9th Annual Complex Cardiovascular Catheter Therapeutics (C3 Conference) Advanced Endovascular and Coronary Intervention Global Summit: June 17-21, 2013 / Orlando, Florida

C3-001 

Single-Center Five-Year Experience Using Anterograde and Retrograde Approaches for Chronic Total Coronary Occlusions Revascularization

A. Kalnins, I. Strele, I.Kurcalte, A. Lejnieks

Percutaneous coronary intervention (PCI) of coronary chronic total occlusion (CTO) is still relatively infrequent due to the uncertainty and paucity of data on the likelihood of successful PCI of CTO. Retrograde approach through the collateral channels has recently improved the success rate of PCI for CTO. The aim of our study was to compare CTO PCI procedural parameters and treatment results using anterograde and retrograde approach.  Methods. The study included all patients undergoing PCI for CTO at a single tertiary PCI center between January 2007 and December 2012. A total of 5568 PCI procedures was done in this period at our institution; 486 (8.64%) of them were CTO PCIs. Retrograde approach was used in 138 cases (28.7% of all CTO PCIs). Patients were separated according to year PCI was performed, approach (anterograde or retrograde), PCI results (successful or unsuccessful), and J-CTO score. Demographic and procedural data were collected at the time of intervention. In-hospital MACE (myocardial infarction, urgent revascularization, stroke or death) was documented at discharge. Postdischarge data were obtained by telephone follow-up. Results. A total of 405 patients undergoing PCI for 486 CTO procedures were included. Median age, 64 years (38-88 years), 76% male. Retrograde approach (RA) was used in 138 cases (28.7%). RA usage has increase from 15.9% in 2007 to 46.8% of cases in 2012. Overall patient and procedural success rates were 77.8% (315/90) and 69.9% (340/146), respectively. Overall success rate increased from 61.4% in 2007 to 87.1% in 2012 (P<.005). The target artery with CTO lesions included the left main (3 cases; 0.62%) right coronary artery (270 cases; 56.1%), left anterior descending artery (165 cases; 34.3%), and left circumflex (42 cases; 8.73%). RA usage was RCA for 34% of cases, LAD for 23%, and LCX for 17%. Three strategies for RA were applied: retrograde as primary strategy, retrograde immediately after antegrade failure, and repeat procedure after previous antegrade failure. RA as the primary strategy was applied in 29/137 patients (21.17%), RA immediately after antegrade failure attempt was performed in 99/137 patients (72.26%), and RA as elective procedure, after previously failed antegrade attempt, was performed in 9/137 patients (6.57%). A better success rate (61%) were founded in the procedures group, which was done in one session —retrograde approach immediately after failed anterograde  in comparison with 55% and 44% success rates in retrograde as primary and retrograde after previous failed anterograde, respectively. J CTO score was calculated for all patients. For less complex CTO lesions (J CTO score 0-1) RA was used in 5.1% and 19.8% of cases, respectively; for intermediately complex lesions (J CTO score 2 and 3), RA was used in 28.5% and 42.3%, respectively, and for very complex lesions (J CTO score 4) RA was used in 70.6% of cases (P<.001). Total complication rate was 13.7% (11.4% in the anterograde patient group and 19.6%  in the retrograde group (P=.018). Better survival results were found in the successful anterograde procedure group, but the difference was not significant (Long-rank test P=.192). Also, better survival was found in the successful retrograde procedure group and the difference was significant (Long-rank test P=.012). Similar survival results were found in both unsuccessful anterograde and unsuccessful retrograde procedure groups (Long-rank test P=.751). Overall survival was found better in patients group after successful procedure (Long-rank test P=0.019). Conclusions. Retrograde approach usage significantly increases CTO PCI success rate.  More complex technique (RA) usage doesn’t significantly increase rate of complications. Indication of RA should be performed in case anterograde wiring seems very difficult in terms of anatomical factors. Long-term outcome and survival after CTO PCI is not dependant on approach (anterograde or retrograde), but on procedural success.

