Aims The longevity of saphenous vein graft (SVG) is relatively poor as compared to mammary graft. It is generally believed that outcomes following PCI to SVG is poor, however there is limited data in the literature that have demonstrated this notion. In this study, we have evaluated long-term clinical outcomes following PCI to saphenous vein graft (SVG) in acute coronary syndrome (ACS). Methods A retrospective analysis was conducted on all patients who received PCI to a saphenous venous graft in the context of acute coronary syndrome between January 2011 to December 2021. Follow-up was achieved by reviewing admission records and previous clinic visits. The outcomes measured included: cardiac death, target-vessel myocardial-infarction (TVMI), target lesion revascularisation (TLR), target vessel revascularisation (TVR) and MACE (combination of cardiac death, target-vessel MI and target vessel revascularisation). Results 306 patients with a mean age of 74 (range 46–91 years) were treated with PCI to SVG in context of ACS of which 17% were ST-segment elevation myocardial-infarction (n=51). 87% were males (n= 268), 41% were diabetic (of those 43% were insulin dependent), 35% (n=178) had renal-dysfunction and 37% had impaired left ventricular function (ejection-fraction < 50%). With regards to procedural characteristics: 73% (n=276) were de-novo and remainder 10% (n=30) were in restenotic lesions. Based on the angiographic review, 21% (n=64) of grafts were considered degenerate (ectatic, aneurysmatic and/or thrombotic). During the procedure, the majority (66%) used semi-compliant balloons, 33% non-compliant balloons and 3% scoring balloons. Intra-vascular imaging was used in 5% of cases, embolic protection devices and thrombus aspiration were used in 8% cases and the use of GPIIB/IIIA inhibitors was 7%. Slow-flow/ no-flow occurred in 21% (n=68) of procedures requiring intracoronary vasodilator but overall success rate was 94% (n= 287). The average stent diameter was 3.4 mm and average stent length was 40 mm. There were 10 deaths before discharge. During a median follow-up of 1438 days (47 months), cardiac death occurred in 94 patients (18.6%), target vessel MI was in 12% (n=36); TLR was 11% (n=35), TVR 14% (n=42) and overall MACE rate was 30.7% (n=94). Conclusions Our data suggests that the long-term outcomes following SVG-PCI in ACS have high MACE rates, but the rate of repeat revascularization is acceptable considering the complex set of population and lesion subsets. Given the high MACE rates, PCI to native circulation should be considered if such options are available especially in the current era where there is significant improvement in the tool kit and expertise especially for undertaking PCI in complex lesion including chronic total occlusion. Conflict of Interest None

Aims The longevity of saphenous vein graft (SVG) is poor. However, if SVG has already been stented and if there is restenosis within the previously stent then long-term outcomes is considered to be poor, although there is no long-term data on the treatment of SVG restenosis. In this study, we have assessed long-term outcomes following treatment of SVG-restenosis in acute coronary syndrome (ACS). Methods A retrospective analysis was conducted on all patients who received PCI to a saphenous venous graft in the context of acute coronary syndrome between January 2011 to December 2021. Follow-up was achieved by reviewing admission records and previous clinic visits. The outcomes measured included: cardiac death, target-vessel myocardial-infarction (TVMI), target lesion revascularisation (TLR), target vessel revascularisation (TVR) and MACE (combination of cardiac death, target-vessel MI and target vessel revascularisation). Results 30 patients with a mean age of 73 (range 56–90 years) were treated with PCI to SVG in context of ACS of which 30% were ST-segment elevation myocardial-infarction (n=9). 80% males (n= 24), 57% were diabetic (of those 71% were insulin dependent), 40% (n=10) had renal-dysfunction (GFR <60 ml/min) and 38% had impaired left ventricular function (ejection-fraction < 50%). Based on the angiographic review, 30% (n=9) of grafts were considered degenerate (ectatic, aneurysmatic and/or thrombotic). During the procedure, the majority (86%) used semi-compliant balloons and 47% non-compliant balloons, thrombus aspiration was used in 17% cases and the use of GPIIB/IIIA inhibitors was 10%. Slow-flow/ no-flow occurred in 27% (n=8) of procedures necessitating use of intra-coronary vasodilator in 10% of cases (n=3) with overall success rate of 96% (n= 29). In 5 cases (16%), drug eluting balloon (DEB) was used, the others (84%) utilised stents (n=25). The average stent diameter was 3.4 mm and length was 25 mm and average DEB diameter was 3.4 mm and length was 31 mm. There were 2 deaths before discharge. During a median follow-up of 1400 days (46 months), cardiac death occurred in 9 patients (30%), target vessel MI was in 10% (n=3); TLR was 17% (n=5), TVR 17% (n=5) and overall MACE rate was 47% (n=14). Conclusions Our data suggest that the long-term outcomes following intervention to re-stenosis of SVG-PCI in ACS has an unacceptably high MACE rate in this small study group. Given this, maybe we should consider PCI to native circulation if there is such an option especially given the current improvement in complex PCI techniques. Conflict of Interest None

