In-Stent CTO Percutaneous Coronary Intervention: Individual Patient Data Pooled Analysis of 4 Multicenter Registries

Clinical Outcome of Paclitaxel-Coated Balloon Angioplasty Versus Drug-Eluting Stent Implantation for the Treatment of Coronary Drug-Eluting Stent In-Stent Chronic Total Occlusion

AIMS

In-stent chronic total occlusion (IS-CTO) represents a unique challenge for percutaneous coronary intervention. Whether the optimal treatment for IS-CTO is angioplasty with paclitaxel-coated balloons (PCBs) or repeat stenting with drug-eluting stents (DESs) is unclear. We aimed to evaluate the long-term clinical outcome of PCB angioplasty and DES repeat stenting for DES IS-CTO.

METHODS

We retrospectively included patients with DES IS-CTO who underwent successful PCB angioplasty or DES repeat stenting from January 2016 to December 2019. The primary endpoints were major adverse cardiac events (MACEs), including cardiac death, myocardial infarction, and target lesion revascularization (TLR). Cox proportional hazards model was performed to compare the risk of MACEs between PCB angioplasty and DES repeat stenting, and to further explore the prognostic factors of patients with DES IS-CTO.

RESULTS

A total of 214 patients with DES IS-CTO were enrolled: 78 patients (36.4%) treated with PCB and 136 patients (63.6%) treated with DES respectively. The median follow-up was 1160 days, and MACEs were observed in 28.2% of patients with PCB angioplasty versus 26.5% of patients with DES repeat stenting (P = 0.784), mainly driven by TLR (21.8% vs. 19.9%, P = 0.735). There was no significant difference in the risk of MACEs between the PCB group and the DES group (hazard ratio [HR] 1.25, 95% confidence interval [CI] 0.64-2.46, P = 0.512). Multivariate Cox analysis revealed that chronic kidney disease and ≥ 3 stent layers in the lesion were independent predictors of MACEs, while switching to another antiproliferative drug was an independent protective factor (all P < 0.05).

CONCLUSIONS

PCB angioplasty was an effective alternative treatment strategy for DES IS-CTO, which had similar long-term outcomes to DES repeat stenting in contemporary practice, but both were accompanied by a high rate of long-term MACEs. Improving the poor prognosis of patients with DES IS-CTO remains a challenge.

Cardiac intensive care unit: where we are in 2023

Cardiac intensive care has been a constantly evolving area of research and innovation since the beginning of the 21st century. The story began in 1961 with Desmond Julian's pioneering creation of a coronary intensive care unit to improve the prognosis of patients with myocardial infarction, considered the major cause of death in the world. These units have continued to progress over time, with the introduction of new therapeutic means such as fibrinolysis, invasive hemodynamic monitoring using the Swan-Ganz catheter, and mechanical circulatory assistance, with significant advances in percutaneous interventional coronary and structural procedures. Since acute cardiovascular disease is not limited to the management of acute coronary syndromes and includes other emergencies such as severe arrhythmias, acute heart failure, cardiogenic shock, high-risk pulmonary embolism, severe conduction disorders, and post-implantation monitoring of percutaneous valves, as well as other non-cardiac emergencies, such as septic shock, severe respiratory failure, severe renal failure and the management of cardiac arrest after resuscitation, the conversion of coronary intensive care units into cardiac intensive care units represented an important priority. Today, the cardiac intensive care units (CICU) concept is widely adopted by most healthcare systems, whatever the country's level of development. The main aim of these units remains to improve the overall morbidity and mortality of acute cardiovascular diseases, but also to manage other non-cardiac disorders, such as sepsis and respiratory failure. This diversity of tasks and responsibilities has enabled us to classify these CICUs according to several levels, depending on a variety of parameters, principally the level of care delivered, the staff assigned, the equipment and technologies available, the type of research projects carried out, and the type of connections and networking developed. The European Society of Cardiology (ESC) and the American College of Cardiology (ACC) have detailed this organization in guidelines published initially in 2005 and updated in 2018, with the aim of harmonizing the structure, organization, and care offered by the various CICUs. In this state-of-the-art report, we review the history of the CICUs from the creation of the very first unit in 1968 to the discussion of their current perspectives, with the main objective of knowing what the CICUs will have become by 2023.

Prevalence, predictors, and management for balloon uncrossable or undilatable lesions in patients undergoing percutaneous coronary intervention with in-stent restenosis chronic total occlusion

Background

Percutaneous coronary intervention for in-stent restenosis (ISR) chronic total occlusion (CTO) has been a great challenge. There are occasions when the balloon is uncrossable or undilatable (BUs) even though the guidewire has passed, leading to failure of the procedure. Few studies have focused on the incidence, predictors, and management of BUs during ISR-CTO intervention.

Methods

Patients with ISR-CTO were recruited consecutively between January 2017 and January 2022 and divided into two groups based on the presence of BUs. The clinical data of the two groups (BUs group and non-BUs group) were retrospectively analyzed and compared to explore the predictors and clinical management strategies of BUs.

Results

A total of 218 patients with ISR-CTO were included in this study, 23.9% (52/218) of whom had BUs. The percentage of ostial stents, stent length, CTO length, the presence of proximal cap ambiguity, moderate to severe calcification, moderate to severe tortuosity, and J-CTO score were higher in the BUs group than in the non-BUs group (p < 0.05). The technical success rate and the procedural success rate were lower in the BUs group than in the non-BUs group (p < 0.05). Multivariable logistic regression analysis showed that ostial stents (OR: 2.011, 95% CI: 1.112-3.921, p = 0.031), the presence of moderate to severe calcification (OR: 3.383, 95% CI: 1.628-5.921, p = 0.024) and moderate to severe tortuosity (OR: 4.816, 95% CI: 2.038-7.772, p = 0.033) were independent predictors of BUs.