C3-002

WATCHMAN Left Atrial Appendage Occluder in Octogenarians: Short-Term and One-Year Follow-up

Sameer Gafoor, Jennifer Franke, Stefan Bertog, Patrick Boehm, Maik Gonzaga, Janine Bauer, Annkathrin Braut, Simon Lam, Laura Vaskelyte, Ilona Hofmann, Horst Sievert

Left atrial appendage (LAA) occlusion is useful in patients with atrial fibrillation to avoid long-term anticoagulation. The safety and efficacy in older patients is not well known. Objective. To document the safety and efficacy of WATCHMAN left atrial appendage occluder in a high-risk cohort ≥80 years of age. Methods.  A retrospective review of patients 80 years or older with atrial fibrillation who underwent LAA occlusion with the WATCHMAN device at our hospital was performed. Baseline demographic, procedural, and follow-up data were obtained. Results. Between June 2006 and June 2011, a total of 26 patients (53.8% male; age, 83 ± 2.6 years) were identified. Hypertension, coronary artery disease, and congestive heart failure were present in 100%, 50%, and 38.4%, respectively. Atrial fibrillation was permanent in 61.5% of patients, with 11.5% and 18.5% having a prior stroke or transient ischemic attack, respectively. Mean CHADS2 and CHADS-VASc scores were 3.2 and 5.3. Anticoagulation with vitamin K antagonists was used in 50% of patients. Multiple appendage lobes were present in 11.5%. Procedures were successful in 92.3% of patients. The procedure was unsuccessful in 2 patients due to device instability and difficulty with positioning. At 6 months, 1 device thrombus and 1 episode of atrial tachycardia were reported. One-year follow-up revealed no deaths, 1 pacemaker implantation, 1 peripheral vascular procedure, and 1 additional hospitalization due to congestive heart failure. No strokes were reported in the follow-up period. Conclusion.WATCHMAN LAA occluder implantation is feasible and safe in octogenarians. Efficiency in stroke prevention is supported by an absence of cerebrovascular events. 

C3-003 

Percutaneous Mitral Commissurotomy for Patients with Mitral Stenosis in Atrial Fibrillation: Immediate and Long-Term Results

Tounsi Ahmed, Abid Dorra, Abid Leila, Akrout Malek, Mallek Souad, Triki Feten, Hentati Mourad, Kammoun Samir

Controversy persists as to whether atrial fibrillation (AF) has a direct negative effect on the outcome of percutaneous mitral commissurotomy (PMC). The study aim was to assess the effect of AF on immediate and 10-year clinical and echocardiographic actuarial results of patients with rheumatic mitral stenosis undergoing PMC. Methods. A total of 155 consecutive patients with AF (group 1) was analyzed and compared with 205 patients in sinus rhythm (group 2), matched for the severity of mitral valve morphological changes. Results. Group 1 patients were older (44.1 ± 13.2 years vs 31.8 ± 12.4 years; P<.001), had higher echocardiographic scores (8.7 ± 1.2 vs 7.86 ± 1; P=.01) and a greater proportion had grade 1 mitral regurgitation (22.8 vs 11.4%; P<.0001). The procedural success was 81.3% in group 1 and 89.75% in group 2 (P=NS), but group 1 patients had a smaller mitral valve area (2.1 ± 0.4 cm² vs 2.3 ± 0.4 cm²; P<.0001). Patients in AF had a lower 10-year survival (91.61% vs 96.58%; P=.03), a lower 10-year event-free-survival (63.22% vs 77%; P=.02), and a lower 10-year freedom from restenosis (47.33% vs 64.4%; P=.05). AF was an independent predictor of overall mortality (odds ratio [OR], 8.8; P<.033) and of combined events (death, redo PMC, or mitral valve surgery; OR, 2.2; P<.01), and was a univariate predictor of restenosis (P=.048). Conclusion. Patients with AF have good immediate results, but poorer long-term outcome after PMC. AF is a marker of worse prognosis in patients with mitral stenosis, as it is in the general population.

