Publications by authors named "Aris Karatasakis"

69 Publications

Factors Associated with Disparities in Appropriate Statin Therapy in an Outpatient Inner City Population.

Healthcare (Basel) 2020 Sep 24;8(4). Epub 2020 Sep 24.

Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA.

Lipid-lowering therapies are essential for the primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD). The aim of this study is to identify discrepancies between cholesterol management guidelines and current practice with a focus on statin treatment in an underserved population based in a large single urban medical center. Among 1042 reviewed records, we identified 464 statin-eligible patients. Age was 61.0 ± 10.4 years and 53.9% were female. Most patients were black (47.2%), followed by Hispanic (45.7%) and white (5.0%). In total, 82.1% of patients were prescribed a statin. An appropriate statin was not prescribed in 32.4% of statin-eligible patients who qualified based only on a 10-year ASCVD risk of ≥7.5%. After adjustment for gender and health insurance status, appropriate statin treatment was independently associated with age >55 years (OR = 4.59 (95% CI 1.09-16.66), = 0.026), hypertension (OR = 2.38 (95% CI 1.29-4.38), = 0.005) and chronic kidney disease (OR = 3.95 (95% CI 1.42-14.30), = 0.017). Factors independently associated with statin undertreatment were black race (OR = 0.42 (95% CI 0.23-0.77), = 0.005) and statin-eligibility based solely on an elevated 10-year ASCVD risk (OR = 0.14 (95% CI 0.07-0.25), < 0.001). Hispanic patients were more likely to be on appropriate statin therapy when compared to black patients (86.8% vs. 77.2%). Statin underprescription is seen in approximately one out of five eligible patients and is independently associated with black race, younger age, fewer comorbidities and eligibility via 10-year ASCVD risk only. Hispanic patients are more likely to be on appropriate statin therapy compared to black patients.
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http://dx.doi.org/10.3390/healthcare8040361DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7712578PMC
September 2020

A Randomized Controlled Trial of Prasugrel for Prevention of Early Saphenous Vein Graft Thrombosis.

J Invasive Cardiol 2020 Dec 22;32(12):E305-E312. Epub 2020 Sep 22.

Shuaib Abdullah, MD, Veterans Affairs North Texas Health Care System, 4500 South Lancaster, 111A, Dallas, TX 75216 USA.

Objectives: To test whether administration of prasugrel after coronary artery bypass grafting (CABG) reduces saphenous vein graft (SVG) thrombosis. Use of aspirin after CABG improves graft patency, but administration of other antiplatelet agents has yielded equivocal results.

Methods: We performed a double-blind trial randomizing patients to prasugrel or placebo after CABG at four United States centers. Almost all patients were receiving aspirin. Follow-up angiography, optical coherence tomography (OCT), intravascular ultrasound (IVUS), and near-infrared spectroscopy (NIRS) were performed at 12 months. The primary efficacy endpoint was prevalence of OCT-detected SVG thrombus. The primary safety endpoint was incidence of Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) severe bleeding.

Results: The study was stopped early due to slow enrollment after randomizing 84 patients. Mean age was 64 ± 6 years; 98% of the patients were men. Follow-up angiography was performed in 59 patients. IVUS was performed in 52 patients, OCT in 53 patients, and NIRS in 33 patients. Thrombus was identified by OCT in 56% vs 50% of patients in the prasugrel vs placebo groups, respectively (P=.78). Angiographic SVG failure occurred in 24% of patients in the prasugrel arm vs 40% in the placebo arm (P=.19). The 1-year incidence of major adverse cardiovascular events was 14.3% vs 2.4% in the prasugrel and placebo groups, respectively (P=.20), without significant differences in GUSTO severe bleeding (P=.32).

Conclusion: Early SVG failure occurred in approximately one-third of patients. Prasugrel did not decrease prevalence of SVG thrombus 12 months after CABG.
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December 2020

Temporal Trends in Chronic Total Occlusion Percutaneous Coronary Interventions: Insights From the PROGRESS-CTO Registry.

J Invasive Cardiol 2020 Apr 20;32(4):153-160. Epub 2020 Mar 20.

Background: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has significantly evolved in recent years.

Methods: We compared the clinical, angiographic, and technical characteristics, as well as procedural outcomes of CTO-PCIs in a multicenter registry between the "early era" (2012-2016) and the "current era" (2017-2019).

Results: Current era patients more often had stage III or IV angina compared with early era patients (71% vs 66%, respectively; P=.03) and were less likely to undergo ad hoc CTO-PCI (13% vs 16%, respectively; P=.04). The J-CTO score was slightly lower in the current era patients vs the early era patients (2.3 ± 1.4 vs 2.5 ± 1.3, respectively; P=.04). Use of antegrade wire escalation increased in the current era (92% vs 83% in the early era patients; P<.001) whereas use of retrograde crossing decreased (29% vs 39% in the early era; P<.001) and antegrade/ dissection re-entry decreased (23% vs 32% in the early era; P<.001). Technical success rates (85% in the current era vs 86% in the early era; P=.69) and procedural success rates (83% in the current era vs 85% in the early era; P=.15) were similar, whereas the incidence of in-hospital major cardiovascular events decreased in the current era (2% vs 3% in the early era; P=.04).

Conclusions: During recent years, ad hoc CTO-PCI decreased along with decreasing use of retrograde crossing and antegrade dissection and re-entry. Technical and procedural success rates remained stable, whereas the incidence of in-hospital MACE decreased.
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April 2020

Radial Versus Femoral Access in Chronic Total Occlusion Percutaneous Coronary Intervention.

Circ Cardiovasc Interv 2019 06 14;12(6):e007778. Epub 2019 Jun 14.

Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (M.M., J.J., M.N.B., E.S.B.).

Background Radial access (RA) is increasingly used in chronic total occlusion (CTO) percutaneous coronary intervention with encouraging results. However, there are concerns about its safety and efficacy because of higher complexity and the need for strong guide catheter support. Methods and Results We performed a systematic review and meta-analysis of all studies published through November 2018 reporting the outcomes of RA versus femoral access in CTO percutaneous coronary intervention. Outcomes included major bleeding, access-site complications, in-hospital major adverse events, and technical success. Nine observational studies with 10 590 patients (10 617 lesions) were included in the meta-analysis. CTO lesions attempted using RA had lower Japan-CTO score (2.3±1.2 versus 2.5±1.3; P<0.001). Use of RA was associated with similar technical success (78.7% versus 78.5%; odds ratio, 1.11; 95% CI, 0.94-1.31; P=0.24; I=23%), lower risk of access-site complications (0.73% versus 1.79%; odds ratio, 0.34; 95% CI, 0.22-0.51; P<0.001; I=0%) and major bleeding (0.18% versus 0.9%; odds ratio, 0.22; 95% CI, 0.10-0.45; P<0.001; I=0%), and similar risk of in-hospital adverse events and in-hospital mortality (odds ratio, 0.36; 95% CI, 0.12-1.07; P=0.07; I=0%) as compared to femoral access. Results were similar when analyzing radial-only versus any femoral access and when excluding the largest study. Conclusions As compared with femoral access, RA is used in CTO percutaneous coronary intervention of less complex lesions and is associated with fewer access-site complications and major bleeding and comparable technical success.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.118.007778DOI Listing
June 2019

Chronic total occlusion percutaneous coronary intervention failure: Learning from failure.

