patients to pre-PCI loading dose and subsequent 1-year DAPT with ticagrelor vs. clopidogrel. Coronary blood flow (CBF) under stepwise adenosine infusion was assessed after drug loading dose and at follow-up and compared between the two drug groups, adjusting for time of follow-up. RESULTS Out of 50 patients with index CBF evaluation, 38 (76%) patients underwent angiographic follow-up (23 and 15 at 1 and 3-year, respectively) and Doppler data was available in 35 (70%). A high CBF area under the curve (AUC), already observed after loading dose in ticagrelor vs. clopidogrel group (p = 0.027), was maintained at follow-up (AUC 34815.22 ± 24,206.06 vs. AUC 22712.47 ± 13,768.95; p = 0.071). Specifically, whereas high ticagrelor loading dose-related CBF was sustained at follow-up (p = 0.933), clopidogrel loading dose-related CBF increased at follow-up (p = 0.039). CONCLUSION The TIGER trial showed that DAPT with ticagrelor maintained a non-significantly higher CBF in a recanalized CTO as compared to clopidogrel, whose treated patients exhibit a lower CBF immediately after PCI with a significant increase at follow-up. The clinical value of such sustained high coronary flow should be evaluated in a larger group of patients. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/ct2/show/NCT02211066 (ClinicalTrials.gov number NCT02211066).
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Affiliation(s)
- Juan J Rodriguez-Arias
- Cardiovascular Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Josep Gomez-Lara
- Heart Disease Institute, Bellvitge University Hospital, University of Barcelona, IDIBELL, Spain
| | - Juan Caballero-Borrego
- Unidad de Cardiologia Intervencionista, Servicio de Cardiologia, Hospital Universitario Clinico San Cecilio, Granada, Spain
| | - Luis Ortega-Paz
- Cardiovascular Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Victor Arévalos
- Cardiovascular Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Luis Teruel
- Heart Disease Institute, Bellvitge University Hospital, University of Barcelona, IDIBELL, Spain
| | - Teresa Gil-Jimenez
- Unidad de Cardiologia Intervencionista, Servicio de Cardiologia, Hospital Universitario Clinico San Cecilio, Granada, Spain
| | - Loreto Oyarzabal
- Heart Disease Institute, Bellvitge University Hospital, University of Barcelona, IDIBELL, Spain
| | - Rafael Romaguera
- Heart Disease Institute, Bellvitge University Hospital, University of Barcelona, IDIBELL, Spain
| | - Gerardo Moreno-Terribas
- Unidad de Cardiologia Intervencionista, Servicio de Cardiologia, Hospital Universitario Clinico San Cecilio, Granada, Spain
| | | | - Manel Sabate
- Cardiovascular Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Salvatore Brugaletta
- Cardiovascular Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, (IDIBAPS), University of Barcelona, Barcelona, Spain.
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Xenogiannis I, Varlamos C, Benetou DR, Alexopoulos D. Antithrombotic Therapy in Chronic Total Occlusion Interventions. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2020.37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Chronic total occlusion (CTO) recanalization is among the most complex subsets of coronary interventions. Hence, optimum peri- and post-procedural anticoagulation and antiplatelet therapy is key for the achievement of successful revascularization and reduction of major adverse cardiovascular outcomes in patients undergoing CTO percutaneous coronary intervention (PCI). Unfractionated heparin is still considered the gold standard anticoagulant because its action can be reversed by protamine administration, with bivalirudin being reserved mainly for patients with heparin-induced thrombocytopenia. However, small studies comparing unfractionated heparin with bivalirudin in CTO interventions have shown similar outcomes. Glycoprotein IIb/IIIa inhibitors should, in general, be avoided. Aspirin in combination with clopidogrel for 6–12 months is the standard post CTO PCI dual antiplatelet regimen. For the most complex cases, clopidogrel can be substituted by a more potent P2Y12 inhibitor, namely ticagrelor or prasugrel.
