Although primary percutaneous coronary intervention (PCI) has been proven to be superior to thrombolytic therapy for the treatment of acute ST-elevation myocardial infarction (STEMI),^1–3 the latter approach is still widely practiced due to reasons such as unavailability of experienced operators or long transport time to a dedicated angioplasty center. Failed reperfusion of the occluded coronary artery after thrombolysis occurs in up to 30% of the patients and is associated with high mortality.⁴ Failed thrombolysis manifests as unsolved chest pain, persistent ST-segment elevation in electrocardiogram (ECG), hemodynamic compromise or a combination of all. Performing PCI in patients after failed thrombolytic therapy, known as rescue PCI, is an available salvage therapy.

Clopidogrel is an oral antiplatelet agent which selectively and irreversibly inhibits the platelet adenosine 5'-diphosphate (ADP) receptor. Antiplatelet effect is synergistic when administered with aspirin. Dual antiplatelet therapy with aspirin and clopidogrel is associated with a low incidence of ischemic events in patients undergoing percutaneous coronary intervention (PCI).¹ Earlier studies have used a loading dose of 300 mg before PCI,² but a subsequent registry of 864 patients demonstrated a high loading dose of 600 mg of clopidogrel given within 2–4 hours before PCI to be safe and produced a more favorable clinical outcome.³ High dose-loading with 600 mg of clopidogrel at least 2 hours before PCI was studied in the large Intracoronary Stenting and Antithrombotic Regimen-Rapid Early Action for Coronary Treatment (ISAR REACT) trial and also in the ISAR-COOL studies.^4,5

Despite several studies showing an advantage of early treatment with clopidogrel in the patient presenting with acute coronary syndrome, or prior to percutaneous coronary intervention (PCI),^1–6 this treatment is frequently not given early enough to achieve maximum benefit. In the United States, PCI is usually applied as an ad hoc procedure at the same time as the cardiac catheterization. Due to concerns regarding increased bleeding risk from clopidogrel at the time of possible coronary artery bypass graft surgery, it is often not administered early, but is witheld until after the coronary anatomy is clarified in case the patient ends up being referred for surgery. Whether this possible bleeding risk justifies withholding clopidogrel prior to cardiac catheterization (with attendant ad hoc angioplasty) remains controversial.

Ostial atherosclerotic lesions constitute a distinct substrate for percutaneous interventions, as they differ from the other lesion sites in management strategies and in clinical outcomes. Since the lesions are more likely fibrotic and calcific, lesion modification techniques are often required prior to stent implantation to achieve a good luminal area after stenting. High-pressure dilatation and debulking techniques such as atherectomy, rotablation and cutting balloon angioplasty¹ are sometimes used to modify the lesion morphology. As coronary stenting has shown to improve the early outcome in ostial lesions^2,3 that were traditionally considered best suitable for coronary artery by pass grafting (CABG), more and more ostial lesion susbsets are being treated with percutaneous methods.

This prospective observational study examines the use of sirolimus-eluting stents (SES) for the treatment of atherosclerotic ostial lesions.¹ Ostial lesions that involve the junction of the aorta and the origin of the right coronary artery, left main stem or a saphenous vein graft are called aorto-ostial. The other main type of ostial lesion occurs at the origin of the left anterior descending artery (LAD) or the left circumflex artery (LCX) arising from the bifurcation of the distal left main stem.
The location of ostial lesions makes them difficult to treat by percutaneous coronary intervention (PCI). In those lesions involving the origin of the LAD or LCX, accurate stent positioning to avoid stent protrusion into the left main stem remains challenging. In aorto-ostial lesions, stent placement to cover the ostium without stent protrusion into the aorta requires fine manipulation of the guide catheter and stent.

Coronary interventions of non-aorto ostial stenoses remain a challenging task with a high rate of procedural complications and restenosis. The lack of efficacy of conventional balloon angioplasty in non-aorto ostial coronary intervention has been attributed to the high incidence of vessel recoil, resulting in suboptimal residual stenosis,¹ and this leads to a higher restenosis rate as documented in the literature.² Rotational atherectomy with the Rotablator system (Boston Scientific, Northwest Technology Center, Redmond, Washington) has been previously reported to be effective in treating ostial stenoses, but the restenosis rates are less than acceptable.³ Recently, coronary stent implantation has been routinely done during angioplasty to reduce procedural complications and restenosis. Coronary stenting after rotational atherectomy (rotastent) for non-aorto ostial stenoses may be associated with excellent long-term outcomes.

Percutaneous coronary intervention (PCI) on thrombus-containing lesions represents a clinical challenge to the interventional cardiologist, since thrombus has been identified as a predictor of adverse outcome.^1,2 While attempting to reestablish coronary perfusion, PCI of thrombus-laden native coronary arteries and bypass saphenous venous grafts can lead to distal embolization.3 Distal embolization of thrombus, fibrin content, and other atherosclerotic plaque particulate matter can lead to flow limiting microvascular obstruction, which may result in the no-reflow phenomenon, abrupt closure, periprocedural myocardial infarction, emergent coronary artery bypass graft surgery, and death.^2,4–6

Percutaneous treatment of patients with a visible intracoronary thrombus has been recognized as a procedure associated with higher risk for complications. For patients with intracoronary thrombus in the stent era, the potentially worse outcome associated with stent placement as compared to balloon angioplasty elevated the significance of how best to approach this important scenario. Focus has centered on the interventionalist’s ability to establish normal antegrade flow in the coronary artery and to minimize how the presence of thrombus interferes with this process (aptly termed slow or no-reflow).

Patients with diabetes mellitus have higher adverse event rates^1–4 and a higher risk of restenosis following percutaneous coronary intervention (PCI) compared to non-diabetic patients.^5–10 The American College of Cardiology (ACC) and the American Heart Association (AHA) guidelines for exercise testing suggest that functional testing (FT) should not be performed routinely following PCI.¹¹ However, these guidelines leave open the possibility that routine FT may be of benefit in selected high-risk patient groups, including patients with diabetes mellitus. These recommendations are based on the assumption that routine FT will lead to earlier detection and management of restenosis, with a subsequent reduction in adverse events. Few data support the current ACC/AHA recommendations,¹² and no randomized trial has examined the utility of a routine post-PCI FT strategy in patients with diabetes.

The Prostar^® XL (Perclose, Redwood City, California) allows the femoral arterial puncture site to be closed percutaneously with two nonabsorbable sutures. The Perclose AcceleRated Ambulation and DischargE (PARADISE) trial1 showed that use of the Prostar XL device, combined with the use of hydrochloride lidocaine containing 1% epinephrine as local anesthesia to reduce blood oozing from subcutaneous tissue, was a safe and effective means to achieve hemostasis and to improve time-to-ambulation and discharge after percutaneous coronary interventions (PCI).