Catheter Cardiovasc Interv 2019 05;93(6):1039-1040

Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota.

Experienced operators can achieve high success rates in chronic total occlusion percutaneous coronary intervention. Complications remain an important cause of chronic total occlusion intervention failure. Every effort should be made to prevent them and treat them appropriately should they occur. The most common failure mechanism for antegrade cases is failure to cross the occlusion with a guidewire. For retrograde cases the causes of failure are inability to cross the collateral (one third), inability to perform reverse CART (one third), and inability to cross with a microcatheter after guidewire crossing (one third).
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http://dx.doi.org/10.1002/ccd.28274DOI Listing
May 2019

Frequency and Outcomes of Ad Hoc Versus Planned Chronic Total Occlusion Percutaneous Coronary Intervention: Multicenter Experience.

J Invasive Cardiol 2019 May 15;31(5):133-139. Epub 2019 Jan 15.

Background: For patients needing coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI), a planned, staged intervention has been recommended by experts. Ad hoc CTO-PCI, however, occurs in practice.

Methods: Observational, contemporary, multicenter, international registry. Our goals were to determine the frequency, characteristics, procedural techniques, and outcomes of patients who underwent ad hoc vs planned CTO-PCI.

Results: Among 2282 patients who underwent CTO-PCI between 2012 and 2017, 318 (14%) were ad hoc. Patients undergoing ad hoc CTO-PCI had lower J-CTO, PROGRESS CTO, and PROGRESS Complications scores. Antegrade-wire escalation was used more often in ad hoc PCI (96% vs 81%; P<.001), whereas antegrade-dissection re-entry (22% vs 32%) and retrograde approaches (14% vs 38%) were more common in planned PCI (P<.001). There was no difference in ad hoc vs planned PCI in technical (85% vs 86%) and procedural success (84% vs 84%). In-hospital major adverse cardiac events (MACE) were more common in patients who underwent planned procedures (0.6% vs 2.9%; P=.02). Multivariable analyses showed that ad hoc CTO-PCI was not associated with technical success or MACE.

Conclusions: Ad hoc CTO-PCI occurs more commonly in less complex lesions and is associated with similarly high success rates as planned CTO-PCI in lower J-CTO score lesions, suggesting that ad hoc CTO-PCI may be an acceptable option for experienced hybrid operators in carefully selected cases. Complex cases, as quantified by the J-CTO score, have a higher in-hospital MACE rate and should preferably be performed following proper planning and preparation.
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May 2019

In-Hospital Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention in Patients With Chronic Kidney Disease.

J Invasive Cardiol 2018 11 15;30(11):E113-E121. Epub 2018 Sep 15.

Minneapolis Heart Institute, 920 E. 28th Street #300, Minneapolis, MN 55407 USA.

Objectives: The effect of chronic kidney disease (CKD) on in-hospital outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study.

Methods: We evaluated the prevalence of CKD and its impact on CTO-PCI outcomes in 1979 patients who underwent 2040 procedures between 2012 and 2017 at 18 centers. CKD was defined as preprocedural estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m².

Results: Compared with patients without CKD (n = 1444; 73%), patients with CKD (n = 535; 27%) had more comorbidities (hypertension, diabetes mellitus, heart failure, peripheral arterial disease, prior myocardial infarction, PCI, coronary artery bypass graft surgery, and stroke), and more severe calcification and proximal vessel tortuosity. Patients with and without CKD had similar technical success rates (84% vs 86%; P=.49) and procedural success rates (83% vs 84%; P=.44). Patients with CKD had higher in-hospital mortality rate (1.9% vs 0.3%; P<.001) and in-hospital major adverse cardiovascular event (MACE) rate (4.3% vs 2.2%; P<.01). In-hospital mortality and MACE rates increased with decreasing eGFR levels (P=.03). In multivariate analysis, an independent association was observed between CKD and in-hospital mortality (adjusted odd ratio, 4.4; 95% confidence interval, 1.2-16.0; P=.02), but not overall MACE (adjusted odds ratio, 1.4; 95% confidence interval, 0.8-2.7; P=.28).

Conclusions: CKD is common among patients undergoing CTO-PCI. High success rates can be achieved in patients with decreased glomerular filtration rate, but CKD may be associated with higher in-hospital mortality.
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November 2018

Shields and garb for decreasing radiation exposure in the cath lab.

Expert Rev Med Devices 2018 Sep 20;15(9):683-688. Epub 2018 Aug 20.

b Minneapolis Heart Institute , Minneapolis , MN , USA.

Introduction: Decreasing radiation exposure of the cardiac catheterization laboratory staff is critical for minimizing radiation-related adverse outcomes and can be accomplished by decreasing patient dose and by shielding. Areas covered: protection from ionizing radiation can be achieved with architectural, equipment-mounted, and disposable shields, as well as with personal protective equipment. Expert commentary: Radiation protective aprons are the most commonly used personal protective equipment and provide robust radiation protection but can cause musculoskeletal strain. Use of a thyroid collar is recommended, as is use of 'shin guards', lead glasses and radioprotective caps, although the efficacy of the latter is being debated. Alternatives to lead aprons include shielding suspended from the ceiling and robotic percutaneous coronary intervention. Radiation protective gloves and cream can be used to protect the hands, but the best protection is to not directly expose them to the radiation beam. Devices that provide real time operator radiation dose monitoring can enable real time adjustments in positioning and shield placement, reducing radiation dose. Shielding can be achieved with architectural, equipment-mounted, and disposable shields. Equipment-mounted shielding includes ceiling-suspended shields, table-suspended drapes, and radioabsorbent drapes. Personal protective equipment and shielding should be consistently and judiciously utilized by all catheterization laboratory personnel.
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http://dx.doi.org/10.1080/17434440.2018.1510771DOI Listing
September 2018

Radiation Safety in the Catheterization Laboratory: Current Perspectives and Practices.