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Affiliation(s)
- Iosif Xenogiannis
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Charalampos Varlamos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Despoina-Rafailia Benetou
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Dimitrios Alexopoulos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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Jeżewski MP, Kubisa MJ, Eyileten C, De Rosa S, Christ G, Lesiak M, Indolfi C, Toma A, Siller-Matula JM, Postuła M. Bioresorbable Vascular Scaffolds-Dead End or Still a Rough Diamond? J Clin Med 2019; 8:E2167. [PMID: 31817876 PMCID: PMC6947479 DOI: 10.3390/jcm8122167] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 12/02/2019] [Accepted: 12/04/2019] [Indexed: 02/06/2023] Open
Abstract
Percutaneous coronary interventions with stent-based restorations of vessel patency have become the gold standard in the treatment of acute coronary states. Bioresorbable vascular scaffolds (BVS) have been designed to combine the efficiency of drug-eluting stents (DES) at the time of implantation and the advantages of a lack of foreign body afterwards. Complete resolution of the scaffold was intended to enable the restoration of vasomotor function and reduce the risk of device thrombosis. While early reports demonstrated superiority of BVS over DES, larger-scale application and longer observation exposed major concerns about their use, including lower radial strength and higher risk of thrombosis resulting in higher rate of major adverse cardiac events. Further focus on procedural details and research on the second generation of BVS with novel properties did not allow to unequivocally challenge position of DES. Nevertheless, BVS still have a chance to present superiority in distinctive indications. This review presents an outlook on the available first and second generation BVS and a summary of results of clinical trials on their use. It discusses explanations for unfavorable outcomes, proposed enhancement techniques and a potential niche for the use of BVS.
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Affiliation(s)
- Mateusz P. Jeżewski
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology, Medical University of Warsaw, 02091 Warsaw, Poland; (M.P.J.); (M.J.K.); (C.E.); (M.P.)
| | - Michał J. Kubisa
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology, Medical University of Warsaw, 02091 Warsaw, Poland; (M.P.J.); (M.J.K.); (C.E.); (M.P.)
| | - Ceren Eyileten
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology, Medical University of Warsaw, 02091 Warsaw, Poland; (M.P.J.); (M.J.K.); (C.E.); (M.P.)
| | - Salvatore De Rosa
- Department of Medical and Surgical Sciences, Division of Cardiology, “Magna Graecia” University, 88100 Catanzaro, Italy; (S.D.R.); (C.I.)
| | - Günter Christ
- Department of Cardiology, 5th Medical Department with Cardiology, Kaiser Franz Josef Hospital, 31100 Vienna, Austria;
| | - Maciej Lesiak
- 1st Department of Cardiology, Poznan University of Medical Sciences, 1061701 Poznań, Poland;
| | - Ciro Indolfi
- Department of Medical and Surgical Sciences, Division of Cardiology, “Magna Graecia” University, 88100 Catanzaro, Italy; (S.D.R.); (C.I.)
| | - Aurel Toma
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 231090 Vienna, Austria;
| | - Jolanta M. Siller-Matula
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology, Medical University of Warsaw, 02091 Warsaw, Poland; (M.P.J.); (M.J.K.); (C.E.); (M.P.)
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 231090 Vienna, Austria;
| | - Marek Postuła
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology, Medical University of Warsaw, 02091 Warsaw, Poland; (M.P.J.); (M.J.K.); (C.E.); (M.P.)