C3-004

Immediate and Mid-Term Results of Repeat Percutaneous Mitral Commissurotomy for Restenosis Following Earlier Percutaneous Mitral Commissurotomy: Our Experience

Tounsi Ahmed, Abid Dorra, Abid Leila, Akrout Malek, Mallek Souad, Triki Feten, Hentati Mourad, Kammoun Samir

This study assessed the results of repeat percutaneous mitral commissurotomy for mitral restenosis following a first procedure. Methods and Results. Repeat balloon commissurotomy was performed in 53 patients who had symptomatic restenosis a mean of 6 ± 2 years (range, 2-11 years) after a successful first procedure; 7 patients had mildly calcified valves. All patients had restenosis with a fusion of both commissures as assessed by echocardiography. A double-balloon was used in 1 case and the Inoue technique in 52 cases. Complications were stroke in 1 patient and severe mitral regurgitation in 2 patients. Valve area increased from 1.03 ± 0.22 cm² to 1.82 ± 0.21 cm² (P<.0001) as assessed by planimetry. Good immediate results, defined as valve area ≥1.5 cm² with no regurgitation >2/4, were obtained in 48 patients (91%). The 5-year survival rate without operation and in New York Heart Association class I or II was 69 ± 11% in the whole population, and 76 ± 11% in the 48 patients who had good immediate results. Conclusion. This study suggests that repeat balloon commissurotomy is a valid treatment for symptomatic restenosis after a first successful procedure. It gives good results in patients selected on the basis of favorable characteristics and the echocardiographic analysis of the mechanism of restenosis.

C3-005

Percutaneous Revascularization of Superficial Femoral Artery Chronic Total Occlusions: A Large Single-Center Experience

Mohammed Salim Aldamluji, Sameer Nagpal, Erik Stilp,Carlos Mena-Hurtado

 Chronic total occlusion (CTO) of the superficial femoral artery (SFA) is present in nearly half of patients with lower-extremity claudication. The anatomically complex nature of these lesions presents technical challenges to percutaneous management. Success rates of crossing SFA CTOs vary based on operator experience, but have improved with newer crossing devices, reported as high as 84% in the PATRIOT IDE study. Our aim was to investigate the methods and the overall procedural success for percutaneous SFA CTO revascularization in a large university practice with a single, experienced operator. Methods. After obtaining Human Investigation Committee approval, we performed retrospective chart review on all cases of percutaneous intervention to SFA CTO between January 1, 2011 and July 1, 2012 at Yale-New Haven Hospital performed by a single operator. Procedure reports for all Current Procedural Terminology codes 37224, 37226, and 37227 (revascularization in the femoral/popliteal territory) occurring during the predefined time period were examined. Cases were included in the review provided the procedure report mentioned CTO or 100% occlusion of one or both SFAs. Data were then abstracted from included patients’ medical records and analyzed utilizing an Epi Info database. Results. Percutaneous SFA CTO revascularization was attempted on 94 culprit lesions in 84 consecutive adult patients during the predefined time period. Average lesion length was 22.8 ± 12.6 cm. Lesions were crossed using either wire and catheter technique (74.5%) or a crossing device (25.5%). Atherectomy was performed in 21% of cases. Bivalirudin was used in 88% of cases. Crossover access approach was used in 92% of procedures. Stents were deployed in 68% of cases, self-expanding bare-metal stents most commonly used (86%). A reentry device was used after subintimal crossing technique in 8.5% of procedures. Successful revascularization, defined as postprocedural angiographic stenosis of less than 30%, was achieved in 86.5% of lesions on the first attempt. Five of the 13 unsuccessful cases were reattempted during the predefined time period, and 4 were successfully revascularized, yielding a patient specific success rate of 91.6%. There were no major periprocedural complications or deaths. Vessel dissection was the most frequent minor periprocedural complication (6.3%). Access-site hematoma was rare (4%), manual pressure used for access point closure (52%). Conclusion. SFA CTO is amenable to percutaneous revascularization with few periprocedural complications and a remarkable rate of success in our large, single-center, single-operator experience. Our results compare favorably to previously published PATRIOT and CONNECT studies with regard to the technical success rate of crossing SFA CTOs, despite a minority of cases requiring a crossing device or reentry catheter.

