scholarly journals Bail-out intravascular lithotripsy for severe stent underexpansion during primary angioplasty: a case report

2021 ◽  
Author(s):  
Niccolò Ciardetti ◽  
Francesca Ristalli ◽  
Giulia Nardi ◽  
Carlo Di Mario
Keyword(s):  
High Pressure ◽  
Coronary Artery ◽  
De Novo ◽  
Treatment Strategies ◽  
Coronary Intervention ◽  
Primary Angioplasty ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
Stent Expansion ◽  
Bail Out

Abstract Background Intravascular lithotripsy is safe and effective for the treatment of de novo coronary artery calcifications. Its bail-out use in acute coronary syndrome and for underexpanded stents, although currently off-label, could be the best option when other conventional techniques fail. Case summary A patient with an inferior ST-segment elevation myocardial infarction underwent a primary percutaneous coronary intervention. Stent underexpansion due to a heavily calcified lesion was refractory to high-pressure balloon dilatations. Complete stent expansion was achieved with intravascular lithotripsy, as evidenced by intravascular ultrasound, and no acute complications occurred. Discussion Treatment strategies for stent underexpansion due to coronary artery calcifications are still debated. High-pressure non-compliant balloon dilatations are rarely sufficient to gain a complete stent expansion. Rotational and orbital atherectomy are contraindicated in presence of thrombus. Given the possible risks of stent damages, intravascular lithotripsy is currently not indicated in acutely deployed stents but could be the best bail-out technique for otherwise undilatable stents due to severely calcified plaques.

The clinical and pathological features of intraplaque hemorrhage in coronary artery -insights from Japan DCA registry-

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
N Nakamura ◽  
S Torii ◽  
T Ijichi ◽  
K Jujo ◽  
M Hara ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Unstable Angina ◽  
De Novo ◽  
Coronary Intervention ◽  
Coronary Plaque ◽  
Active Cell ◽  
Intraplaque Hemorrhage ◽  
Histopathological Analysis ◽  
Coronary Syndrome ◽  
Clinical Presentations

Abstract Introduction Intraplaque hemorrhage (IPH) is known to play an important role in plaque vulnerability in coronary artery. However, the biological reaction in IPH and clinical features of patients with IPH remain unknown, since most histological studies of IPH in coronary artery were performed on autopsy cases. Directional coronary atherectomy (DCA) enables the direct pathological evaluation of collected tissue from “living” patients. Purpose We aimed to clarify the clinical presentations and histopathologic features of IPH using specimens obtained by DCA. Method This multicentral prospective observational study included consecutive patients who underwent percutaneous coronary intervention for de novo lesions using DCA from June 2015 to February 2018. Histopathological sections that were collected from coronary plaques by DCA were evaluated and classified by the presence of IPH. IPH in DCA specimens was defined as clusters of hemosiderin (Figure A, arrows), erythrocytes (Figure B, arrow heads) and fibrin (Figure C, arrows) within the coronary plaque. A total of 154 de novo lesions from 154 patients were ultimately analyzed, and were divided into IPH group (n=37) and non-IPH group (n=117). Result Clinical profiles of patients in the two groups were comparable, except that unstable angina rather than chronic coronary syndrome was significantly more prevalent in the IPH group (32.4% vs. 16.2%, P=0.04). Histopathological analysis showed a significantly higher incidence of cellular-rich plaque (46.0% vs. 25.6%, P=0.02) and spindle-shaped cells (18.9% vs. 6.0%, P=0.02), which indicate active cell proliferations, in the IPH group. The prevalence of necrotic core was also higher in IPH group compared to non-IPH group (48.7% vs. 13.7%, P<0.01). Conclusion Pathohistological analysis revealed that coronary plaques with IPH had an active cell proliferation, and patients with IPH likely to had clinical presentations of unstable angina. Figure 1 Funding Acknowledgement Type of funding source: None

What Are Optimal P2Y12 Inhibitor and Schedule of Administration in Patients With Acute Coronary Syndrome?

2019 ◽  
Vol 25 (2) ◽  
pp. 121-130 ◽  
Author(s):  
Michael V. Cohen ◽  
James M. Downey
Keyword(s):  
Coronary Artery ◽  
Platelet Reactivity ◽  
Artery Bypass ◽  
Metabolic Activation ◽  
Coronary Intervention ◽  
Myocardial Salvage ◽  
Require Time ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
Oral Agents

