December 2019 Table of Contents

Original Contributions

Coronary Artery Disease

Dedicated Bifurcation Stents for Coronary Bifurcation Lesions: A Systematic Review and Meta-Analysis of Randomized-Controlled Trials

Mohamed O. Mohamed, MBBCh, MRCP(UK);  Mamas A. Mamas, BMBCh, DPhil, MRCP;  Vinayak Nagaraja, MBBS, MS, MMed (ClinEpi), FRACP;  M. Chadi Alraies, MD;  Pablo Lamelas, MD, MSc;  Nikolaos Tzemos, MD;  Diana Ayan, MSc;  Shahar Lavi, MD;  Rodrigo Bagur, MD, PhD

Percutaneous coronary intervention (PCI) of coronary bifurcation lesions (CBL) remains a challenge in contemporary practice due to the procedural and technical difficulties involved. We sought to review the current evidence on the safety and clinical outcomes of dedicated bifurcation stent (DBS) implantation in comparison with established treatment strategies for CBL-PCI. We therefore conducted a comprehensive search to identify randomized control trials reporting 1-year clinical and angiographic outcomes of patients undergoing CBL-PCI with DBS vs conventional CBL-PCI strategies. A total of 5 RCTs comprising 1249 participants met the inclusion criteria. The present analysis suggests that CBL-PCI with DBS may be associated with similar 1-year clinical and angiographic outcomes compared with conventional CBL-PCI strategies. However, the low quality of evidence and limited follow-up warrant further studies.

J INVASIVE CARDIOL 2019;31(12):E344-E355.

Coronary Artery Disease

Primary Patency With Stenting Versus Balloon Angioplasty for Arteriovenous Graft Failure: A Systematic Review and Meta-Analysis

Konstantinos Marmagkiolis, MD*;  Cezar Iliescu, MD*;  Mohan Mallikarjuna Rao Edupuganti, MD; Marwan Saad, MD, PhD;  Konstantinos Dean Boudoulas, MD;  Akash Gupta;  Nikolaos Lontos, MD;  Mehmet Cilingiroglu, MD       *Joint first authors

End-stage renal disease rates and the need for hemodialysis are increasing worldwide. Arteriovenous grafts (AVGs) remain a common dialysis access site. Several techniques have been previously suggested to restore and preserve AVG patency. We evaluated the efficacy of advanced stent technology in the management of failing AVGs by examining the literature from January 2006 to December 2017. Studies comparing the primary patency rates with stent placement vs balloon angioplasty alone in patients with failed AVGs were included. Seven studies with a total of 1109 patients met the inclusion criteria. The mean graft age was 2.89 years in the stent group and 3.29 years in the balloon angioplasty group. Stent placement was associated with improved primary patency rates compared with balloon angioplasty alone at 3- and 6-month follow-up. The primary patency rates remained favorable with stent placement at 12- and 24-month follow-up compared with balloon angioplasty alone. 

J INVASIVE CARDIOL 2019;31(12):E356-E361.

Coronary Artery Disease

The Deep-Wire Crossing Technique: A Novel Method for Treating Balloon-Uncrossable Lesions

Dmitrii Khelimskii, MD;  Aram Badoyan, MD;  Oleg Krestyaninov, MD, PhD

Inability to cross the lesion with a balloon is the second-most common cause of technical failure, with the most common cause being the inability to cross with the wire. We propose a new, effective method for treating balloon-uncrossable lesions, called the “deep-wire crossing” (DWC) technique. The aim of this study was to evaluate the procedural outcomes of the DWC technique for treating balloon-uncrossable lesions. From 2017 to 2018, a total of 95 patients with balloon-uncrossable lesions were treated using the DWC technique at our center. Successful DWC technique was achieved in 74 patients (77.9%). In-hospital MACE rate was 3.2%. Coronary perforation required pericardiocentesis in only 1 patient. Periprocedural myocardial infarction occurred in 1 patient and was managed conservatively; urgent revascularization was required for 1 patient. Our experience with the DWC technique demonstrated that it can be a viable option for treating balloon-uncrossable lesions, and operators should become familiar with it.

