Background Excess radiation exposure is a limiting factor in percutaneous coronary intervention (PCI) for chronic total coronary occlusion (CTO). Objectives The aim of this study was to analyze changes in radiation dose for CTO PCI with increasing risk awareness during the past decade and the determinants of these changes. Methods A total of 16,439 procedures performed by 14 operators continuously participating in the European Registry of CTO-PCI from 2012 to 2023 were analyzed. Changes in air kerma (AK) were assessed, and a dose rate index (DRI) was calculated as AK per fluoroscopy time (FT). Results Lesion complexity increased from a median J-CTO (Multicenter CTO Registry in Japan) score of 2 (Q1-Q3: 1-3) to 3 (Q1-Q3: 2-3) (P < 0.001), and technical success improved from 89.1% to 94.9% (P < 0.001), with stable FT. AK decreased from 2.50 Gy (Q1-Q3: 1.54-4.04 Gy) to 1.20 Gy (Q1-Q3: 0.66-2.12 Gy), a reduction of 52.0% (P < 0.001). Excess radiation of AK >5 Gy was reduced from 15.8% in 2012-2013 to 3.7% in 2022-2023. Clinical determinants of excess radiation were body mass index, gender, and previous bypass surgery; procedural determinants were FT, retrograde approach, and intravascular ultrasound use; and equipment determinants were radiographic equipment updates and fluoroscopy dose mode. Operators reduced DRI by 21.7% from 62.6 mGy/min (Q1-Q3: 44.7-89.3 mGy/min) to 49.0 mGy/min (Q1-Q3: 35.4-71.2 mGy/min) before a radiographic equipment update; after the update, DRI was further reduced to 31.5 mGy/min (Q1-Q3: 22.0-45.6 mGy/min), a decrease of 28.0% (P < 0.001) The interoperator comparison of DRI indicated considerable variability in radiation management. Conclusions AK for CTO PCI was reduced during the past decade to a level such that most procedures no longer must be aborted because of excess radiation. Equipment updates were instrumental, but interoperator differences remained.

Background and Objectives: Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) is often associated with longer total stent length. Our aim was to evaluate the long-term safety and effectiveness of bioresorbable scaffold (BRS) implantation in CTO to avoid using a full metal jacket. Materials and Methods: We conducted a single-center prospective longitudinal case study including 34 patients who underwent PCI of CTO with at least one BRS and drug-eluting stent (DES) implantation (n = 27) or BRS-only at the Latvian Centre of Cardiology between 2016 and 2018. Quantitative coronary angiography (QCA) and intravascular ultrasound were performed during the index procedure and long-term follow-up. Results: Of 34 patients with a mean age of 60.6 ± 9.5 years, 76.5% were male. The most common CTO artery was the right coronary artery (73.5%, n = 25). The median length of occlusion was 23.0 mm (interquartile range (IQR) = 13.9–32.7), with a total mean BRS/DES length of 49.6 ± 20.4 mm. During the median follow-up of 5.6 years (IQR = 5.0–5.9), the primary endpoint of target vessel re-occlusion occurred in 5.9% (n = 2) of patients. Target lesion revascularization (TLR) was performed in 35.3% (n = 12) of patients, with a mean time to TLR of 62.5 (95% confidence interval (CI), 53.9–71.2) months. Through QCA, there was a statistically significant increase in median residual diameter stenosis (20.1–31.4%, p < 0.01) and residual length of stenosis (5.2–7.1%, p = 0.04) compared with the index procedure. Conclusions: Our study demonstrates that BRS is a safe and feasible option for PCI of CTO, allowing for the avoidance of long segment stenting and ensuring long-term patency of the coronary artery.

Aims Radiation exposure is a limiting factor for percutaneous coronary interventions (PCI) of chronic total coronary occlusion (CTO) lesions. This study was designed to analyze changes in patient radiation dose for CTO-PCI and parameters associated with radiation dose. Methods and results We analyzed a cohort of 12,136 procedures performed by 23 operators between 2012 and 2017 from the European Registry of CTO-PCI. Radiation exposure was recorded as air kerma (AK) and dose area product (DAP). A dose rate index (DRI) was calculated as AK per fluoroscopy time to normalize for individual differences in fluoroscopy time. The lesion complexity increased from Japanese-CTO (J-CTO) score of 2.19 ± 1.44 to 2.46 ± 1.28, with an increase of retrograde procedures from 31.1% to 40.7%; still, procedural success improved from 87.7% to 92.1%. Fluoroscopy time remained similar, but AK decreased by 14.9%, from 2.35 Gy (interquartile range [IQR], 1.29-4.14 Gy) to 2.00 Gy (IQR, 1.08-3.45 Gy) and DAP decreased by 21.5%, from 130 Gy•cm² (IQR, 70-241 Gy•cm²) to 102 Gy•cm² (IQR, 58-184 Gy•cm²). Radiation exposure was determined by the lesion complexity (J-CTO score) and procedural complexity (antegrade or retrograde). DRI was determined by fluoroscopy frame rate and type of equipment used, but the major influence remained interoperator differences. Conclusions Radiation exposure decreased during the observation period despite an increase in lesion and procedural complexity. While many operators already achieved a goal of low radiation exposure, there were considerable interoperator differences in radiation management, indicating further potential for improvement.