Background Drug coated balloons (DCBs) in Europe are mainly used in restenotic lesions as endorsed by the European Society of Cardiology, with a class IA recommendation. However, some of the recent data suggest, it can also be considered in a subset of denovo lesions, especially in small vessels. Most DCBs used are coated with Paclitaxcel. There is no data on the efficacy of Sirolimus in DCBs, the drug of choice in drug eluting stents. In this study, we report outcomes from the use of a Sirolimus coated balloon (SCB) in de novo small-vessel coronary lesions, from a single high yield centre. Methods A retrospective analysis was conducted on all patients treated with an SCB between March 2018 and October 2020. Follow-up was achieved with clinic visits, telephone calls and admission records. The outcomes measured include cardiac death, target-vessel myocardial-infarction, target lesion revascularisation and MACE (combination of cardiac death, target-vessel MI and TLR). Results During the study period, 279-patients (with 332-lesions) with de novo lesions were treated with an SCB. The mean age of patients was 65 ± 12 years, 219 (79%) were male, 36% (n=100) had diabetes, 16% (n=45) had chronic kidney disease and 61% were in the setting of acute coronary syndrome (n=169). Predilatation was performed in 96% (320-lesions). Bailout stenting (with DES) was required in 5% lesions (n=18) and of which 16 were due to dissections and 2 were due to recoil >30% following DCB use. The mean diameter and length of DCBs were 2.35 mm and 26 mm respectively. During a median follow-up of 584-days (19-months) cardiac death was reported in 8 patients (3%). Target vessel MI was in 3% (n=9), TLR per lesion was 8% (n=26) and the MACE rate was 11% (n=31). There were no documented cases of acute vessel closure. Conclusion The long-term outcome from the first ever study on sirolimus eluting balloon in de novo small vessel lesions appears promising with low rates of hard endpoints, and acceptable repeat rates of TLR despite a complex group of patients (50% ACS, 36% diabetics and 19% CKD) and lesion subsets (small vessel and diffuse disease). Implanting stents in these subsets renders them vulnerable to restenosis, making it difficult to treat, making treatment challenging and resulting in high rates of recurrence. Conflict of Interest None to declare

BACKGROUND:Angioplasty for ISR remains a challenge with relatively high rates of recurrence. Although there is a plethora of data on ISR, there is relatively less data on intra-stent-CTO. In this study, we explore the long-term clinical outcomes following angioplasty to intra-stent CTO and study the differences in clinical outcomes between three treatment-arms: POBA vs. DES vs. DCB. METHODS AND RESULTS:We evaluated all patients who underwent PCI to intra-stent CTO between 2011 and 2017. The endpoints used were: cardiac-death, TVMI, TLR, TVR, and MACE.During the study period, 403-patients with a mean age of 69.2 years had successful PCI to intra-stent CTO. 50% were diabetic, 38% had CKD and 32% had left ventricular dysfunction. 93% of cases were stable angina. 22% (n = 88) received only POBA, 28% (n = 113) received DCB and 50% (n = 202) received DES. During the median follow-up of 48-months, cardiac-death occurred in 5.8% (n = 23), TVMI in 4% (n = 16), TLR in 45.6% (n = 182), TVR in 48.7% (n = 194) and MACE of 46%. There were no differences in the hard endpoints between the 3treatment arms. However, the TLR and overall MACE were better in DCB and DES-groups as compared to POBA (TLR: 33%vs.42%vs.49%; p = 0.06); MACE (34% vs. 45% vs. 52%; p = 0.05). CONCLUSION:This is the first study that has focussed on the outcomes following angioplasty to intra-stent CTOs with a very long-term follow-up. The hard endpoints were low, although the TLR rates were high. In regards to treatment strategy, the DCB and DES provide relatively better outcomes than POBA.