J INVASIVE CARDIOL 2019;31(12):E362-E368.

Coronary Artery Disease

Relationship Between Platelet Reactivity and Periprocedural Myonecrosis in Patients Undergoing Percutaneous Coronary Intervention

Sun Young Choi, PhD;  Moo Hyun Kim, MD;  Kyung-Yae Hyun, PhD;  Michael S. Lee, MD

The impact of platelet reactivity on periprocedural myonecrosis (PMN) in East Asian patients with stable ischemic heart disease or non-ST elevation acute coronary syndrome (ACS) undergoing PCI is unclear. We enrolled 256 patients with normal high-sensitivity troponin I levels who underwent PCI for stable ischemic heart disease or non-ST elevation ACS. Residual platelet reactivity was assessed by VerifyNow point-of-care P2Y12 assay before PCI and at 18-24 hours following PCI. The rate of PMN was 55.9% and was significantly higher for pre-PCI and post-PCI platelet reactivity unit (PRU) values in the fourth quartile compared with those in the first quartile. The rate of PMN was higher in patients with high platelet reactivity (HPR), regardless of the criteria used. Multivariable analysis revealed that pre-PCI HPR was an independent predictor of increased risk of PMN. Achievement of optimal platelet reactivity may decrease the risk of PMN.

J INVASIVE CARDIOL 2019;31(12):E369-E375.

Plaque Modification

Tips and Tricks for Rotational Atherectomy

Gianmarco Iannopollo, MD*;  Francesco Gallo, MD*;  Antonio Mangieri, MD; Alessandra Laricchia, MD;  Andrea Erriquez, MD;  Georgios Tzanis, MD, PhD;  Antonio Colombo, MD;  Francesco Giannini, MD         *Joint first authors

The use of debulking devices improved in the last few years, due to the expanding indications to percutaneous coronary angioplasty, involving an elevated number of coronary stenoses with heavy calcification. Rotational atherectomy has become one of the most used devices in this challenging scenario. The aim of this review is to analyze the components and the use of the Rotablator System (Boston Scientific) and to better understand helpful tips and tricks in order to face the most common complications occurring during the procedure.

J INVASIVE CARDIOL 2019;31(12):E376-E383.

Chronic Total Occlusion

Evaluation of Chronic Total Occlusion Recanalization: A Physiologic Assessment Perspective by Dynamic Exercise Tests

Georgios Tzanis, MD, PhD;  Francesco Giannini, MD;  Serafim Nanas, MD; PhDAntonio Colombo, MD

Chronic total occlusion (CTO) recanalization and its effects on left ventricular function and patient outcomes has intrigued the interventional community over the last several years. Now that there is plenty of knowledge and experience on “how to treat” the lesion, another scientific effort should focus on “when to treat” the lesion. Physiologic assessment has altered the way we treat coronary artery stenosis to improve cardiovascular outcomes. We tend to assess the effects of CTO recanalization by evaluating resting parameters, although the effects of ischemia and concomitant left ventricular dysfunction manifest mainly during exercise. Physiologic assessment in CTOs by implementation of cardiopulmonary exercise testing, in order to indirectly assess the physiological effect of exercise-induced left ventricular dysfunction, could represent a novel approach to monitor the effects of CTO recanalization and hopefully to identify the responders after recanalization.

J INVASIVE CARDIOL 2019;31(12):E384-E386.

