Distal embolic protection during percutaneous coronary intervention in patients with acute coronary syndromes: The RUBY study

Ubiquitous Nature of Distal Athero/Thromboembolic Events during Lower Extremity Atherectomy Procedures Involving the Superficial Femoral Artery

This study aims to evaluate occurrence, size, composition, and clinical significance of embolized debris during superficial femoral artery atherectomy using all commercially available atherectomy devices. Distal athero/thromboembolic events (DATE) are a universal phenomenon in lower extremity atherectomy procedures (LEAPs) due to the sheer volume of atheroma and the thrombus burden in peripheral arterial disease. Some of these events can be clinically significant. We prospectively gathered clinical and histopathological data on all commercially available atherectomy devices by using embolic protection devices (EPD) in every case. After intervention, the contents of EPD were examined both microscopically and macroscopically. Data from 59 consecutive patients undergoing LEAP were analyzed. DATE occurred 100% of the time. The composition of particulate debris varied with the device used. Grossly visible agglomerated debris was captured by the filter in the majority of patients 54/59 (91.5%). Clinically significant debris, defined by the Preventing Lower Extremity Distal Embolization Using Embolic Filter Protection registry as particle diameter > 0.2 cm, was found in 33/59 (56%) patients. The size of captured debris particles ranged from 0.1 to 2.4 mm. While DATE occurred in all patients, clinically significant DATE occurred in 56% patients undergoing LEAP regardless of the atherectomy device. In spite of a large fraction of the clinically significant debris occurring on our routine dual antiplatelet regimen, no patient suffered an amputation. Although DATE was prevented by the use of EPD in all 59 cases, more data are needed to determine whether the use of EPD translates into a long-term clinical benefit. Use of EPD and optimal thromboprophylaxis should be considered in patients, especially in the setting of compromised distal runoff.

Coronary plaque characteristics that indicate distal embolization during percutaneous coronary intervention in patients with stable angina-virtual histology intravascular ultrasound study

Distal embolization (DE) is a serious complication of percutaneous coronary intervention (PCI) in patients with stable angina. The purpose of this study was to evaluate the coronary plaque characteristics that indicate DE during PCI in patients with stable angina using virtual histology intravascular ultrasound (VH-IVUS). Three hundred and sixty-four consecutive stable angina patients who underwent PCI were enrolled in this study. The patients were divided into two groups as follows: patients exhibiting DE (DE group, n = 10) and patients without DE (non-DE group, n = 354). Coronary plaque compositions were assessed by VH-IVUS. The fibro-fatty (FF) ratio (28 ± 17 vs. 11 ± 9 %, p < 0.0001) was higher in the DE group compared with the non-DE group. The best cut-off value of FF ratio for prediction of DE was 20 %, with a sensitivity of 0.80 and a specificity of 0.81 (odds ratio; 17.1, 95 % confidence interval 3.56-82.5, p = 0.0004). Coronary plaques with a high FF ratio may be the predictor of indicating DE in patients with stable angina during PCI.

Comparison of embolic load in femoropopliteal interventions: percutaneous transluminal angioplasty versus stenting

PURPOSE

To compare the incidence of distal emboli occurring during percutaneous transluminal angioplasty (PTA) and primary stent on the superficial femoral artery (SFA) METHODS: A total of 50 consecutive patients were entered in a prospective, randomized trial. Inclusion criteria were the presence of symptomatic limb ischemia due to stenosis or occlusion of the SFA. An embolic protection device was placed in the popliteal artery. The patients were then randomly assigned to undergo primary stent implantation or PTA. The filters were retrieved and sent for histologic examination.

RESULTS

Stenting in the SFA produced more emboli (1.44 mm(3)) than PTA (0.772 mm(3)), P = .031. Reanalyzing the patients according to actual treatment performed, volume of debris in the stent group was 1.271 mm(3) and in the PTA group was 0.191 mm(3), P = .00087.

CONCLUSION

Volume of embolized material during endovascular interventions in the SFA-above-knee popliteal artery is higher when a stent is used.

Use of the TIMI frame count in the assessment of coronary artery blood flow and microvascular function over the past 15 years

Since its introduction, the TIMI frame count method has contributed to the understanding of the pathophysiology of coronary artery disease. In this article, the evolution of the TFC method and its applicability in the assessment of various therapeutic modalities are described.