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Levesque S, Gamet A, Lattuca B, Lemoine J, Bressollette E, Avran A, Motreff P, Boudou N, Faurie B, Christiaens L. Post-stEnting assessment of Re-endothelialization with optical Frequency domain imaging aftEr Chronic Total Occlusion procedure: The PERFE-CTO Study Design and Rationale. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 21:760-764. [PMID: 31679911 DOI: 10.1016/j.carrev.2019.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/07/2019] [Accepted: 10/21/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The treatment of chronic total occlusion of coronary arteries by percutaneous coronary intervention (CTO PCI) is one of the most representative technical advances in ischemic cardiomyopathy of last decade. However, how the complex histopathological remodeling and the new techniques affect healing processes after stent implantation remains unknown. OBJECTIVE The objective of the PERFE-CTO study is to analyze stent coverage, malapposition and other mechanical abnormalities 3 months after CTO recanalization using intravascular imaging. METHODS In a French prospective interventional multicenter study, stent strut coverage, acquired malapposition and neointimal hyperplasia (NIH) proliferation will be systematically assessed with 3 months angiogram control and intracoronary optical frequency domain imaging (OFDI) after successful CTO PCI of >20 mm in length. The impact of routine systematical intracoronary imaging after these complex procedures will also be evaluated by measuring the rate of significant mechanical abnormalities (strut malapposition, edge dissection, thrombus) that was undetected by fluoroscopy alone and by complementary PCI when needed. Secondarily, these data will be compared according to clinical characteristics, antiplatelet therapy use or desobstruction technique (antegrade vs. retrograde, true lumen vs. subintima). Each patient will undergo a one-year clinical follow-up. A total of 150 analyzed CTO lesions is expected. CONCLUSION The PERFE-CTO study will provide essential understanding of the early history after CTO recanalization and the identification of inadequate evolution (stent thrombosis, restenosis or late delayed stent endothelization and cardiovascular outcomes) using intravascular imaging to improve long-term CTO results.
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Affiliation(s)
- Sébastien Levesque
- Department of Cardiology, Centre Hospitalier Universitaire de Poitiers, Poitiers, France.
| | - Alexandre Gamet
- Department of Cardiology, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Benoit Lattuca
- Department of Cardiology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Julien Lemoine
- Department of Cardiology, Clinique Louis Pasteur, Nancy, France
| | | | - Alexandre Avran
- Department of Cardiology, Institut Arnaud Tzanck, Saint Laurent du Var, France
| | - Pascal Motreff
- Department of Cardiology, Centre Hospitalier Universitaire de Clermont-Ferrand, France
| | - Nicolas Boudou
- Department of Cardiology, Centre Hospitalier Universitaire Rangueil, Toulouse, France
| | - Benjamin Faurie
- Department of Cardiology, Groupe Hospitalier Mutualiste, Grenoble, France
| | - Luc Christiaens
- Department of Cardiology, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
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Ticagrelor versus clopidogrel for recovery of vascular function immediately after successful chronic coronary total occlusion recanalization: A randomized clinical trial. Am Heart J 2018; 204:205-209. [PMID: 30149889 DOI: 10.1016/j.ahj.2018.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 07/17/2018] [Indexed: 11/21/2022]
Abstract
Coronary vascular function of a chronic coronary total occlusion (CTO) immediately after recanalization is known to be poor. We sought if ticagrelor may augment adenosine-induced coronary blood flow vs. clopidogrel immediately after successful CTO percutaneous coronary intervention (PCI).
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Shatila W, Krajcer Z. Chronic total occlusion: Does anti-platelet choice impact outcomes? Catheter Cardiovasc Interv 2018; 91:7-8. [PMID: 29314641 DOI: 10.1002/ccd.27456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 11/29/2017] [Indexed: 11/05/2022]
Abstract
Chronic total occlusion (CTO) is associated with worse outcomes compared to non CTO percutaneous coronary intervention (PCI). CTO might be associated with vasomotor dysfunction Ticagrelor is a novel P2Y12 inhibitor that increases local adenosine The TIGER-BVS trial plans to assess the impact of using ticagrelor vs. clopidogrel on vasomotor activity and outcomes after successful CTO PCI.
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Affiliation(s)
- Wassim Shatila
- Department of Cardiology, Texas Heart Institute, Houston, Texas.,Department of Cardiology, Baylor College of Medicine, Houston, Texas.,CHI St. Luke's Health-Baylor St. Luke's Medical Center, Houston, Texas
| | - Zvonimir Krajcer
- Department of Cardiology, Texas Heart Institute, Houston, Texas.,Department of Cardiology, Baylor College of Medicine, Houston, Texas.,CHI St. Luke's Health-Baylor St. Luke's Medical Center, Houston, Texas
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