Spot Stenting Preferable in Long Diffuse Coronary Lesions

The treatment of long and diffuse coronary lesions with percutaneous coronary intervention (PCI) has been problematic. Since the era of plain balloon angioplasty,  lesion  length  has been a factor related to higher rates of restenosis and target lesion revascularization (TLR). With the advent of bare-metal stents, long and multiple stents were used to completely cover the diseased segments in order to improve outcomes. It has been shown that stenting of long coronary lesions (>20 mm) is related to significantly higher rates of TLR than more discrete lesions and  lesion  length   remained  an independent risk factor for restenosis. The risk was further increased by the multiplicity of implanted stents. Full-cover stenting of long lesions is likely to give rise to diffuse, malignant in-stent restenosis which may necessitate multiple additional PCI procedures and often bypass surgery. Thus, covering the lesion with the least number of non-overlapping stents might reduce the risks of restenosis.  This strategy, called spot stenting,... (excerpt

Transradial Percutaneous Coronary Intervention in Acute Coronary Syndromes: a Case Report and Review of the Literature

The radial approach to perform coronary angiography and percutaneous coronary interventions (PCI) is currently supported by voluminous literature and has been repetitively shown to minimize access site related complications, reduce hospitalization time and costs and increase patient comfort compared to the femoral approach. Most importantly, in acute coronary syndromes the radial access has the potential to significantly decrease serious bleeding complications, which are related to increased morbidity and mortality rates. Despite gradually gaining popularity the radial approach is still used in only a small fraction of the total number of coronary procedures. We present herein the case of a woman suffering from acute inferior myocardial infarction referred to our hospital for emergency catheterization after failed fibrinolysis and treated successfully with transradial rescue PCI. The case presentation is followed by a concise  overview of data supporting the wider use of the radial approach,  especially focusing on acute coronary syndromes

Percutaneous Coronary Intervention for Intra-stent Chronic Total Occlusion Assisted by Stent Visualization Enhancement Technology

A 50-year-old female patient with a history of prior acute inferior myocardial infarction successfully treated 2 years earlier by primary percutaneous coronary intervention (PCI) with thrombus aspiration and implantation of a 3x30 mm bare-metal stent in the proximal right coronary artery (RCA) was submitted to coronary angiography after reappearance of effort angina. An initial coronary angiogram showed a chronic total occlusion (CTO) intra-stent with Rentrop III collateral filling of the RCA originating from distal left anterior descending (LAD). A mid LAD 60% stenosis and a 60% mid circumflex stenosis were considered non-significant since fractional flow reserve (FFR) was measured at 0.84 and 0.90 respectively. After demonstrating inferior wall viability by cardiac magnetic resonance imaging (MRI), a PCI was programmed two months after the initial coronary angiogram. The intra-stent CTO was ≥ 30 mm long, with no blunt stump and at least 2 small branches originating at its proximal cap level. Mid and distal RCA antegrade filling existed due to bridging collaterals. The crossing technique by guidewire exchange and use of a microcatheter is described. After balloon predilatation the RCA was recanalized. The use of a stent visualization enhancement technology (StentViz) helped understand the most probable procedure-related restenosis mechanisms (stent undersizing and underexpansion) and guided the subsequent successful implantation of two drug-eluting stents. The use of this technology is described step by step for this intervention

Very Late Thrombosis of an Undersized Bare-Metal Stent

A 52-year-old gentleman was admitted with anterior non ST elevation myocardial infarction. He had a history of stenting of the left anterior descending (LAD) – first diagonal (D1) bifurcation with two bare-metal stents (BMS) according to the provisional T-technique ten years earlier. He was also submitted to a simple balloon angioplasty for focal LAD in-stent restenosis 14 months ago.  The urgent coronary angiography this time showed a very late stent thrombosis  of the LAD BMS fortunately with preserved distal flow. He was initially treated successfully with aspiration thrombectomy combined to few days of aspirin, prasugrel and enoxaparin to enable complete thrombus dissolution.  Five days later the LAD stent was examined with optical coherence tomography (OCT) which revealed severe malapposition proximally to the D1 due to initial BMS undersizing. The stent was expanded and a kissing-balloon inflation was performed at the LAD – D1 bifurcation with appropriately sized balloons. Finally, after verifying the correct stent expansion and apposition by OCT, a drug-eluting balloon inflation was performed in-stent in order to minimize the risk of restenosis. Subsequent clinical course was uneventful. Details and images concerning these procedures are presented and discussed herein