C3-006

Preliminary Results From the Jetstream Navitus System 

Endovascular Therapy Post-Market (JET) Registry

Nicolas W. Shammas, William Gray, Lawrence Garcia, Rajesh Dave, Henry Meltser, Greg Kasper for the JET Investigators

Treatment of complex lesions in the femoropopliteal (FP) artery including long, occluded, diffuse, thrombotic, or calcified lesions carries an increased risk of major adverse events (MAE), reduced patency at 1 year and recurrent target lesion revascularization (TLR). The Jetstream NAVITUS system is a rotating and aspirating atherectomy catheter approved for active removal of atherosclerotic disease and thrombus in peripheral vasculature. The post-market JET registry will evaluate acute procedural success, MAE, and patency at 1 year in de novo or non-stent restenotic lesions of the FP artery. Methods. JET is a multicenter, open-label, non-randomized registry in up to 75 sites with a target enrollment of 500 patients, Rutherford category 1-3, and with de novo or non-stent restenotic FP lesions ≥4 cm in length and ≥70% in severity. Lesions with in-stent restenosis, crossed via a subintimal approach, or treated within 1 month prior to index procedure are excluded. The primary endpoint is binary stenosis at 12 months as defined by duplex-ultrasound derived systolic velocity ratio >2.5. Secondary endpoints include procedural success as defined by successful revascularization of target vessel, defined as ≤30% residual diameter stenosis following atherectomy ± adjunctive therapy, improvement in ankle-brachial index through 12 months compared to preprocedural baseline, and MAE through 30 days. MAE is defined as amputation, death, TLR, target vessel revascularization, myocardial infarction, or angiographic distal embolization requiring separate intervention or hospitalization. Index angiogram and duplex ultrasound assessment of binary stenosis will be evaluated by core laboratory. Results. Preliminary results from the first 60 patients are as follows: mean age, 65.5 years; male 68.3%; diabetic 50%; smoking history 63.4%; hypertension 87.8%; preprocedure ABI 0.68; non-stent restenotic lesions 78.8%; lesion length 174 mm; reference diameter 5.7 mm; pretreatment stenosis 90%; post Jetstream stenosis 45%; and post adjunctive treatment 9%. The JetStream total run was 3.52 minutes, and adjunctive stenting rate was 30.9%. Distal embolic protection was used in only 3.6% of patients. There were no in-hospital complications. Conclusion. Preliminary data are encouraging, with a high procedural success rate and no in-hospital complications and notably no distal embolization requiring further pharmacologic or mechanical treatment. 

C3-007

Orbital Atherectomy Outcomes of the Critical Limb Ischemia Patient Population Within the CONFIRM Series

Tony Das, Jeffrey Indes, Nilesh Doshi, Jihad Mustapha, George L. Adams

Peripheral arterial disease (PAD) that results in critical limb ischemia (CLI) is associated with significant morbidity and mortality. Twenty-five to 30% of CLI patients will die and 30% will undergo amputation within the first year of diagnosis. In this patient population, which includes advanced age, diabetes, and renal insufficiency, intraarterial calcium is typically a predictor of poor endovascular treatment success. Methods of treating PAD have evolved and now include minimally-invasive endovascular procedures, utilizing orbital atherectomy (OA) which modifies calcific plaque both above and below the knee. Methods. Three consecutive CONFIRM patient registries (the CONFIRM series) were conducted prospectively under a naturalistic “real-world” procedure-focused registry (2009 to 2011). The only inclusion criteria being medically necessary treatment in accordance with the device’s Instructions for Use. Thus, a total of 3135 patients suffering from PAD were enrolled on an “all-comers” basis, resulting in registries that provide an analysis of the CLI data as it pertains to the correlation of plaque morphology/calcification to the outcomes within the CLI patient population after OA treatment. Results. A total of 43.8% of the patients in the CONFIRM series had CLI (Rutherford categories 4-6). Procedural complications in the entire CLI patient population (n = 1340) included dissection (flow limiting [FL], 1.2%; non-FL, 4.6%; unknown, 3.8%), perforation (0.8%), embolism (2.1%), and thrombus (1.4%). In the CLI patient population, 85.7% (n = 1149) presented with severe-to-moderate calcium plaque burden. After treatment with orbital atherectomy, the occurrences of adverse events in this severe calcium CLI group were: no event, 88.5%; dissection (FL, 1.1%; non-FL, 4.4%; unknown, 3.6%); and perforation, 0.9%. Conclusion. The majority of the CLI patients in this study had lesions with moderate-to-severe calcification, yet the occurrences of adverse events were low after treatment with orbital atherectomy. Orbital atherectomy is a safe tool for restoring blood flow in the lower extremities of CLI patients regardless of calcium burden.