Coronary Artery Disease

Periprocedural Bivalirudin Versus Unfractionated Heparin During Percutaneous Coronary Intervention Following Fibrinolysis for ST-Segment Elevation Myocardial Infarction

Mohammed K. Rashid, MD;  Kuljit Singh, MD, PhD;  Jordan Bernick, MSc;  George A. Wells, PhD;  Benjamin Hibbert, MD;  Juan Russo, MD;  Derek Y. So, MD;  Michel R. Le May, MD; on behalf of the CAPITAL PCI Group

A pharmacoinvasive strategy for STEMI management combines the use of fibrinolysis with the routine transfer to coronary angiography, with PCI if needed. This method reduces the risk of MACE compared with fibrinolysis alone; however, it is associated with higher bleeding risk. We sought to assess the bivalirudin compared with unfractionated heparin (UFH) used during PCI as part of a pharmacoinvasive strategy. We identified 200 consecutive patients (123 patients in the bivalirudin group and 77 patients in the UFH group). The periprocedural use of bivalirudin vs UFH was associated with similar rates of MACE and bleeding. Given the expense of bivalirudin and lack of demonstrable clinical superiority, UFH remains the first-line periprocedural anticoagulant in a pharmacoinvasive strategy. 

J INVASIVE CARDIOL 2019;31(12):E387-E391.

Clinical Images 

Multiple Coronary Artery Aneurysms in Alport Syndrome

Johann Auer, MD and Gudrun Lamm

Alport syndrome (AS) is a genetic disorder characterized by abnormal alpha chains of type IV collagen in multiple organs including the kidney, cochlea, cornea, lens, and retina. Aortic disease including dissection and aneurysm has been described with AS. We report the first case of multiple coronary aneurysms as a manifestation of AS. 

J INVASIVE CARDIOL 2019;31(12):E392-E393.

Clinical Images

Single Sheath for Dual Injection Prior to CTO Intervention

Eleftherios Kontopodis, MD;  Nikolaos Oikonomidis, MD;  Ioannis Tsiafoutis, MD;  Efstathios Lazaris, MD;  Michael Koutouzis, MD, PhD

To our knowledge, this is the first reported case of a dual injection using a single sheath approach, in order to evaluate a CTO and plan a future intervention. 

J INVASIVE CARDIOL 2019;31(12):E394.

Clinical Images

Longitudinal Stent Deformation: Precise Diagnosis With Optical Coherence Tomography

Harold Hernández-Matamoros, MD;  Ariana Gonzálvez-Garcia, MD;  Raúl Moreno-Gómez, MD, PhD;  Santiago Jiménez-Valero, MD

Longitudinal stent deformation (LSD) is a recognized complication of coronary angioplasty; however, it is difficult to detect angiographically. This case illustrates the value of OCT to identify and correctly diagnose LSD.

J INVASIVE CARDIOL 2019;31(12):E395.

Clinical Images

Acquired Coronary Fenestration

Abdul Moiz Hafiz, MD;  Mary Perras, MS, ANP;  Nikolaos Kakouros, MBBS, PhD

OCT in a 74-year-old woman highlights how an angiographic coronary fenestration can be acquired through calcific nodule atherosclerosis in the coronary arteries. We demonstrate how tandem anatomic and physiologic assessment can be used to diagnose, functionally evaluate, and effectively treat this rare finding.

J INVASIVE CARDIOL 2019;31(12):E396.

Clinical Images

Reverse-Loop Technique for Percutaneous Transvenous Mitral Commissurotomy in a Patient With Huge Left Atrium  

Rajesh Vijayvergiya, MD;  Sudhanshu Budhakoty, MD;  Ganesh Kasinadhuni, MD;  Kewal Kanabar, MD

A 34-year-old man was referred for percutaneous transvenous mitral commissurotomy (PTMC); he had undergone 2 PTMC attempts at another institute, but both attempts failed because of inability to cross the mitral valve with the balloon. We present an alternative reverse-loop technique for PTMC in patients with large left atrium. 

J INVASIVE CARDIOL 2019;31(12):E397.

Clinical Images

Coronary Guidewire Fracture Into a Radial Artery Loop: A New Complication in the Transradial Era?

Giuseppe Talanas, MD;  Roberta Siciliano, MD;  Guido Parodi, MD; PhD

To date, complete fracture of a coronary wire into a radial artery loop has never been reported. We describe the occurrence of a new complication in the transradial intervention era. 

J INVASIVE CARDIOL 2019;31(12):E398.