SCAI Expert Consensus Statement on the Management of Calcified Coronary Lesions

Acute Stent Thrombosis Following Reprotrusion of a Calcified Nodule in the Left Main Coronary Artery

Calcified nodule (CN) is a high-risk phenotype of coronary artery calcification that causes in-stent restenosis frequently. Stent thrombosis (ST) is a critical complication following percutaneous coronary intervention, and its onset is associated with severely calcified lesions. However, the association between CN and ST remains unclear. Moreover, while reprotrusion of CNs through the stent strut is not uncommon immediately after stenting, the risk of ST associated with this acute reprotrusion of CNs is not well recognized. We present a case of a 70-year-old female who developed acute ST following reprotrusion of a CN in the left main coronary artery. After the successful stenting to a large CN, a prominent acute protrusion occurred, followed by the acute occlusion of the implanted stent due to massive thrombus formation. This case highlights the importance of careful monitoring for thrombus formation even after good stent expansion, especially when large acute reprotrusion of CNs is observed.

Multimodal Intravascular Imaging of the Vulnerable Coronary Plaque

Vulnerable coronary plaques are atherosclerotic lesions which, due to their specific phenotype, are prone to plaque rupture and to cause acute coronary syndromes, with subsequent relevant morbidity and mortality. Strategies to break the chain link between plaque vulnerability and adverse clinical events include optimized pharmacologic prevention and potentially also preemptive percutaneous coronary interventions (previously defined as "plaque sealing" or "plaque passivation"). Various morphologic features of the vulnerable plaques have been described, including aspects regarding the large necrotic lipid content, the thin fibrous cap, the presence and extent of the presence of calcifications with small size and calcification angle, and as well as the large macrophage infiltration within the plaque. The detection of these features of plaque vulnerability is possible with intravascular imaging modalities such as intravascular ultrasound (IVUS), near-infrared spectroscopy (NIRS), and optical coherence tomography (OCT). This review explores the peculiarities of these three imaging modalities for the detection of vulnerable coronary plaque features.

SCAI Expert Consensus Statement on the Management of Patients With STEMI Referred for Primary PCI

ST-elevation myocardial infarction (STEMI) remains a leading cause of morbidity and mortality in the United States. Timely reperfusion with primary percutaneous coronary intervention is associated with improved outcomes. The Society for Cardiovascular Angiography & Interventions puts forth this expert consensus document regarding best practices for cardiac catheterization laboratory team readiness, arterial access with an algorithm to help determine proper arterial access in STEMI, and diagnostic angiography. This consensus statement highlights the strengths and limitations of various diagnostic and therapeutic interventions to access and treat a patient with STEMI in the catheterization laboratory, reviews different options to manage large thrombus burden during STEMI, and reviews the management of STEMI across the spectrum of various anatomical and clinical circumstances.

In-stent restenosis caused by a reprotruding calcified nodule and stent fracture in the hinged coronary artery

Calcified nodules (CNs) cause in-stent restenosis (ISR) frequently. Although reprotrusion of CNs through stent struts is one of the mechanisms of ISR, the process of this phenomenon has not been understood. Furthermore, little is known about stent fracture (SF) occurring at the site of CNs. We are presenting a case of an 82-year-old male who developed early ISR due to the combination of an in-stent CN and SF in the hinged right coronary artery. The process of progression of the in-stent CN was recorded sequentially with angiography and intravascular ultrasound (IVUS). IVUS from the fulcrum of hinge motion revealed the repetitive protruding movement of the CN into the stent lumen.

Challenges and Advances in Interventional Cardiology for Coronary Artery Disease Management

The development of percutaneous coronary intervention (PCI) has been one of the greatest advances in cardiology and has changed clinical practice for patients with coronary artery disease (CAD). Despite continuous improvements in operators' experience, techniques, and the development of new-generation devices, significant challenges remain in improving the efficacy of PCI, including calcification, bifurcation, multivascular disease, stent restenosis, and stent thrombosis, among others. The present review aims to provide an overview of the current status of knowledge of endovascular revascularization in CAD, including relevant trials, therapeutic strategies, and new technologies addressing particular scenarios that can impact the prognosis of this vulnerable population.