Abstract Introduction Use of drug coated balloons (DCBs) in coronary intervention is escalating and the guidelines recommend its use in restenotic lesions. However, recent data suggest it can also be considered in a subset of denovo lesions especially; small vessels, ostium of an important side-branch and in patients unable to tolerate dual antiplatelet therapy for a prolonged period. Most DCBs used elute Paclitaxcel, but there is no data on Sirolimus eluting DCB, which is the drug of choice in currently available drug eluting stents. In this study, we report outcomes from the use of a Sirolimus coated balloon (SCB) in de novo coronary lesions. Methods We retrospectively analysed all patients treated with an SCB between April and December 2018. Results are reported as cardiac death, target vessel myocardial infarction (TVMI), target lesion revascularisation (TLR), target vessel revascularisation (TVR) and MACE (combination of cardiac death, target vessel MI and TLR). Results During the study period, 351 patients (with 414 lesions) with de novo lesions were treated with an SCB. The mean age of patients was 65.6±11.5 years, 275 (78%) were male and 39% (n=212) had diabetes. Most lesions treated were in the LAD/diagonal system (n=173, 42%). Predilatation was performed in 98% (405 lesions). Bailout stenting (with a drug eluting stent) was required in 7% lesions (n=30), of which 11 were due to dissections and 19 were due to recoil >50% following DCB use. The mean diameter and length of DCBs were 2.47 mm and 26 mm respectively. During a median follow-up of 322-days (11-months) cardiac death was reported in 8 patients (2.3%). Target vessel MI was in 3%; n=10, TLR and TVR per lesion were 8% (n=34) and 9% (n=37) respectively. The MACE rate was 11%. There were no documented cases of acute vessel closure. Conclusion The mid-term outcome from the first ever study on sirolimus coated balloons in de novo lesions appears promising with low rates of hard endpoints with no documented cases of acute vessel closure. The MACE rates appear promising, although we need longer follow-up which is ongoing and we will be able to report outcomes from even longer follow-up during the presentation. Funding Acknowledgement Type of funding sources: None.

Aims The bailout stenting post-drug coated balloon (DCB) is performed with second generation drug eluting stents (DES). For paclitaxel DCBs (PCB), it will result in delivery of 2 different drugs to the vessel wall (Paclitaxel from DCB + Limus from DES), on the contrary for sirolimus DCBs (SCB) it will result in double dose of a same drug (Limus from DCB + Limus from DES). In this study, we study the differences in the clinical outcomes between the two groups (PCB + Limus stent vs. SCB + Limus stent) assessing for either a synergistic or a toxic-effects. Methods and Results We evaluated patients treated with DCB between January 2016 and June 2019 at our centre. Results are reported as death, cardiac death, target vessel myocardial infarction (TVMI), target lesion revascularisation (TLR) and MACE (combination of cardiac death, TVMI and TLR). During the study period; 890 lesions (766-patients) were treated with DCB. Of them; 433 were treated with PCB and 477 with SCB. Total of 81-lesions (9%) needed bailout stenting for either dissection and/or recoil of >50%. This included; 42-lesions in PCB group and 39-lesions in SCB group. There were no significant differences in the baseline characteristics between the two groups. During the median follow-up period of 18-months, the clinical outcomes between PCB and SCB group were; death: 3 (7%) vs. 0; p=0.3, cardiac death: 2 (5%) vs. 0; p=0.5, TVMI: 0 vs. 1 (2.6%); p=0.4, TLR: 1 (2.4%) vs. 3 (7.7%); p=0.5, MACE: 3 (7%) vs. 3 (7.7%); p=0.7. There were no reported cases of stent thrombosis in either group. Conclusions The bailout stenting rate was relatively low in our group (9%) as compared to previously published studies. No significant differences were observed between the two-bailout stenting groups, although numerically PCB + limus stent group had lower rates of TLR, but had higher mortality rates as compared to SCB + limus stent, implying potential synergistic effect, but maybe at the cost of toxicity? This needs to be confirmed with larger patient group with multi-centre experience. Conflict of Interest None