J Invasive Cardiol 2018 08 15;30(8):296-300. Epub 2018 Jun 15.

Minneapolis Heart Institute, 920 E. 28th Street, #300, Minneapolis, MN 55407 USA.

Background: There is great variability in radiation safety practices in cardiac catheterization laboratories around the world.

Methods: We performed an international online survey on radiation safety including interventional cardiologists, electrophysiologists, interventional radiologists, and vascular surgeons.

Results: A total of 570 responses were received from various geographic locations, including the United States (77.9%), Asia (7.9%), Europe (6.8%), Canada (2.8%), and Mexico and Central America (2.1%). Most respondents (73%) were interventional cardiologists and 23% were electrophysiologists, with 14.4 ± 10.2 years in practice. Most respondents (75%) were not aware of their radiation dose during the past year and 21.2% had never attended a radiation safety course; 58.9% are "somewhat worried" and 31.5% are "very worried" about chronic radiation exposure. Back pain due to lead use was reported by 43.0% and radiation-related health complications including cataracts and malignancies were reported by 6.3%. Only 37.5% of respondents had an established radiation dose threshold for initiating patient follow-up. When comparing United States operators with the other respondents, the former were more likely to attend radiation safety courses (P<.001), wear dosimeters (P<.001), know their annual personal radiation exposure (P<.001), and have an established patient radiation dose threshold (P<.001). They were also more likely to use the fluoro store function, under-table shields, leaded glasses, ceiling lead glass, and disposable radiation shields, and were more concerned about the adverse effects of radiation.

Conclusions: Radiation safety is of concern to catheterization laboratory personnel, yet there is significant variability in radiation protection practices, highlighting several opportunities for standardization and improvement.
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August 2018

Diverse perspectives and training paths in cardiology: An analysis of authorship in the Journal of the American College of Cardiology.

Hellenic J Cardiol 2019 Nov - Dec;60(6):352-354. Epub 2018 Mar 15.

VA North Texas Healthcare System, UT Southwestern Medical Center, Dallas, TX, USA; Minneapolis Heart Institute, Minneapolis, MN, USA. Electronic address:

Background: The role of women and foreign medical graduates (FMGs) in cardiology research published in the United States has received limited study.

Methods: We examined the characteristics of the first and last authors of all original contributions and review articles published in the Journal of the American College of Cardiology from October 1, 2015, to October 1, 2016.

Results: A total of 345 articles were identified, with 687 first and last authors originating from ≥50 different countries. Overall, 17% of authors were women (20% of the first and 14% of the last authors). Overall, 86% of authors held a medical degree (MD) or equivalent, and 25% of those also held another advanced degree (PhD, MPH, and/or MBA). The proportion of authors with an advanced degree in addition to an MD/equivalent was higher among foreign graduates and international contributors as compared with American graduates (31% vs. 30% vs. 17%, respectively, p < 0.0001). Of US-based authors with an MD/equivalent, 67% were American medical graduates (AMGs) and 33% were FMGs. Women authors represented 11% of FMGs, 16% of AMGs, and 12% of international physicians as contributors (p = 0.23).

Conclusion: Foreign graduates and international researchers contribute substantially to cardiology research in the US, but women authors remain under-represented.
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http://dx.doi.org/10.1016/j.hjc.2018.02.010DOI Listing
June 2020

Contemporary Use of Laser During Percutaneous Coronary Interventions: Insights from the Laser Veterans Affairs (LAVA) Multicenter Registry.

J Invasive Cardiol 2018 06 15;30(6):195-201. Epub 2018 Mar 15.

Dallas VA Medical Center, 4500 S. Lancaster Road (151/3S), Dallas, TX 75216 USA.

Background: The contemporary use and outcomes of excimer laser coronary atherectomy (ELCA) in percutaneous coronary intervention (PCI) are not well described.

Methods: We examined the baseline clinical and angiographic characteristics and procedural outcomes of 130 target lesions in 121 consecutive PCIs (n = 116 patients) in which ELCA was performed at three United States Department of Veterans Affairs (VA) medical centers between 2008 and 2016.

Results: Mean age was 68.5 ± 9 years and 97% of the patients were men. Patients had high prevalence of diabetes mellitus (63%), prior coronary artery bypass graft surgery (41%), and prior myocardial infarction (60%). The most common target vessel was the left anterior descending (32%), followed by the right coronary artery (30%), circumflex artery (20%), and saphenous vein graft (12%). The target lesions were highly complex, with moderate/severe calcification in 62% and in-stent restenosis in 37%. The most common indication for ELCA was balloon-uncrossable lesions (43.8%), followed by balloon-undilatable lesions (40.8%) and thrombotic lesions (12.3%). Use of ELCA was associated with high technical success rate (90.0%) and procedural success rate (88.8%), and low major adverse cardiac event (MACE) rate (3.45%). Mean procedure time was 120 min (interquartile range [IQR], 81-191 min), air kerma radiation dose was 2.76 Gy (IQR, 1.32-5.01 Gy), and contrast volume was 273 mL (IQR, 201-362 mL).

Conclusion: In a contemporary multicenter United States registry, ELCA was commonly used in highly complex lesions and was associated with high technical and procedural success rates and low incidence of MACE.
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June 2018

Mechanical Circulatory Support in Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From a Multicenter U.S. Registry.

J Invasive Cardiol 2018 03;30(3):81-87

Henry Ford Hospital, K2- Catheterization Laboratory, 2799 West Grand Boulevard, Detroit, MI 48202 USA.

Objective: To study outcomes with use of percutaneous mechanical circulatory support (MCS) devices in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

Methods: We examined characteristics and outcomes of 1598 CTO-PCIs performed from 2012-2017 at 12 high-volume centers.

Results: Patient age was 66 ± 10 years; 86% were men. An MCS device was used electively in 69 procedures (4%) and urgently in 22 procedures (1%). The most commonly used elective MCS device was Impella 2.5 or CP (62%). Compared to patients without elective MCS, patients with elective MCS had higher prevalence of prior heart failure (55% vs 29%; P<.001), prior coronary artery bypass graft surgery (49% vs 35%; P=.02), and lower left ventricular ejection fraction (34 ± 14% vs 50 ± 14%; P<.001). MCS patients had a higher prevalence of moderate/ severe calcification (88% vs 55%; P<.001) and higher J-CTO scores (3.1 ± 1.2 vs 2.6 ± 1.2; P<.01), and a greater proportion underwent retrograde crossing attempts (55% vs 39%; P<.01). Despite more complex characteristics in MCS patients, technical success rates (88% vs 87%; P=.70) and procedural success rates (83% vs 87%; P=.32) were similar in the two groups. Use of elective MCS was associated with longer procedure and fluoroscopy times, and higher incidences of in-hospital major adverse cardiovascular events (8.7% vs 2.5%; P<.01) and bleeding (7.3% vs 1.0%; P<.001).