C3-008

Percutaneous Balloon Aortic Valvuloplasty and Clinical Outcomes in Severe Aortic Stenosis

Bhavin M. Patel, Michael Hakimi, David Ambrose, Jon C. George

Percutaneous balloon aortic valvuloplasty (PBAV) is primarily used as a palliative therapeutic option for relief of severe aortic stenosis (AS) in patients who are poor candidates or as a bridge to definitive surgical therapy or transcatheter aortic valve replacement (TAVR). The rationale behind limited use of PBAV is due to poor tolerance, complications, and high rates of recoil and recurrence in earlier studies. Our study describes the largest single-center experience of PBAV with current clinical outcomes. Methods. We reviewed the prior 10 years of data on all patients who underwent PBAV at Deborah Heart and Lung Center, totaling 357 patients. Extensive pre- and postprocedural data were analyzed on the last 100 patients, from October 2006 to January 2010, to determine current-day outcomes. Number of balloon inflations, change in pre- and postprocedure mean gradients, duration until repeat PBAV or surgical valve replacement, and mortality were recorded and evaluated as endpoints for outcomes. Results. Of the 100 patients analyzed, there were no hospital or procedure-related deaths, strokes, or emergent cardiac surgeries. Mean gradients (MG) across the aortic valve improved from 38.5 mm Hg to 19.2 mm Hg with an average change in mean gradient (ΔMG) of 19.1 mm Hg. The number of inflations performed during PBAV correlated to increase in ΔMG (1 inflation = 17.4 mm Hg ΔMG; >2 inflations = 20.0 mm Hg ΔMG; >3 inflations = 20.9 mm Hg ΔMG). The number of inflations also reflected an increased duration until repeat PBAV (1 inflation = 7.9 months; >2 inflations = 10.4 months; >3 inflations = 11.3 months). There were a total of 29 patients (29%) who underwent repeat PBAV with a mean duration of 9.5 months to the repeat procedure. The average ΔMG among those who required repeat PBAV was 20.6 mm Hg. The ΔMG was further linked to durability of procedure, such that when ΔMG <20 mm Hg, duration to PBAV = 8.7 months and when ΔMG >20 mm Hg, duration to repeat PBAV = 10.8 months. The mortality rate after PBAV was 10% over a mean follow-up period of 10 months, with an average ΔMG within this subset of 21.5 mm Hg. Discusion. PBAV provides a modest improvement in valve function and continues to be a safe and feasible option in experienced hands for select patients who are high risk for surgery or TAVR. The use of additional inflations during PBAV and ΔMG >20 mm Hg resulted in better long-term outcomes.

C3-009

Long-Term Patency Rate After Nitinol Self-Expandable Stent Implantation in Long Totally Occluded Femoropopliteal (TASC C&D) Lesions (Retrospective Study)

Mahmoud Farouk Elmahdy, Piergiovanni Buonamici, Maurizio Trapani, Renato Valenti, Angela Migliorini, Guido Parodi, David Antoniucci

Aim. To evaluate the long-term patency of nitinol self-expandable stents implanted in TASC C&D femoropopliteal lesions, and determine predictors of reocclusion or restenosis. Methods. All patients treated by nitinol self-expandable stents for totally occluded long femoropopliteal lesions between January 2002 and December 2010 were reviewed. Patient demographics, clinical features, anatomic, and procedure factors were retrospectively analyzed. Outcomes evaluated included long-term primary patency rate at 3 years and predictors of reocclusion or restenosis. Results. The study group included 240 TASC C&D limbs in 213 patients (mean age, 70.91 ± 9.37 years; 66.2% male). Limb claudication occurred in 154 (72.3%), while 59 limbs (27.6%) underwent treatment for critical limb ischemia, including 31 limbs (14.5%) with tissue loss. All lesions were total occlusion of the femoral artery ± the popliteal artery, with mean length of 17.94 ± 11.38 cm, and 31.2% of the target lesions were heavily calcified. A total of 509 nitinol self-expandable stents were implanted (average, 2.1 stents/limb), with 95.8% techniqual success. There was 1 procedure-related mortality or amputation. Follow-up was available for 240 limbs at a mean of 36 ± 22.6 months. No patient required a major amputation during this follow-up period. Thirty-nine limbs (16.2%) experienced reocclusion and 21 limbs (8.7%) experienced restenosis; all these limbs underwent reintervention during the follow-up time. Primary patency rates at 1, 2, and 3 years were 99.2%, 87.4%, and 74.4%, respectively. Independent predictors for reocclusion were male gender, severely calcified, and TASC D lesions, while diabetes, smoking, and TASC D lesions were the predictors for restenosis. Conclusions. Nitinol self-expandable stent implantation can be safely performed in long, totally occluded, and heavily calcified femoropopliteal (TASC C& D) lesions, with highly comparable long-term primary patency rate to venous bypass surgery. TASC D lesion is the most important predictor for reocclusion or restenosis.