Guidelines recommend treatment with a P2Y12 platelet adenosine diphosphate receptor inhibitor in patients undergoing elective or urgent percutaneous coronary intervention (PCI), but the optimal agent or timing of administration is still not clearly specified. The P2Y12 inhibitor was initially used for its platelet anti-aggregatory action to block thrombosis of the recanalized coronary artery or deployed stent. It is now recognized that these agents also offer potent cardioprotection against a reperfusion injury that occurs in the first minutes of reperfusion if platelet aggregation is blocked at the time of reperfusion. But this is difficult to achieve with oral agents which are slowly absorbed and often require time-consuming metabolic activation. Patients with ST-segment elevation myocardial infarction who usually have a large mass of myocardium at risk of infarction seldom have sufficient time for upstream-administered oral agents to achieve a therapeutic P2Y12 level of inhibition by the time of balloon inflation. However, optimal treatment could be assured by initiating an IV cangrelor infusion shortly prior to stenting followed by subsequent post-PCI transition to an oral agent, that is, ticagrelor, once success of the recanalization and absence of need for surgical intervention are confirmed. Not only should this sequence provide optimal protection against infarction, it should also negate bleeding if coronary artery bypass grafting should be required since stopping the cangrelor infusion at any time will quickly restore platelet reactivity. It is anticipated that cangrelor-induced myocardial salvage will help preserve myocardial function and significantly diminish postinfarction heart failure.

Should the primary percutaneous coronary intervention pathway be redesigned?

2019 ◽  
Vol 14 (8) ◽  
pp. 1-15
Author(s):  
Sue Dean
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Acute Coronary Syndrome ◽  
Coronary Artery ◽  
Primary Percutaneous Coronary Intervention ◽  
Coronary Intervention ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
St Segment ◽  
Percutaneous Coronary ◽  
Elevation Acute Coronary Syndrome

Background/Aims The primary percutaneous coronary intervention pathway for patients experiencing an ST segment elevation acute coronary syndrome excludes patients with aVR ST elevation. These patients are treated on the non-ST segment elevation acute coronary syndrome pathway, which means that they have a coronary angiogram +/− intervention during their inpatient stay. Patients with non-ST segment elevation acute coronary syndrome have worse outcomes nationally. As such, research is required to demonstrate areas for improvement. This article examines the association between aVR ST segment elevation on the electrocardiogram and significant left main stem, proximal left anterior descending, or 3-vessel coronary artery stenosis in acute coronary syndrome to establish whether the primary percutaneous coronary intervention pathway should be redesigned. Methods Existing literature was searched, and relevant studies were considered and evaluated. Data were collected within local NHS Trusts on patients who had aVR ST segment elevation on the electrocardiogram. The data were analysed, and the findings were compared and synthesised with the literature. Results The study demonstrated a relationship between aVR ST segment elevation and significant disease. However, because of the numbers involved, analysis to demonstrate statistical significance was not possible, with the exception of aVR ST segment elevation and left main stem coronary artery, left anterior descending coronary artery and triple vessel disease, where p<0.05 in the population with left main stem coronary artery occlusion +/− other disease. The study demonstrated that aVR ST segment elevation should be treated as an ST segment elevation acute coronary syndrome equivalent, as it is a high-risk finding. These patients should go immediately to the cardiac catheter laboratory for a primary percutaneous coronary intervention. Conclusion The need for a change in the primary percutaneous coronary intervention pathway was established.

Acute Myocardial Infarction – The Role of Drug-eluting Stents in Treatment Strategies

2011 ◽  
Vol 7 (2) ◽  
pp. 113 ◽  
Author(s):  
Ronald K Binder ◽  
Ahmed A Khattab ◽  
◽  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Coronary Artery ◽  
Treatment Strategies ◽  
Coronary Intervention ◽  
Drug Eluting Stents ◽  
Artery Dissection ◽  
Coronary Artery Dissection ◽  
St Segment Elevation ◽  
Drug Eluting

Although primary percutaneous coronary intervention (PCI) has become the cornerstone in the treatment of ST-segment elevation acute myocardial infarction (AMI), systemic fribrinolysis may still be considered for patients in areas where PCI is not accessible. The downside of initial plain balloon angioplasty, mainly coronary artery dissection and vessel re-occlusion, was effectively solved by the application of coronary stents. The incidence of target vessel failure, witnessed after bare metal stent (BMS) implantation, was dramatically reduced by the introduction of drug-eluting stents (DES), which significantly and effectively alleviate restenosis in the overall population. A minute incidence of late and very late DES thrombosis led to some safety concerns, which were soon rebutted, particularly by the development of newer generation DES. DES have consequently outplayed BMS among almost all anatomical and clinical subgroups of coronary artery disease patients. However, AMI remains one of the last contested territories. Today there is a growing body of evidence to support the use of DES as a safe and effective treatment of AMI.

scholarly journals The Association of Baseline N-terminal Pro-B-type Natriuretic Peptide With Short and Long-term Prognosis Following Percutaneous Coronary Intervention in Non-ST Segment Elevation Acute Coronary Syndrome With Multivessel Coronary Artery Disease: a Retrospective Cohort Study