Conclusion: Elective MCS was used in 4% of patients undergoing CTO-PCI. Despite more complex clinical and angiographic characteristics, elective use of MCS in high-risk patients is associated with similar technical and procedural success rates, but higher risk of complications, compared to cases without elective MCS.
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March 2018

Randomized Comparison of a CrossBoss First Versus Standard Wire Escalation Strategy for Crossing Coronary Chronic Total Occlusions: The CrossBoss First Trial.

JACC Cardiovasc Interv 2018 02;11(3):225-233

Department of Cardiovascular Diseases, VA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas.

Objectives: The authors performed a multicenter, randomized-controlled, clinical trial comparing upfront use of the CrossBoss catheter versus antegrade wire escalation for antegrade crossing of coronary chronic total occlusions.

Background: There is equipoise about the optimal initial strategy for crossing coronary chronic total occlusions.

Methods: The primary endpoints were the time required to cross the chronic total occlusion or abort the procedure and the frequency of procedural major adverse cardiovascular events. The secondary endpoints were technical and procedural success, total procedure time, fluoroscopy time required to cross and total fluoroscopy time, total air kerma radiation dose, total contrast volume, and equipment use.

Results: Between 2015 and 2017, 246 patients were randomized to the CrossBoss catheter (n = 122) or wire escalation (n = 124) at 11 U.S. centers. The baseline clinical and angiographic characteristics of the study groups were similar. Technical and procedural success were 87.8% and 84.1%, respectively, and were similar in the 2 groups. Crossing time was similar: 56 min (interquartile range: 33 to 93 min) in the CrossBoss group and 66 min (interquartile range: 36 to 105 min) in the wire escalation group (p = 0.323), as was as the incidence of procedural major adverse cardiovascular events (3.28% vs. 4.03%; p = 1.000). There were no significant differences in the secondary study endpoints.

Conclusions: As compared with wire escalation, upfront use of the CrossBoss catheter for antegrade crossing of coronary chronic total occlusions was associated with similar crossing time, similar success and complication rates, and similar equipment use and cost.
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http://dx.doi.org/10.1016/j.jcin.2017.10.023DOI Listing
February 2018

Long-Term Outcomes of Percutaneous Coronary Intervention for Chronic Total Occlusion in Patients Who Have Undergone Coronary Artery Bypass Grafting vs Those Who Have Not.

Can J Cardiol 2018 03 26;34(3):310-318. Epub 2017 Dec 26.

Interventional Cardiology, McGill University Health Centre, Montreal, Quebec, Canada; Division of Interventional Cardiology, Quebec Heart and Lung Institute and Laval University, Quebec City, Quebec, Canada. Electronic address:

Background: We aimed to investigate the procedural and long-term outcomes of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in patients who had undergone previous coronary artery bypass grafting (CABG) vs those who had not, and to evaluate the role of the Registry of CrossBoss and Hybrid procedures in France, the Netherlands, Belgium, and United Kingdom (RECHARGE) score in predicting acute and long-term outcomes.

Methods: We compiled a multicentre registry of consecutive patients undergoing CTO PCI at 7 centres between January 2009 and April 2017. The primary end point was target-vessel failure (TVF), a composite of cardiac death, target-vessel myocardial infarction, and target-vessel revascularization on follow-up.

Results: Overall, 2058 patients were included (patients who underwent CABG, n = 401; CABG-naïve patients, n = 1657). Patients who had undergone CABG were older and had a higher prevalence of comorbidities and higher occlusion complexity (RECHARGE score, 3.6 ± 1.3 vs 1.8 ± 1.2; P < 0.001). Antegrade dissection/re-entry techniques and the retrograde approach were used more frequently in patients who had undergone CABG. Procedural metrics were worse, and technical (82% vs 88%; P = 0.001) and procedural (81% vs 87%; P = 0.001) success was lower in patients who had undergone CABG. They also experienced a higher rate of major complications (3.7% vs 1.5%; P = 0.004). The RECHARGE score was inversely associated with technical success (P < 0.001). Median follow-up was 377 days (interquartile range, 277-766 days). The 24-month TVF rate was higher in patients who had undergone CABG than in CABG-naïve patients (16.1% vs 9.0%; P < 0.001). On multivariable analysis, the RECHARGE score (hazard ratio, 1.61; P < 0.001) remained an independent predictor of TVF, together with longer total stent length and not using a drug-eluting stent.

Conclusions: Compared with CABG-naïve patients, CTO PCI in patients who had undergone CABG shows higher procedural complexity, worse success rates, and higher adjusted risk of TVF on follow-up.
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http://dx.doi.org/10.1016/j.cjca.2017.12.016DOI Listing
March 2018

Prevalence, Presentation and Treatment of 'Balloon Undilatable' Chronic Total Occlusions: Insights from a Multicenter US Registry.

Catheter Cardiovasc Interv 2018 03 23;91(4):657-666. Epub 2018 Jan 23.

Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota.

Background: The prevalence, treatment and outcomes of balloon undilatable chronic total occlusions (CTOs) have received limited study.

Methods: We examined the prevalence, clinical and angiographic characteristics, and procedural outcomes of percutaneous coronary interventions (PCIs) for balloon undilatable CTOs in a contemporary multicenter US registry.

Results: Between 2012 and 2017 data on balloon undilatable lesions were available for 425 consecutive CTO PCIs in 415 patients in whom guidewire crossing was successful: 52 of 425 CTOs were balloon undilatable (12%). Mean patient age was 65 ± 10 years and most patients were men (84%). Patients with balloon undilatable CTOs were more likely to be diabetic (67 vs. 41%, P < 0.001) and have heart failure (44 vs. 28%, P = 0.027). Balloon undilatable CTOs were longer (40 mm [interquartile range, IQR 20-50] vs. 30 [IQR 15-40], P = 0.016), more likely to have moderate/severe calcification (87 vs. 54%, P < 0.001), and had higher J-CTO score (3.2 ± 1.1 vs. 2.5 ± 1.3, P < 0.001) and PROGRESS-CTO complications score (3.9 ± 1.7 vs. 3.1 ± 2.0, P < 0.005). They were associated with lower technical and procedural success (92 vs. 98%, P = 0.024; and 88 vs. 96%, P = 0.034, respectively) and higher risk for in-hospital major adverse events (8 vs. 2%, P = 0.008) due to higher perforation rates. The most frequent treatments for balloon undilatable CTOs were high pressure balloon inflations (64%), rotational atherectomy (31%), laser (21%), and cutting balloons (15%).