Background Use of drug coated balloons (DCBs) in coronary intervention is escalating. There is a plethora of data on Paclitaxcel-DCB. However, when it comes of stents, Limus-drugs are preferred over Paclitaxel. There is very limited data on Sirolimus coated balloons (SCB). MagicTouch-SCB (Concept Medical, FL) elutes Sirolimus via nano-technology and have been used in our centers since March 2018. We report a mid-term follow-up with this relatively novel-technology. Methods and results We retrospectively analyzed all patients treated with MagicTouch-SCB between March-2018 and February-2019. Results are reported as cardiac-death, target-vessel myocardial-infarction (TVMI), target lesion revascularization (TLR) and Major Adverse Cardiac Events (MACE). During the study period, 288-patients (373-lesions) with a mean age of 65.8 were treated with MagicTouch-SCB. 84% (n = 241) were male, 155 (54%) were in the setting of acute coronary syndrome, 38% (n = 110) had diabetes and 62% (n = 233) were in de-novo lesions. Most lesions treated were in the LAD/diagonal-system (n = 170; 46%). Pre-dilatation was performed in 92% (n = 345) of cases. Bailout stenting was required in 9% lesions (n = 35). The mean diameter and length of SCBs were 2.64 +/- 0.56 mm and 24 +/- 8.9 mm respectively. During a median follow-up of 363 days (IQR: 278-435), cardiac death and TVMI occurred in 5-patients (1.7%) and 10-patients (3.4%) respectively, TLR per-lesion was 12%. The MACE rate was 10%. There were no documented cases of acute vessel closure. Conclusions The results from mid-term follow-up with this relatively new technology SCB is encouraging with a low rates of hard endpoints and acceptable MACE rates despite complex group of patients and lesion subsets.

Use of drug-coated balloon (DCB) in de novo lesions is usually preferred in small vessels, and the recently reported Basket small 2 trial showed that DCBs were noninferior to second-generation DES. All the available data DCBs in de novo lesions have been extrapolated from paclitaxel-eluting balloons

Abstract Background The incidence of bailout stenting post-drug coated balloon use (DCB) in the literature has been more than 10%; ranging up-to 21% in Bello trial and this variation could be due to the different criteria used to consider bailout stenting and may also reflect aggressive pre-dilatation. Our eyes are trained to expect stent like result and anything less is considered sub-optimal and this could be one of the reasons for high incidence of bailout stenting. The current recommendation is to use drug eluting stent (DES) for bailout stenting and hence raising in the possibility of drug toxicity or maybe even synergistic effect from combination of Paclitaxel (DCB) and limus (DES). Aim We have evaluated the incidence and outcomes of patients needing bailout stenting in our centre. Methods and results We evaluated all patients who were treated with DCB between January 2016-August 2017. Bailout stenting per lesion were identified and studied for endpoints which included cardiac death, target vessel MI, stent thrombosis, target lesion revascularization and target vessel revascularisation. Between the study period; 468 lesions (in 364 patients) were treated with paclitaxel DCB (Sequent Please, B Braun, Germany). Bailout stenting was required in 23 lesions (4.9%) and of which 12 (52%) was for flow limiting dissections (type C or more) and the remaining 11 was for recoil of more than 50%. Majority of the lesions were de novo (18; 78%). All bailout stenting was performed with third generation limus eluting stents. During a median follow-up of 18.14 months; range; 7–33 months, there was no cardiac death and target vessel MI occurred in 1 patient (4.3%), TLR and TVR were in 3 lesions (13%). MACE rate (combination of cardiac death, target vessel MI and TVR) was 13%. There were no cases of stent thrombosis as per the ARC definition. Conclusion One of the highlighting features of our study is very low-rates of bailout stenting. This may be due to our criteria of not stenting mild dissections (unless they are flow limiting) and also to accepting recoil of up-to 50% post-DCB use. The outcome in bailout stenting group is acceptable especially with hard endpoints (cardiac death, target vessel MI and stent thrombosis) although TLR and TVR rates were higher indicating synergistic effect of paclitaxel and limus may not offer additional benefits.