2020 ◽  
Author(s):  
Wen-fei He ◽  
Lei Jiang ◽  
Yi-yue Chen ◽  
Yuan-hui Liu ◽  
Peng-yuan Chen ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Percutaneous Coronary Intervention ◽  
Coronary Artery ◽  
Coronary Intervention ◽  
Multivessel Coronary Artery Disease ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
Percutaneous Coronary ◽  
Artery Disease

Abstract Background: Although several studies have shown that N-terminal pro-B-type natriuretic peptide (NT-proBNP) is strongly correlated with coronary artery lesion complexity as well as prognosis in non-ST segment elevation acute coronary syndrome (NSTE-ACS) patients, the prognostic value of NT-proBNP in patients with NSTE-ACS and multivessel coronary artery disease undergoing PCI remains unclear. This study aimed to reveal the relationship between NT-proBNP levels and prognosis among NSTE-ACS patients with multivessel coronary artery disease undergoing successfully percutaneous coronary intervention.Methods: We consecutively enrolled 1022 patients from January 2010 to December 2014. Patients with a diagnosis of NSTE-ACS with multivessel coronary artery disease and NT-proBNP levels were included. The primary outcome was in-hospital all-cause death. The 3-year follow-up all-cause death was also ascertained.Results: A total of 12 (1.2%) deaths occurred during hospitalization. The 4th quartile group of NT-proBNP (>1287 pg/ml) had the highest rate of in-hospital all-cause death (4.3%) (P<0.001). Logistic analyses revealed that increasing NT-proBNP was robustly associated with a higher risk of in-hospital all-cause death (adjusted OR: 2.86, 95% CI=1.16-7.03, P=0.022). NT-proBNP had a good ability to predict in-hospital all-cause death (AUC=0.888, 95% CI=0.834-0.941, P<0.001; cutoff: 1568pg/ml). The cumulative event analyses exhibited a statistically significant relationship between a higher level of NT-proBNP and a higher rate of the long-term all-cause death compared with a lower level of NT-proBNP (P< 0.0001).Conclusions: Increasing NT-proBNP is significant associated with a high risk of in-hospital and long-term all-cause death in NSTE-ACS patients with multivessel coronary artery disease who received percutaneous coronary intervention. NT-proBNP > 1568pg/ml was associated with all-cause, in-hospital death.

scholarly journals The association of baseline N-terminal pro-B-type natriuretic peptide with short and long-term prognosis following percutaneous coronary intervention in non-ST segment elevation acute coronary syndrome with multivessel coronary artery disease: a retrospective cohort study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Wen-fei He ◽  
Lei Jiang ◽  
Yi-yue Chen ◽  
Yuan-hui Liu ◽  
Peng-yuan Chen ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Coronary Intervention ◽  
Multivessel Coronary Artery Disease ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
St Segment ◽  
Percutaneous Coronary ◽  
Artery Disease

Abstract Background Several studies have shown that N-terminal pro-B-type natriuretic peptide (NT-proBNP) is strongly correlated with the complexity of coronary artery disease and the prognosis of patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS), However, it remains unclear about the prognostic value of NT-proBNP in patients with NSTE-ACS and multivessel coronary artery disease (MCAD) undergoing percutaneous coronary intervention (PCI). Therefore, this study aimed to reveal the relationship between NT-proBNP levels and the prognosis for NSTE-ACS patients with MCAD undergoing successful PCI. Methods This study enrolled 1022 consecutive NSTE-ACS patients with MCAD from January 2010 to December 2014. The information of NT-proBNP levels was available from these patients. The primary outcome was in-hospital all-cause death. In addition, the 3-year follow-up all-cause death was also ascertained. Results A total of 12 (1.2%) deaths were reported during hospitalization. The 4th quartile group of NT-proBNP (> 1287 pg/ml) showed the highest in-hospital all-cause death rate (4.3%) (P < 0.001). Besides, logistic analyses revealed that the increasing NT-proBNP level was robustly associated with an increased risk of in-hospital all-cause death (adjusted odds ratio (OR): 2.86, 95% confidence interval (CI) = 1.16–7.03, P = 0.022). NT-proBNP was able to predict the in-hospital all-cause death (area under the curve (AUC) = 0.888, 95% CI = 0.834–0.941, P < 0.001; cutoff: 1568 pg/ml). Moreover, as revealed by cumulative event analyses, a higher NT-proBNP level was significantly related to a higher long-term all-cause death rate compared with a lower NT-proBNP level (P < 0.0001). Conclusions The increasing NT-proBNP level is significantly associated with the increased risks of in-hospital and long-term all-cause deaths among NSTE-ACS patients with MCAD undergoing PCI. Typically, NT-proBN P > 1568 pg/ml is related to the all-cause and in-hospital deaths.