Conclusions: Balloon undilatable CTOs are common and are associated with lower success and higher complication rates.
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http://dx.doi.org/10.1002/ccd.27510DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5849516PMC
March 2018

Subadventitial stenting around occluded stents: A bailout technique to recanalize in-stent chronic total occlusions.

Catheter Cardiovasc Interv 2018 09 4;92(3):466-476. Epub 2018 Jan 4.

Interventional Cardiology, McGill University Health Centre, Montreal, Quebec.

Objectives: To evaluate the outcomes of subadventitial stenting (SS) around occluded stents for recanalizing in-stent chronic total occlusions (IS-CTOs).

Background: There is little evidence on the outcomes of SS for IS-CTO.

Methods: We examined the outcomes of SS for IS-CTO PCI at 14 centers between July 2011 and June 2017, and compared them to historical controls recanalized using within-stent stenting (WSS). Target-vessel failure (TVF) on follow-up was the endpoint of this study, and was defined as a composite of cardiac death, target-vessel myocardial infarction, and target-vessel revascularization.

Results: During study period, 422 IS-CTO PCIs were performed, of which 32 (7.6%) were recanalized with SS, usually when conventional approaches failed. The most frequent CTO vessel was the right coronary artery (72%). Mean J-CTO score was 3.1 ± 0.9. SS was antegrade in 53%, and retrograde in 47%. Part of the occluded stent was crushed in 37%, while the whole stent was crushed in 63%. Intravascular imaging was used in 59%. One patient (3.1%) suffered tamponade. Angiographic follow-up was performed in 10/32 patients: stents were patent in six cases, one had mild neointimal hyperplasia, and three had severe restenosis at the SS site. Clinical follow-up was available for 29/32 patients for a mean of 388 ± 303 days. The 24-month incidence of TVF was 13.8%, which was similar to historical controls treated with WSS (19.5%, P = 0.49).

Conclusions: SS is rarely performed, usually as last resort, to recanalize complex IS-CTOs. It is associated with favorable acute and mid-term outcomes, but given the small sample size of our study additional research is warranted.
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http://dx.doi.org/10.1002/ccd.27472DOI Listing
September 2018

Mid-term outcomes of chronic total occlusion percutaneous coronary intervention with subadventitial vs. intraplaque crossing: A systematic review and meta-analysis.

Int J Cardiol 2018 02;253:29-34

Department of Cardiology, UT Southwestern Medical Center and VA North Texas Health Care System, Dallas, TX, United States; Division of Interventional Cardiology, Minneapolis Heart Institute, Minneapolis, MN, United States. Electronic address:

Background: Some reports have demonstrated increased risk with subadventitial chronic total occlusion (CTO) crossing, whereas others suggest equipoise between subadventitial and intraplaque crossing techniques. We sought to clarify the effect of subadventitial lesion crossing on mid-term outcomes of CTO percutaneous coronary intervention (PCI).

Methods: We conducted a systematic review and meta-analysis of studies reporting post-discharge outcomes after CTO PCI performed via subadventitial vs. intraplaque approaches.

Results: Five studies comprising a total of 2,539 patients were included. Compared with intraplaque crossing (n=1,654, 65.1%), subadventitial cases (n=885, 34.9%) had a higher J-CTO score (2.9±1.2 vs. 1.6±1.2, p<0.001), and required significantly longer stent lengths (difference in means: 19.66 mm [95% confidence interval (CI), 11.23 to 28.08]; p<0.001). At a median follow-up of 12.0months, subadventitial CTO crossing was associated with a higher overall rate of target vessel revascularization (TVR, crude rate, 11.5% vs. 7.6%, odds ratio [OR]: 2.19 [95% CI, 1.62 to 2.95]; p<0.001); the risk was higher in studies of extensive compared with limited dissection and re-entry techniques (OR: 3.46 [95% CI: 2.24 to 5.36] vs. 1.52 [95% CI, 0.94 to 2.46], p=0.013). The rates of stent thrombosis, myocardial infarction, and cardiovascular mortality did not vary significantly between subadventitial and intraplaque crossing.

Conclusions: CTOs treated with subadventitial crossing were significantly more complex as compared with CTOs treated with intraplaque crossing. Extensive subadventitial crossing techniques were associated with higher TVR rates as compared with limited techniques, supporting the important role of limited techniques in the treatment of complex CTOs.
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http://dx.doi.org/10.1016/j.ijcard.2017.08.044DOI Listing
February 2018

Effect of PCSK9 Inhibitors on Clinical Outcomes in Patients With Hypercholesterolemia: A Meta-Analysis of 35 Randomized Controlled Trials.

J Am Heart Assoc 2017 Dec 9;6(12). Epub 2017 Dec 9.

VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, TX

Background: We sought to examine the efficacy and safety of 2 PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors: alirocumab and evolocumab.

Methods And Results: We performed a systematic review and meta-analysis of randomized controlled trials comparing treatment with and without PCSK9 inhibitors; 35 randomized controlled trials comprising 45 539 patients (mean follow-up: 85.5 weeks) were included. Mean age was 61.0±2.8 years, and mean baseline low-density lipoprotein cholesterol was 106±22 mg/dL. Compared with no PCSK9 inhibitor therapy, treatment with a PCSK9 inhibitor was associated with a lower rate of myocardial infarction (2.3% versus 3.6%; odds ratio [OR]: 0.72 [95% confidence interval (CI), 0.64-0.81]; <0.001), stroke (1.0% versus 1.4%; OR: 0.80 [95% CI, 0.67-0.96]; =0.02), and coronary revascularization (4.2% versus 5.8%; OR: 0.78 [95% CI, 0.71-0.86]; <0.001). Overall, no significant change was observed in all-cause mortality (OR: 0.71 [95% CI, 0.47-1.09]; =0.12) or cardiovascular mortality (OR: 1.01 [95% CI, 0.85-1.19]; =0.95). A significant association was observed between higher baseline low-density lipoprotein cholesterol and benefit in all-cause mortality (=0.038). No significant change was observed in neurocognitive adverse events (OR: 1.12 [95% CI, 0.88-1.42]; =0.37), myalgia (OR: 0.95 [95% CI, 0.75-1.20]; =0.65), new onset or worsening of preexisting diabetes mellitus (OR: 1.05 [95% CI, 0.95-1.17]; =0.32), and increase in levels of creatine kinase (OR: 0.84 [95% CI, 0.70-1.01]; =0.06) or alanine or aspartate aminotransferase (OR: 0.96 [95% CI, 0.82-1.12]; =0.61).