Introduction Bailout stenting post-Paclitaxcel drug coated balloon use (DCB) is done with Limus eluting stent as we don’t use Paclitaxcel eluting stent anymore. However, when using Sirolimus DCB, bailout stenting is done with Limus eluting stent, but this raises the issue of drug toxicity with double dose of Limus to the vessel wall. In this study, we evaluate all patients treated with Limus DCB that required bailout stenting for safety and clinical outcomes. Methods and Results We evaluated all patients who were treated with MagicTouch Sirolimus eluting DCB (Concept Medical limited, India) March 2018-June 2019. Bailout stenting per lesion were identified and studied for endpoints which included cardiac death, target vessel MI, stent thrombosis, target lesion revascularisation and MACE. Between the study period; 406 patients (477-lesions) with a mean age of 66 ± 11.2 years (range; 37-90) were treated with MagicTouch DCB. Bailout stenting was required in 39 lesions (8%) and of which 22 were due to dissections and 17 were due to >50% recoil following DCB use. During a median follow-up of 302 days; there were no cases of cardiac death, 1-case of target vessel MI (2.6%) and 3-cases (7%) of TLR. The MACE rate was 7%. There were no cases of stent thrombosis as per the ARC definition. Conclusion One of the highlighting features of our study is low-rates of bailout stenting (9%). This may be due to our criteria of not stenting mild dissections (unless they are flow limiting) and not to expect stent like results. The outcomes in the bailout stenting group is excellent with very low hard clinical endpoints indicating there may not be any toxic effect from double dose of Limus drug (DCB + DES). Conflict of Interest None

Use of drug-coated balloons (DCBs) in coronary intervention is escalating. Most available DCBs elute paclitaxel, and there is a plethora of data on them. However, we prefer limus-eluting over paclitaxel-eluting stents. There is very limited data on sirolimus-eluting DCBs. MagicTouch (Concept Medical

Since the first catheterisation of a human heart was performed by Werner Forssmann in 1929, access site practice has undergone considerable evolution and technical refinement. Early operators accessed the left side of the heart using a surgical technique to expose and cannulate the brachial artery in the antecubital fossa. Although expert operators can obtain excellent results with this technique, it requires considerable surgical expertise to identify, dissect out, cannulate, and repair the selected vessel.w1 Because of these issues, most cardiologists moved to the technically simpler percutaneous femoral access site. Performing cardiac procedures via a percutaneous approach to the femoral artery has important disadvantages related to its unfavourable neurovascular anatomy.w2 Because of this unfavourable neurovascular anatomy, femoral artery access site complications can have major life or limb threatening consequences. The risk of major femoral access site complications is substantially increased when intensive antithrombotic regimens are employed.w3 These femoral access site problems have not been solved by vascular access closure devices.w4 Radial artery access for coronary angiography was first described by Campeau in 1989, with coronary intervention performed by this route shortly after.1 Initial success rates with this access site were suboptimal. Improvements in technique and equipment have resolved this problem, and more recent success rates are comparable to those obtained via the transfemoral route.2 Radial operators have extended their practice, demonstrating that excellent results can be achieved by skilled operators in challenging patient subsets.w5 w6 Meta-analysis of randomised trials confirms that radial access is associated with a significant reduction in access site bleeding.3 Prevention of bleeding is of great clinical importance, and may explain the recent finding that radial access is associated with a reduction of mortality in angioplasty patients.4 Additional benefits of radial access include improved patient comfort, reduced nursing requirements, …

The pathophysiology underlying the initiation and progression of cardiovascular disorders is highly complex and multifactorial. The endothelium also plays a crucial role in the pathogenesis of thrombogenesis and atherogenesis, and a continuum of endothelial activation, dysfunction or damage is evident in many cardiovascular disorders both at the macro and microscopic level(s). This review article aims to provide an overview of the assessment of endothelial (dys) function and discuss the implications and limitations of such assessments.