C3-010

Short-Term and Long-Term Clinical Outcomes in Veterans Treated with Clopidogrel Compared to Prasugrel after Percutaneous Coronary Intervention

Arslan Shaukat, Mir B Basir, Sudesh K Srivastav, Islam Bolad

Studies have shown that prasugrel has higher efficacy compared to clopidogrel in reducing major cardiovascular events after percutaneous coronary intervention (PCI), but a higher risk of bleeding. There have been no studies conducted on a veteran population, which is characterized by male predominance, high average age, and a large burden of chronic diseases. Aim. To determine the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE) in our veterans treated with clopidogrel compared to prasugrel after PCI. Methods. Veterans who underwent PCI from January 2009 to October 2011 were included in this observational, single-center, retrospective study. Patients required PCI for stable and unstable angina, non-ST elevation myocardial infarction (MI), and ST-elevation MI. All patients received a loading dose of clopidogrel 300 or 600 mg or prasugrel 60 mg in addition to aspirin 325 mg prior to PCI. A total of 308 patients were included in this study, of which 251 received clopidogrel 75 mg daily or twice daily and 57 received prasugrel 10 mg daily, in addition to aspirin. A majority of the patients (~90%) were given prasugrel due to high platelet reactivity (VerifyNow P2Y12 reaction unit >235). The primary endpoint was MACCE, including non-fatal MI, cardiac death, stent thrombosis, target vessel revascularization and stroke at 1 month and 1 year. The key safety endpoint was bleeding events during this time period. All data were analyzed using chi-square test and/or Fisher’s exact test at the 5% level of significance using Statistical Analysis Software 9.1 (SAS Institute). Results.  In veterans receiving clopidogrel compared to prasugrel, there was no significant difference at 1 month and 1 year in the incidence of non-fatal MI (0.8 vs 3.5%; P=.16; 3.2 vs 5.2%; P=.22), cardiac death (0.4 vs 0%; P=1.0; 0.4 vs 0%; P=1.0), stent thrombosis (0.79 vs 1.75%; P=.46; 1.21 vs 1.75%; P=.57), target vessel revascularization (1.19 vs 1.75%; P=.56; 4.05 vs 5.26%; P=.72), or stroke (1.59 vs 0%; P=1.0; 0.81 vs 3.51%; P=.16). There was also no significant difference in the occurrence of bleeding episodes (3.17 vs 0%; P=.36; 7.29 vs 3.51%; P=.39). Conclusions. In our population of veterans, treatment with clopidogrel or prasugrel (in clopidogrel non-responders) following PCI demonstrated similar short-term and long-term incidence of major adverse cardiovascular, cerebrovascular, and bleeding events.

C3-011

JETSTREAM Atherectomy System Can Remove Superficial Calcium in Severely Calcified Peripheral Arteries

William Gray, Thomas Davis, Malcolm Foster, Venkatesh Ramaiah, Thomas Shimshak, Joseph Ricotta