Bifurcation percutaneous coronary intervention (PCI) is challenging and is associated with lower rate of procedural success and higher risk of complications. The aim of this study was to evaluate intrahospital and long-term outcomes of patients who underwent PCI for bifurcation lesions involving

BACKGROUND A retrograde approach improves the success rate of percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs).OBJECTIVES The authors describe the European experience with and outcomes of retrograde PCI revascularization for coronary CTOs.METHODS Follow-up data were collected from 1,395 patients with 1,582 CTO lesions enrolled between January 2008 and December 2012 for retrograde CTO PCI at 44 European centers. Major adverse cardiac and cerebrovascular events were defined as the composite of cardiac death, myocardial infarction, stroke, and further revascularization.RESULTS The mean patient age was 62.0 +/- 10.4 years; 88.5% were men. Procedural and clinical success rates were 75.3% and 71.2%, respectively. The mean clinical follow-up duration was 24.7 +/- 15.0 months. Compared with patients with failed retrograde PCI, successfully revascularized patients showed lower rates of cardiac death (0.6% vs. 4.3%, respectively; p < 0.001), myocardial infarction (2.3% vs. 5.4%, respectively; p = 0.001), further revascularization (8.6% vs. 23.6%, respectively; p < 0.001), and major adverse cardiac and cerebrovascular events (8.7% vs. 23.9%, respectively; p < 0.001). Female sex (hazard ratio [HR]: 2.06; 95% confidence interval [CI]: 1.33 to 3.18; p = 0.001), prior PCI (HR: 1.73; 95% CI: 1.16 to 2.60; p = 0.011), low left ventricular ejection fraction (HR: 2.43; 95% CI: 1.22 to 4.83; p = 0.011), J-CTO (Multicenter CTO Registry in Japan) score >= 3 (HR: 2.08; 95% CI: 1.32 to 3.27; p = 0.002), and procedural failure (HR: 2.48; 95% CI: 1.72 to 3.57; p < 0.001) were independent predictors of major adverse cardiac and cerebrovascular events at long-term follow-up.CONCLUSIONS The number of retrograde procedures in Europe has increased, with high percents of success, low rates of major complications, and good long-term outcomes. (C) 2015 by the American College of Cardiology Foundation.

Comparison of Intravascular Imaging and Quantitative Coronary Angiography to Evaluate Neointimal Proliferation after Complex Lesion Stenting Unlike quantitative coronary angiography (QCA), intravascular imaging methods allow direct visualisation of the arterial wall. Our goal was to determine several intravascular ultrasound (IVUS) and optical coherence tomography (OCT) parameters of neointimal proliferation and stent endothelisation after complex lesion intervention compared to QCA. We examined 261 patients who had underwent percutaneous intervention with bare metal (BMS) or drug eluting stent (DES) implantation for complex coronary lesions and had IVUS or OCT images at six-month follow-up. Percent diameter stenosis (QCA) was 25.2 ± 16.0 in BMS vs 21.7 ± 17.4 in DES (P < 0.05). Percent neointimal volume obstruction (IVUS) was 19.5 ± 14.4 in BMS vs. 5.8 ± 7.7 in DES (P < 0.001). A moderate correlation was observed between QCA and IVUS with an r value of 0.384 overall, 0.472 for BMS and 0.416 for DES (P < 0.001 for all). In patients with chronic total occlusions (n = 161) QCA was similar in BMS and DES patients (P > 0.05) while IVUS showed less neointima in DES (P < 0.05). Total number of uncovered stent struts per OCT image was 0.4 ± 0.8 while per IVUS image 1.2 ± 1.5 (P < 0.001). In conclusion, angiographic indexes correlate with volumetric intravascular parameters. Although IVUS was more sensitive than QCA to assess neointimal proliferation, the assessment of stent endothelisation was more precise using OCT.

Long-term Clinical Results for Randomised Comparison of Paclitaxel-eluting versus Bare-metal Stents in Unprotected Left Main Coronary Artery Disease To optimise percutaneous coronary intervention (PCI) strategy for unprotected left main (ULMCA) disease we performed a randomised study: IVUS-guided bare metal stent (BMS) versus paclitaxel-eluting stent (PES) implantation after lesion pre-treatment with cutting balloon (CB) for unprotected LM lesions. The purpose of this randomized study was to evaluate six-month and three-year clinical results. Several recent publications have demonstrated good short- and midterm outcomes in patients with left main artery disease after stent implantation. However, data on long-term comparison of BMS and PES for LM lesions are limited. Patients with left main coronary artery disease enrolled at Latvian Centre of Cardiology were randomly assigned to either BMS (n = 50) or PES implantation (n = 53). All interventions were IVUS-guided and CB pre-treatment before stenting was performed in all patients. All patients were scheduled for six-month and three-year follow-up. The primary endpoint was major adverse cardiac events (MACE) defined as death, Q wave myocardial infarction or target lesion revascularisation (TLR). Baseline clinical and procedural characteristics were comparable in both groups. At six months, the MACE-free survival rate was 70% in BMS and 87% in PES patients (P < 0.05). At three years, MACE occurred in 18 patients (36.0%) in the BMS and seven patients (13.2%) in the PES group (P < 0.05). The current study demonstrates the benefit of IVUS guided paclitaxel-eluting stent implantation after cutting balloon pre-treatment in left main coronary artery disease over bare metal stent implantation at six months and three years.