Conclusions: Treatment with a PCSK9 inhibitor is well tolerated and improves cardiovascular outcomes. Although no overall benefit was noted in all-cause or cardiovascular mortality, such benefit may be achievable in patients with higher baseline low-density lipoprotein cholesterol.
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http://dx.doi.org/10.1161/JAHA.117.006910DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5779013PMC
December 2017

Retrograde CTO-PCI of Native Coronary Arteries Via Left Internal Mammary Artery Grafts: Insights From a Multicenter U.S. Registry.

J Invasive Cardiol 2018 03 15;30(3):89-96. Epub 2017 Nov 15.

Minneapolis Heart Institute, 920 E. 28th Street #300, Minneapolis, MN 55407 USA.

Background: Retrograde percutaneous coronary intervention (PCI) of native coronary artery chronic total occlusion (CTO) via left internal mammary artery (LIMA) graft has received limited study.

Methods And Results: We compared the clinical and procedural characteristics and outcomes of retrograde CTO-PCI through LIMA grafts vs other conduits in a contemporary multicenter CTO registry. The LIMA was used as the collateral channel in 20 of 990 retrograde CTO-PCIs (2.02%) performed at 18 United States centers. The mean age of the study patients was 69 ± 7 years and 95% were men. The most common CTO target vessel was the right coronary artery (55%). The mean J-CTO score in the LIMA group was high (3.45 ± 0.76). The technical success rates were 70% for retrograde PCI via LIMA graft vs 81.05% for retrograde via other conduits (P=.25), while procedural success rates were 70% for retrograde PCI via LIMA graft and 78.19% for retrograde via other conduits (P=.41). The incidence of major in-hospital complications was also similar between the LIMA and non-LIMA retrograde groups (5% vs 6%; P>.99). Use of guide-catheter extensions (40% vs 28%; P=.22), intravascular ultrasound (45% vs 31%; P=.20), and left ventricular assist devices (24% vs 10%; P=.08) was numerically higher in retrograde CTO-PCIs via LIMA grafts.

Conclusions: Retrograde CTO-PCI is infrequently performed via LIMA grafts and is associated with similar success and major in-hospital complication rates as retrograde CTO-PCI performed via other conduits.
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March 2018

Does the end justify the means? The contemporary role of dissection/re-entry strategies for recanalization of coronary chronic total occlusions.

Catheter Cardiovasc Interv 2017 11;90(5):713-714

Division of Interventional Cardiology, Minneapolis Heart Institute, Minneapolis, Minnesota.

Antegrade and retrograde dissection/re-entry techniques are frequently utilized in contemporary CTO PCI, especially for complex lesions. One-year outcomes with modern dissection/re-entry techniques appear favorable and comparable with those achieved after intraplaque crossing, supporting their increased use. Randomized data on the procedural safety, efficiency, and long-term outcomes of subadventitial CTO PCI techniques are needed.
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http://dx.doi.org/10.1002/ccd.27361DOI Listing
November 2017

Current Perspectives and Practices on Chronic Total Occlusion Percutaneous Coronary Interventions.

J Invasive Cardiol 2018 02 15;30(2):43-50. Epub 2017 Oct 15.

Minneapolis Heart Institute, 920 E. 28th Street #300, Minneapolis, MN 55407 USA.

Objectives: We sought to examine contemporary perspectives and practices on chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

Background: The frequency and success of CTO-PCI have been increasing in recent years.

Methods: An online questionnaire was created and distributed to cardiologists within the United States and internationally.

Results: A total of 1149 responses were obtained. The United States (n = 845; 73.5%), Asia (n = 98; 8.5%), Europe (n = 88; 7.7%), South America (n = 42; 3.7%), and Canada (n = 33; 2.9%) accounted for most responses. Mean practice duration of the respondents was 16.4 ± 11.5 years and 66.9% were interventional cardiologists. Most respondents agreed that CTO-PCI results in an improvement of patient symptoms (90.7%), left ventricular function (79.3%), arrhythmia risk (69.2%), and overall survival (63.1%). Interventional cardiologists had a more favorable view of the benefits of CTO-PCI as compared with non-interventional cardiologists (P<.001). Most respondents estimated the procedural success rates of contemporary CTO-PCI to be between 51%-75% (34.2%) and 76%-85% (30.2%), with interventional cardiologists estimating higher success rates than non-interventionalists (P<.001). Perforation, mortality, and tamponade were the three most concerning complications. Time and procedure complexity were reported to be the most significant barriers to the development of a CTO-PCI program.

Conclusions: Most cardiologists believe that CTO-PCI can provide significant clinical benefits and can be accomplished with moderate to high success rates. Interventional cardiologists have a more favorable view of CTO-PCI as compared with non-invasive cardiologists.
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February 2018

Incidence, Treatment, and Outcomes of Coronary Perforation During Chronic Total Occlusion Percutaneous Coronary Intervention.

Am J Cardiol 2017 Oct 24;120(8):1285-1292. Epub 2017 Jul 24.

VA North Texas Healthcare System/UT Southwestern Medical Center, Dallas, Texas; Minneapolis Heart Institute, Minneapolis, Minnesota. Electronic address:

Coronary perforation is a potential complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We analyzed 2,097 CTO PCIs performed in 2,049 patients from 2012 to 2017. Patient age was 65 ± 10 years, 85% were men, and 36% had prior coronary artery bypass graft surgery. Technical and procedural success were 88% and 87%, respectively. A major periprocedural adverse cardiovascular event occurred in 2.6%. Coronary perforation occurred in 85 patients (4.1%); The frequency of Ellis class 1, 2, and 3 perforations was 21%, 26%, and 52%, respectively. Perforation occurred more frequently in older patients and those with previous coronary artery bypass graft surgery (61% vs 35%, p < 0.001). Cases with perforation were angiographically more complex (Multicenter CTO Registry in Japan score 3.0 ± 1.2 vs 2.5 ± 1.3, p < 0.001). Twelve patients (14%) with perforation experienced tamponade requiring pericardiocentesis. Patient age, previous PCI, right coronary artery target CTO, blunt or no stump, use of antegrade dissection re-entry, and the retrograde approach were associated with perforation. Adjusted odds ratio for periprocedural major periprocedural adverse cardiovascular events among patients with perforation was 15.04 (95% confidence interval 7.35 to 30.18). In conclusion, perforation occurs relatively infrequently in contemporary CTO PCI performed by experienced operators and is associated with baseline patient characteristics and angiographic complexity necessitating use of advanced crossing techniques. In most cases, perforations do not result in tamponade requiring pericardiocentesis, but they are associated with reduced technical and procedural success, higher periprocedural major adverse events, and reduced procedural efficiency.
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http://dx.doi.org/10.1016/j.amjcard.2017.07.010DOI Listing
October 2017

Radiation-associated lens changes in the cardiac catheterization laboratory: Results from the IC-CATARACT (CATaracts Attributed to RAdiation in the CaTh lab) study.