Prognostic Significance of Relative Hyperglycemia after Percutaneous Coronary Intervention in Patients with and without Recognized Diabetes

2020 ◽  
Vol 19 (1) ◽  
pp. 91-101 ◽  
Author(s):  
Qi Zhao ◽  
Ting-Yu Zhang ◽  
Yu-Jing Cheng ◽  
Yue Ma ◽  
Ying-Kai Xu ◽  
...  
Keyword(s):  
Prognostic Significance ◽  
Coronary Intervention ◽  
Major Adverse Cardiovascular Events ◽  
St Segment Elevation ◽  
Glycemic Level ◽  
Prognostic Effect ◽  
Coronary Syndrome ◽  
St Segment ◽  
Diabetic Population ◽  
Shape Curve

Background: The research on the association between the relative glycemic level postpercutaneous coronary intervention (PCI) and adverse prognosis in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients is relatively inadequate. Objective: The study aimed to identify whether the glycemic level post-PCI predicts adverse prognosis in NSTE-ACS patients. Methods: Patients (n=2465) admitted with NSTE-ACS who underwent PCI were enrolled. The relative glycemic level post-procedure was calculated as blood glucose level post-PCI divided by HbA1c level, which was named post-procedural glycemic index (PGI). The primary observational outcome of this study was major adverse cardiovascular events (MACE) [defined as a composite of all-cause death, non-fatal myocardial infarction (MI) and any revascularization]. Results: The association between PGI and MACE rate is presented as a U-shape curve. Higher PGIs [hazard ratio (HR): 1.669 (95% confidence interval (CI): 1.244-2.238) for the third quartile (Q3) and 2.076 (1.566-2.753) for the fourth quartile (Q4), p<0.001], adjusted for confounding factors, were considered to be one of the independent predictors of MACE. The association between the PGI and the risk of MACE was more prominent in the non-diabetic population [HR (95%CI) of 2.356 (1.456-3.812) for Q3 and 3.628 (2.265-5.812) for Q4, p<0.001]. There were no significant differences in MACE risk between PGI groups in the diabetic population. Conclusion: Higher PGI was a significant and independent predictor of MACE in NSTE-ACS patients treated with PCI. The prognostic effect of the PGI is more remarkable in subsets without pre-existing diabetes than in the overall population. The predictive value of PGI was not identified in the subgroup with diabetes.

Should Percutaneous Coronary intervention be the Standard Treatment Strategy for Significant Coronary Artery Disease in all Octogenarians?.

2020 ◽  
Vol 16 ◽  
Author(s):  
George Kassimis ◽  
Grigoris V. Karamasis ◽  
Athanasios Katsikis ◽  
Joanna Abramik ◽  
Nestoras Kontogiannis ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Percutaneous Coronary Intervention ◽  
Coronary Artery ◽  
Elderly Patients ◽  
Symptom Relief ◽  
Coronary Intervention ◽  
St Segment Elevation ◽  
St Segment ◽  
Percutaneous Coronary ◽  
Artery Disease

Coronary artery disease (CAD) remains the leading cause of cardiovascular death in octogenarians. This group of patients represents nearly a fifth of all patients treated with percutaneous coronary intervention (PCI) in real-world practice. Octogenarians have multiple risk factors for CAD and often greater myocardial ischemia than younger counterparts, with a potential of an increased benefit from myocardial revascularization. Despite this, octogenarians are routinely under-treated and belittled in clinical trials. Age does make a difference to PCI outcomes in older people, but it is never the sole arbiter of any clinical decision, whether in relation to the heart or any other aspect of health. The decision when to perform revascularization in elderly patients and especially in octogenarians is complex and should consider the patient on an individual basis, with clarification of the goals of the therapy and the relative risks and benefits of performing the procedure. In ST-segment elevation myocardial infarction (MI), there is no upper age limit regarding urgent reperfusion and primary PCI must be the standard of care. In non-ST-segment elevation acute coronary syndromes, a strict conservative strategy must be avoided; whereas the use of a routine invasive strategy may reduce the occurrence of MI and need for revascularization at follow-up, with no established benefit in terms of mortality. In stable CAD patients, invasive therapy on top of the optimal medical therapy seems better in symptom relief and quality of life. This review summarizes the available data on percutaneous revascularization in the elderly patients and particularly in octogenarians, including practical considerations on PCI risk secondary to ageing physiology. We also analyse technical difficulties met when considering PCI in this cohort and the ongoing need for further studies to ameliorate risk stratification and eventually outcomes in these challenging patients.

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