The mechanism of lumen gain when using the JETSTREAM Atherectomy System to treat calcified lesions in peripheral arteries is unknown. Aim. To evaluate the effects of the JETSTREAM Atherectomy System when treating moderate-to-severely calcified peripheral arterial lesions in the common femoral, superficial femoral, and popliteal arteries. Methods. The JETSTREAM Calcium Study is a prospective, single-arm, multicenter study. Patients with symptomatic peripheral vascular disease undergoing percutaneous intervention with moderate-to-severe obstructive intraluminal calcium were considered as candidates for the study. Included were lesions with superficial calcium >90° in arc and >5 mm in length as evaluated by intravascular ultrasound (IVUS). Primary endpoints are calcium removal and luminal gain, measured from pre- to post-treatment with the JETSTREAM device.  Three slices per lesion with significant calcium reduction were selected from pre- and postatherectomy IVUS images and analyzed. Secondary endpoints include major adverse events (target lesion or vessel revascularization, death, unplanned amputation or myocardial infarction) within 30 days and adjunctive therapy use (balloon or stent). Results. Fifty-eight patients underwent angiographic screening; 26 (45%) met IVUS inclusion criteria. Lesion location was common or superficial femoral artery in 81% of cases, of which 67% had severe calcification and 33% had moderate calcification by angiography. Mean device run-time was 5.4 ± 3.1 minutes. Comparison of the pre- and postatherectomy IVUS images showed the minimum lumen area (MLA) increased from 5.1 ± 2.8 mm² to 8.3 ± 2.6 mm². In segments with significant calcium reduction, lumen area increased from 6.4 ± 3.1 mm² to 9.6 ± 3.1 mm² (P<.0001); calcium reduction was responsible for 78 ± 27% of the lumen area increase. A convex shape of the superficial calcium was seen in 66% of cases before treatment and in 26% after JETSTREAM treatment (P<.0001). An irregular surface was seen in 54% of cases before treatment and in 31% after JETSTREAM treatment (P<.0001). Although the arc of superficial calcium did not change (149 ± 81° to 141 ± 88°; P=.55), the arc of reverberation increased significantly (25 ± 29° to 71 ± 70°; P=.0008), indicating device-related modification of the lesion calcium. Adjunctive balloon angioplasty was performed in 71% and stent implantation in 24%. In 11 cases with adjunctive balloon dilation, the MLA increased significantly post adjunctive balloon from 7.1 mm² (6.4-7.8 mm²) post Jetstream to 11.9 mm² (10.3-13.5 mm²); P<.001 (shown as median and IQR). Although dissection was observed in 8 cases with adjunctive balloon dilation, the maximum arc of dissection was small (26 [20, 49]°), with preserved lumen area (15.0 [13.3, 16.6] mm²) within the dissection. No major adverse events occurred. Conclusions. In treating moderate to severely obstructed peripheral arteries, the JETSTREAM Atherectomy System removes and modifies superficial calcium to achieve significant lumen gain without major complications.

C3-012

Devising Useful Algorithms Based on Electrocardiographic Findings to Discriminate Between Right Coronary Artery and Left Circumflex Artery Occlusion in Acute Inferior Wall Myocardial Infarction Patients

Sachin K. Ramdhany, Ning Guo, Yong Zhang, Zuyi Yuan 

Although it has been generally considered that the patients with acute ST-segment elevation myocardial infarction (STEMI) in the inferior wall have more favorable prognosis than those in the anterior wall, potential complications exist when the culprit artery is the right coronary artery (RCA). We therefore compared the old and new electrocardiographic (ECG) criteria that can be useful for early identification of the culprit vessel between RCA and left circumflex (LCX) artery in patients with inferior-wall STEMI. Methods. A total of 194 patients with acute STEMI in the inferior wall admitted consecutively to our hospital were enrolled into this study. Eighteen-lead ECG recorded on admission of speed 25 mm/s with voltage 10 mm/mV was analyzed. ST-segment deviation was measured with a hand-held calliper and magnifying glass at J-point in all available leads. Coronary angiography was performed within the first 12 hours from symptom onset. Of these, a total of 166 patients were identified with culprit lesion in RCA and 28 patients in LCX. Results. Altogether the sensitivity and specificity of 10 old and 6 new ECG criteria were examined. Two of new criteria proved their utility in identifying the RCA and the LCX as the infarct-related artery: (1) The Ratio STD I /aVL ≤1, which yielded a sensitivity of 86.7%, a specificity of 92.8% and a positive predictive value of 98.6%, made it an accurate marker for RCA occlusion; (2) STE or isoelectric ST in lead I, which yielded a sensitivity of 93%, a specificity of 88%, and a positive predictive value of 56.5%, making it a highly accurate criteria to diagnose LCX as the infarct-related artery in patients with acute inferior wall STEMI. Conclusions. Two new ECG criteria in combination with those previously used can be used to discriminate the RCA from the LCX as the culprit artery at the bedside in patients with acute inferior wall STEMI. ECG is useful in differentiating between RCA and LCX involvement in acute inferior-wall STEMI before primary percutaneous coronary intervention, allowing decisions about therapy to be made at the earliest possible time.