Catheter Cardiovasc Interv 2018 03 14;91(4):647-654. Epub 2017 Jul 14.

Department of Cardiology, VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, Texas.

Objective: To examine the relationship between occupational exposure to ionizing radiation and the prevalence of lens changes in interventional cardiologists (ICs) and catheterization laboratory ("cath-lab") staff.

Background: Exposure to ionizing radiation is associated with the development of lens opacities. ICs and cath-lab staff can receive high doses of ionizing radiation without protection, and may thus be at risk for lens opacity formation.

Methods: We conducted a cross-sectional study at an interventional cardiology conference. Study participants completed a questionnaire pertaining to occupational exposure to radiation and potential confounders for the development of cataracts, followed by slit-lamp examination and grading of lens findings.

Results: A total of 117 attendees participated in the study, including 99 (85%; 49 ± 11 years-old; 82% male) with occupational exposure to ionizing radiation and 18 (15%; 39 ± 12 years-old; 61% male) unexposed controls. The prevalence of overall cortical and posterior subcapsular lens changes (including subclinical findings) was higher in exposed participants compared with controls (47 vs. 17%, P = 0.015). Occupational exposure and age over 60 were independent predictors of lens changes (odds ratio [95% CI]: 6.07 [1.38-43.45] and 7.72 [1.60-43.34], respectively). The prevalence of frank opacities was low and similar between the two groups (14 vs. 6%, P = 0.461). Most lens findings consisted of subclinical changes in the periphery of the lens without impact on visual acuity.

Conclusions: Compared with unexposed controls, ICs and cath-lab staff had a higher prevalence of lens changes that may be attributable to ionizing radiation exposure. While most of these changes were subclinical, they are important due to the potential to progress to clinical symptoms, highlighting the importance of minimizing staff radiation exposure.
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http://dx.doi.org/10.1002/ccd.27173DOI Listing
March 2018

A Meta-Analysis of Contemporary Lesion Modification Strategies During Percutaneous Coronary Intervention in 244,795 Patients From 22 Studies.

J Invasive Cardiol 2017 Dec 15;29(12):E167-E176. Epub 2017 Jul 15.

Minneapolis Heart Institute, 920 E. 28th Street #300, Minneapolis, MN 55407 USA.

Objectives: Outcomes with use of lesion-modification strategies in the drug-eluting stent era have received limited study.

Methods: We conducted a meta-analysis of 22 studies published between 2004-2016 reporting outcomes after use of rotational atherectomy, cutting-balloon, and scoring-balloon angioplasty.

Results: In observational trials, acute luminal gain was higher after lesion modification as compared with control (standardized mean difference, 0.23 mm; 95% confidence interval [CI], 0.01-0.44; P=.04), with no difference in acute gain in randomized studies. Compared with control, lesion modification was associated with lower restenosis in randomized trials (odds ratio [OR], 0.64; 95% CI, 0.45-0.90; P=.01). Ninety-day incidence of major adverse cardiovascular event (MACE) was higher after lesion modification in observational studies (OR, 1.39; 95% CI, 1.05-1.83; P=.02), but similar in randomized trials. Ninety-day incidence of target-lesion or target-vessel revascularization (TLR-TVR) and myocardial infarction (MI) was similar. Ninety-day incidence of death was higher after lesion modification in observational studies (OR, 1.42; 95% CI, 1.04-1.95; P=.03), but similar in randomized trials. At 1 year, the MACE rate was similar for lesion modification compared with control in observational studies, but lower after lesion modification in randomized trials (OR, 0.65; 95% CI, 0.48-0.88; P<.01). TLR-TVR was higher with lesion modification in observational studies, but lower in randomized trials (OR, 0.64; 95% CI, 0.46-0.88; P<.01).

Conclusions: While observational studies suggest a higher early MACE rate and more restenosis, randomized trials show similar short-term and improved long-term outcomes with pre-stenting lesion modification compared with control.
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December 2017

The Impact of Proximal Vessel Tortuosity on the Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From a Contemporary Multicenter Registry.

J Invasive Cardiol 2017 Aug 15;29(8):264-270. Epub 2017 May 15.

Minneapolis Heart Institute, 920 E. 28th Street #300, Minneapolis, MN 55407 USA.

Introduction: We examined the impact of proximal vessel tortuosity on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

Methods: The baseline clinical and angiographic characteristics and procedural outcomes of 1618 consecutive CTO-PCIs performed between 2012 and 2016 at 14 United States centers in 1589 patients were reviewed.

Results: Mean patient age was 65.3 ± 10.0 years and 85% were men. Moderate/severe proximal vessel tortuosity was present in 35.7% of target lesions. Compared with non-tortuous lesions, tortuous lesions had longer length (30 mm [interquartile range, 20-50 mm] vs 28 mm [interquartile range, 16-40 mm]; P<.001), more proximal cap ambiguity (36% vs 28%; P<.01), and more frequent utilization of the retrograde approach (52% vs 37%; P<.001). Moderate/severe proximal vessel tortuosity was associated with lower technical success rates (84.1% vs 91.3%; P<.001) and procedural success rates (82.3% vs 89.9%; P<.001), but similar incidence of major cardiac adverse events (3.0% vs 2.5%; P=.59). Moderate/severe tortuosity was associated with longer procedure time and fluoroscopy time, higher air kerma radiation dose, and larger contrast volume.

Conclusion: In a contemporary multicenter registry, moderate/severe proximal vessel tortuosity was present in approximately one-third of target CTO lesions and was associated with more frequent use of the retrograde approach and lower success rates, but similar complication rates.
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August 2017

Radial artery occlusion after transradial coronary catheterization.

Cardiovasc Diagn Ther 2017 Jun;7(3):305-316

Second Department of Cardiology, Hellenic Red Cross Hospital of Athens, Athens, Greece.

The transradial approach (TRA) for coronary angiography and interventions is increasingly utilized around the world. Radial artery occlusion (RAO) is the most common significant complication after transradial catheterization, with incidence varying between 1% and 10%. Although RAO is rarely accompanied by hand ischemia, it is an important complication because it prohibits future transradial access and radial artery utilization as a conduit for coronary artery bypass grafting or arteriovenous fistula formation. In this review, we discuss factors predicting the occurrence of RAO, aspects of accurate and prompt recognition, methods that contribute to its prevention and possible treatment options.
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http://dx.doi.org/10.21037/cdt.2017.03.14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5440258PMC
June 2017

Impact of Calcium on Chronic Total Occlusion Percutaneous Coronary Interventions.

