Chronic total occlusions (CTO) are present in up to 40% of patients with angiographically documented coronary artery disease and represent at least 10% of the target for coronary angioplasty attempts.1 However, despite improvements in angioplasty equipment — primarily guidewires — and operator skills, the success rate of CTO recanalization has reached the plateau of around 70%.¹ Recent studies^2,3 suggest that compared with unsuccessful CTO recanalization, those with successful procedures have a much better long-term outcome. In addition, the availability of drug-eluting stents would further improve the durable benefit of the successful procedure.⁴

Percutaneous therapy of total coronary occlusions is generally more challenging than the treatment of stenotic lesions. It more frequently entails the risk of irreversibly disrupting a protruding plaque, of advancing the wire through a false route, or rarely, of causing coronary perforation. Furthermore, the length of the occlusion is usually either unknown or can only be vaguely estimated during injection into the contralateral coronary artery as a result of distal opacification by collaterals. The procedural difficulty involved in treating total occlusions and the associated risks are more pronounced than treating nonocclusive lesions that are usually easier to cross.^1–3

Transradial coronary angiography (TRA) has proven to be a feasible, safe, and effective method, and steadily growing in popularity.^1,2 Furthermore, TRA carries great advantages in terms of reducing the risk of major entry-site complications, hospital staff workload and cost. Until recently, tourniquets and hemostatic compressive devices (CD) have been used routinely to induce hemostasis at the radial artery access site.³ However, tourniquets and other compressive devices carry serious disadvantages: restriction of wrist movement, necessity for prolonged application of the device, and the risk of lateral occlusion.

The article published in this issue of the Journal regarding initial experience with the SPIDER™ Embolic Protection Device (ev3 Inc., Plymouth, Minnesota) provides further evidence of the merit of these newer-generation “gizmos” in reducing complication rates of carotid stenting. The earlier generation protection devices such as the PercuSurge device (Medtronic, Inc., Minneapolis, Minnesota), the Angiogard device (Cordis Corporation, Miami, Florida), and the Accunet™ device (Guidant Corporation, Indianapolis, Indiana) all have inherent advantages and disadvantages. Certainly, those of us who performed early carotid stenting believe distal protection is vital to the procedure.

Over the past 15 years, there has been an exponential increase in the number of procedures performed in the electrophysiology (EP) laboratory. These procedures can be technically difficult with relatively long fluoroscopy times and high radiation dose exposure to patients, operators and laboratory staff.^1,2

Feasibility and short- and mid-term safety of catheter-based intravascular brachytherapy (IVBT) has been demonstrated in several clinical trials.^1–4 Moreover, randomized studies using IVBT (beta or gamma) have reported a significant reduction of restenosis, as well as intrastent neointimal proliferation in patients with in-stent restenosis (ISR) lesions.^5–7 Although the overall clinical benefit of IVBT has been sustained in long-term follow-up, it is important to note that there are few data regarding significant angiographic and intravascular ultrasonic in-stent lumen deterioration beyond the habitual 6-month analysis after the index radiation procedure, or so-called “late catch-up process” in the treatment of ISR. The aim of the present study is to compare the angiographic and intravascular ultrasound (IVUS) outcomes of patients with ISR treated with balloon angioplasty followed by IVBT at 6 and 12 months.

Methods

“The clinical impact of this phenomenon does not affect the long-term efficacy and longevity of the intracoronary radiation therapy when compared with conventional therapeutic approach.”¹
The delayed in-stent lumen loss may also be related to the significant aggressive pattern of in-stent restenosis (ISR) (diffuse-proliferative or total occlusion) in 80% of these patients. Nevertheless these elegant quantitative methods (QCA and IVUS) give us an understanding of the process involved, which may affect the long-term clinical result. In the Mehran paper, the target lesion revascularization (TLR) rate at one year after conventional treatment for these patterns of ISR went from 34.5% to 83.4%, which was related to a much higher angiographic restenosis rate than was documented in this study.²

The use of the left internal mammary artery (LIMA) to bypass the left anterior descending artery (LAD) is the “gold standard” of coronary artery revascularization. Studies have shown improved patency^1–4 and survival^3,5–9 with LIMA use.

It is unclear whether routine visualization of the LIMA prior to CABG is necessary.^10–12 Although infrequent, dissection, embolization with subsequent cerebrovascular ischemia, as well as higher contrast and radiation exposure may occur with routine LIMA visualization. On the other hand, the functional patency of the grafted LIMA may be dependent upon the absence of: 1) significant proximal subclavian artery stenosis; 2) large proximal lateral costal branches; 3) a narrow lumen LIMA diameter; or 4) an obstructive stenosis in the LIMA.

In the aging population, stroke is the most common and disabling neurological disorder, with more than 500,000 annual strokes in the United States.1 Carotid artery stenosis is a significant risk factor for stroke. Surgical treatment for carotid artery stenosis has been the traditional standard of care.² In the North American Symptomatic Carotid Endarterectomy Trial (NASCET), it was documented that carotid endarterectomy (CEA) is beneficial in reducing stroke risk in those patients with significant stenosis.^3,4 CEA has a significant perioperative morbidity and mortality rate, the risk of which depends on the skill and experience of the surgeon and staff.^3,4 Carotid artery stenting (CAS) is a nonsurgical way of unblocking the atherosclerotic carotid arteries. Embolic protection prevents particles that become dislodged during CAS from moving to the brain where they can cause stroke or death.

The superficial femoral artery (SFA) and popliteal arterial systems are among the last of the large arterial trees to be plagued by clinically excessive restenosis rates. The SFA and popliteal are difficult arteries to treat endovascularly. They are generally diffusely diseased, often occluded, and lie in an area of the body subject to substantial motion. The SFA and popliteal undergo multiple stresses including extension, contraction, compression, elongation, flexion and torsion.