Conclusion

The initial rate of BUs in ISR-CTO was 23.9%. Ostial stents, presence of moderate to severe calcification, and moderate to severe tortuosity were independent predictors of BUs.

Coronary In-Stent Restenosis: JACC State-of-the-Art Review

The introduction and subsequent iterations of drug-eluting stent technologies have substantially improved the efficacy and safety of percutaneous coronary interventions. However, the incidence of in-stent restenosis (ISR) and the resultant need for repeated revascularization still occur at a rate of 1%-2% per year. Given that millions of drug-eluting stents are implanted each year around the globe, ISR can be considered as a pathologic entity of public health significance. The mechanisms of ISR are multifactorial. Since the first description of the angiographic patterns of ISR, the advent of intracoronary imaging has further elucidated the mechanisms and patterns of ISR. The armamentarium and treatment strategies of ISR have also evolved over time. Currently, an individualized approach using intracoronary imaging to characterize the underlying substrate of ISR is recommended. In this paper, we comprehensively reviewed the incidence, mechanisms, and imaging characterization of ISR and propose a contemporary treatment algorithm.

Management of in-stent restenosis

In-stent restenosis (ISR) remains the most common cause of stent failure after percutaneous coronary intervention (PCI). Recent data suggest that ISR-PCI accounts for 5-10% of all PCI procedures performed in current clinical practice. This State-of-the-Art review will primarily focus on the management of ISR but will begin by briefly discussing diagnosis and classification. We then move on to detail the evidence base underpinning the various therapeutic strategies for ISR before finishing with a proposed ISR management algorithm based on current scientific data.

Association between LDL/HDL ratio and in-stent restenosis in patients with acute coronary syndrome after stent implantation

Background: The relationship between LDL/HDL ratio and in-stent restenosis in acute coronary syndrome is unknown. Methods: This observational study recruited 256 patients with acute coronary syndrome who were being followed up by angiography after stenting. The patients were divided into in-stent restenosis (59%) and non-in-stent restenosis (41%) groups. Three stepwise multivariate logistic regression models and area under the curve were conducted to determine the role of LDL/HDL ratio in predicting in-stent restenosis. Results: LDL/HDL ratio was significantly associated with risk of in-stent restenosis (odds ratio ≈ 2.00; p < 0.05 for all) in three models. A good predictive performance of LDL/HDL ratio on in-stent restenosis was found with an area under the curve of 0.74. Conclusion: LDL/HDL ratio was independently associated with the risk of in-stent restenosis in acute coronary syndrome.

Contemporary Issues in Chronic Total Occlusion Percutaneous Coronary Intervention

Remarkable progress has been achieved in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in recent years, with refinement of the indications and technical aspects of the procedure, imaging, and complication management. Randomized controlled trials and rigorous prospective registries have provided high-quality data on the benefits and risks of CTO PCI. Global collaboration has led to an agreement on nomenclature, indications, endpoint definition, and principles of clinical trial design that have been distilled in global consensus documents such as the CTO Academic Research Consortium. Increased use of preprocedural coronary computed tomography angiography and intraprocedural intravascular imaging, as well as development of novel techniques and structured CTO crossing and complication management algorithms, allow a systematic, stepwise approach to this difficult lesion subset. This state-of-the-art review provides a comprehensive discussion about the most recent developments in the indications, preprocedural planning, technical aspects, complication management, and future directions of CTO PCI.

Effects of Tirofiban and Nicorandil on Effective Reperfusion and the Levels of IL-4 and sICAM-1 After PCI for Chronic Coronary Total Occlusion

Aim: The effects of tirofiban combined with nicorandil on effective reperfusion, and the levels of interleukin-4 (IL-4)and soluble intercellular adhesion molecule-1 (sICAM-1) after percutaneous coronary intervention (PCI) for chronic coronary total occlusion (CTO) were investigated.Method: From January 1, 2017, to June 31, 2019, a total of 40 patients with CTO receiving PCI in Shandong QianfoshanHospital were randomly divided into a control group (treated with single tirofiban) and a cocktail group (treated with nicorandil combined with tirofiban). Effective reperfusion was compared between groups. In addition, differences in coronary serum IL-4 and sICAM-1 levels before and 10 min after the operation were compared between groups, and the incidence rates of adverse reactions were observed. Finally, patient follow-up occurred at 1 month and 6 months, and the total incidence rates of adverse cardiac events in both groups were assessed.Results: The levels of IL-4 and sICAM-1 in the cocktail group significantly decreased after the operation (P < 0.05).In addition, after the operation, significantly greater decreases in the IL-4 and sICAM-1 levels were observed in thecocktail group than the control group (P < 0.05). The Seattle Angina Scale (SAQ) score of the cocktail group, comparedwith the control group, showed a significant improvement after vessel opening in the patients with CTO. At the 1-month follow-up, the SAQ score of the cocktail group, compared with the control group, indicated further improvements in terms of angina attack frequency. No significant differences were observed in the incidence rates of adverse reactions between groups (P > 0.05).Conclusion: The treatment of patients with CTO undergoing PCI with nicorandil and tirofiban alleviated the inflammatoryresponse, improved the SAQ scores, and decreased the occurrence of angina pectoris in patients. Moreover, this treatment is safe and reliable, and has important clinical significance.