Am J Cardiol 2017 07 13;120(1):40-46. Epub 2017 Apr 13.

Department of Cardiology, Veterans Affairs North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas; Center for Advanced Coronary Interventions, Minneapolis Heart Institute, Minneapolis, Minnesota. Electronic address:

We sought to examine the impact of calcific deposits on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The outcomes of 1,476 consecutive CTO PCIs performed in 1,453 patients (65.5 ± 10 years, 85% male) between 2012 and 2016 at 11 US centers were evaluated. Moderate or severe quantity of calcium was present in 58% of target lesions. Calcified lesions were more tortuous and more likely to have proximal cap ambiguity and interventional collaterals. PCI of moderately/severely calcified CTOs more often required use of the retrograde approach (54% vs 30%, p <0.001) and was associated with longer procedure and fluoroscopy time and higher air kerma radiation dose and contrast volume. Moderate/severe quantity of calcium was associated with lower technical (86.6% vs 93.8%, p <0.001) and procedural (84.4% vs 92.7%, p <0.001) success rates and higher incidence of major adverse cardiac events (3.7% vs 1.8%, p = 0.033). On multivariate analysis, the presence of moderate/severe quantity of calcium was not independently associated with technical success. Balloon angioplasty was the most common lesion preparation technique for calcified lesions, followed by rotational atherectomy and laser. To conclude, in a contemporary, multicenter registry, moderate/severe calcific deposits were present in 58% of attempted CTO lesions and were associated with higher use of the retrograde approach, lower success, and higher complication rates. However, on multivariable analysis, the amount of calcium was not independently associated with technical success.
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http://dx.doi.org/10.1016/j.amjcard.2017.03.263DOI Listing
July 2017

Management of Guidewire Entrapment With Laser Atherectomy.

J Invasive Cardiol 2017 May;29(5):E61-E62

Minneapolis Heart Institute, 920 East 28th Street #300, Minneapolis, MN 55407 USA.

A 62-year-old man was referred for percutaneous coronary intervention of a severe circumflex lesion. The guidewire became entangled in the previously implanted left anterior descending artery stent. The left main was engaged with a second guide catheter, followed by balloon dilations, various microcatheters, and laser atherectomy. The wire eventually fractured without protruding into the aorta. The circumflex lesion was stented with two stents, followed by left main stenting that covered the fragment. Caution should be used when wiring through stents; wire fracture can be treated with stent implantation, as long as the wire fragment does not protrude into the aorta.
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May 2017

Comparison of the American College of Cardiology/American Heart Association and the European Society of Cardiology Guidelines for the Management of Patients With Valvular Heart Disease.

J Invasive Cardiol 2017 Sep 15;29(9):320-326. Epub 2017 Apr 15.

Minneapolis Heart Institute, 920 E. 28th Street #300, Minneapolis, MN 55407 USA.

Background: The American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC) have developed guidelines to assist clinicians in making evidence-based decisions. This study compares the ACC/AHA and ESC guidelines for the management of patients with valvular heart disease (VHD).

Methods: The current ACC/AHA and ESC guidelines for VHD, last updated in 2014 and 2012, respectively, were compared by class of recommendation (COR), level of evidence (LOE), and content.

Results: The ACC/AHA and ESC VHD guidelines contain 229 and 85 recommendations, respectively. The COR distributions of the ACC/AHA and ESC VHD guidelines were 47.6% vs 44.7% class I [P=.65]; 46.3% vs 55.3% class II [P=.16]; and 6.1% vs 0.0% class III [P=.01], respectively. The LOE distributions were 3.1% vs 0.0% LOE A [P=.20]; 47.2% vs 10.6% LOE B [P<.001]; and 49.8% vs 89.4% LOE C [P<.001], respectively. The recommendation type distributions were 31.0% vs 2.4% diagnostic [P<.001]; 23.1% vs 16.5% medical therapy [P=.20]; and 45.9% vs 81.2% interventional/surgical recommendations [P<.001], respectively. The content of the guidelines was similar, with only minor differences in a few recommendations.

Conclusions: The ACC/AHA VHD guidelines contain significantly more recommendations. The distribution of COR was similar, but the ACC/AHA guidelines included more LOE B recommendations and fewer LOE C recommendations, suggesting that the ACC/AHA guidelines place greater emphasis on published data than expert opinion. Overall, the ACC/AHA and ESC guidelines provide similar recommendations, suggesting consistency in practice; however, the relative paucity of LOE A recommendations highlights the need for additional research.
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September 2017

Further validation of the hybrid algorithm for CTO PCI; difficult lesions, same success.

Cardiovasc Revasc Med 2017 Jul - Aug;18(5):328-331. Epub 2017 Feb 22.

Henry Ford Hospital and Wayne State University, Detroit, MI. Electronic address:

Objectives: To evaluate the success rates and outcome of the hybrid algorithm for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) by a single operator in two different clinical settings.

Methods: We compared 279 consecutive CTO PCIs performed by a single, high-volume operator using the hybrid algorithm in two different clinical settings. Data were collected through the PROGRESS CTO Registry. We compared 145 interventions performed in a community program (cohort A) with 134 interventions performed in a referral center (cohort B).

Results: Patient in cohort B had more complex lesions with higher J-CTO (3.0 vs. 3.41; p<0.001) and Progress CTO (1.5 vs.1.8, P=0.003) scores, more moderate to severe tortuosity (38% vs. 64%; p<0.001), longer total occlusion length (25 vs. 40mm; p<0.001) and higher prevalence of prior failed CTO PCI attempts (15% vs. 35%; p=0.001). Both technical (95% vs. 91%; p=0.266) and procedural (94% vs. 88%; p=0.088) success rates were similar between the two cohorts despite significantly different lesion complexity. Overall major adverse cardiovascular events were higher in cohort B (1.4% vs. 7.8%; p=0.012) without any significant difference in mortality (0.7% vs. 2.3%, p=0.351).

Conclusions: In spite of higher lesion complexity in the setting of a quaternary-care referral center, use of the hybrid algorithm for CTO PCI enabled similarly high technical and procedural success rates as compared with those previously achieved by the same operator in a community-based program at the expense of a higher rate of MACE.
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http://dx.doi.org/10.1016/j.carrev.2017.02.014DOI Listing
May 2018