Spot Stenting is Preferable in Long Diffuse Coronary Lesions: Possible Incremental Value of Physiologic and Intracoronary Imaging Modalities

The treatment of long and diffuse coronary lesions with percutaneous coronary intervention (PCI) has been problematic since the era of plain balloon angioplasty. With the advent of bare-metal stents (BMS), long and multiple stents were used to completely cover the diseased segments in order to improve outcomes.  Lesion length has been proven to be a factor related to higher rates of restenosis and target lesion revascularization (TLR) and the risk was further increased by the multiplicity of implanted stents. Covering the lesion with the least number of non-overlapping stents might reduce the risk of restenosis.  This strategy, called spot stenting, was initially tested in the BMS era to treat discrete high-grade disease within moderately diseased vessel segments and has been shown to significantly reduce restenosis rates. Drug-eluting stents (DES) have been consistently shown to reduce restenosis and the need for TLR and thus provide improved clinical efficacy compared with BMS. However, even with DES, diffuse disease and long lesions are still associated with an increased risk of restenosis, need for TLR and major adverse cardiac events (MACE). A major long-term concern regarding DES is the potential for stent thrombosis which is increased after complex procedures with implantation of longer, multiple and overlapping stents. Data are limited but recent reports suggest that even when DES are used, selective stenting of only the severely narrowed areas of long lesions reduces the risk of MACE compared to full lesion coverage. The data supporting the spot stenting approach along with some considerations regarding the technique are presented herein

An Example of Angiographic Projection “Fine Tuning” in Primary PCI for Acute Anterior Myocardial Infarction

A 52-year-old gentleman was admitted with acute anterior myocardial infarction. He was submitted to emergency coronary angiography intending to perform primary percutaneous coronary intervention (PCI). The left anterior descending (LAD) coronary artery was missing. The standard initial angiographic projections failed to reveal the stump of the very proximally occluded LAD, which was consistently hidden by the proximal part of the left circumflex artery. Only the right anterior oblique cranial view, after slightly modifying the initial angle, finally delineated the LAD stump.  Primary PCI was successfully performed and the patient had an uncomplicated in-hospital course

ST-Elevation Myocardial Infarction: Preventive Percutaneous Coronary Intervention in the Non-Culprit Vessel

Patients with ST-segment elevation myocardial infarction (STEMI) and multi-vessel disease (MVD) have poorer outcomes after primary percutaneous coronary intervention (PCI) compared to those with one-vessel coronary artery disease. Current STEMI guidelines recommend revascularization of the infarct related artery (IRA) only during primary PCI, while PCI for non-IRA lesions should be performed after objective evidence of residual ischemia. Evidence regarding the optimal management strategy for non-IRA lesions in STEMI patients with MVD has been limited and mainly based on retrospective, contradictory and probably biased data. A recently published randomized study, PRAMI, challenges the guidelines since preventive acute multi-vessel PCI for significant stenoses in non-IRAs has been associated with a reduction of major adverse cardiovascular events (MACE) compared to PCI limited to the IRA. A review of the literature and a discussion about the implications of the PRAMI study regarding the optimal revascularization strategy for STEMI with MVD are presented herein

Revascularization of the Infarct-Related Artery: Never Too Late?

During the early phase of an acute myocardial infarction (MI), current consensus is that reperfusion of the infarct-related artery (IRA) should be implemented as soon as possible, more effectively accomplished via percutaneous coronary intervention (PCI). The clinical approach to the occluded IRA late after MI remains controversial, but current practice shows a strong trend in favour of PCI, which is based on the late open artery hypothesis. However, late PCI on IRAs also has the potential for harm from procedure-related complications. An attempt is made herein to critically overview the current data on this important topic, mainly based on recent meta-analyses with somewhat diverging results, indicating that clinical judgment and an individualized approach still remains a valid guide

Revascularization of the Infarct-Related Artery: Never Too Late?

During the early phase of an acute myocardial infarction (MI), current consensus is that reperfusion of the infarct-related artery (IRA) should be implemented as soon as possible, more effectively accomplished via percutaneous coronary intervention (PCI). The clinical approach to the occluded IRA late after MI remains controversial, but current practice shows a strong trend in favour of PCI, which is based on the late open artery hypothesis. However, late PCI on IRAs also has the potential for harm from procedure-related complications. An attempt is made herein to critically overview the current data on this important topic, mainly based on recent meta-analyses with somewhat diverging results, indicating that clinical judgment and an individualized approach still remains a valid guide