Full text is available on www.invasivecardiology.com Safety of Percutaneous Left Heart Catheterization Directly Performed by Cardiology Fellows: A Cohort Analysis Pierfrancesco Agostoni, MD, Maurizio Anselmi, MD, Gabriele Gasparini, MD, et al. Background. No previous study has analyzed the possible responsibility of fellows-in-training in terms of the risk of complications during cardiac catheterization. Thus, we sought to identify possible risk factors for access site complications following cardiac catheterization procedures, with particular attention to the role of cardiology fellows. Methods. A total of 1,288 left heart catheterization procedures (both diagnostic and interventional), performed over a 1-year period at a university hospital, were retrospectively evaluated to determine the incidence of local complications (pseudoaneurysm, arterio-venous fistula, major hematoma or bleeding, vascular dissection). Several clinical (age, gender, previous coronary artery bypass surgery, indication to the exam) and procedural (procedure performed by the fellow, access site, type of procedure, urgent setting, use of glycoprotein IIb/IIIa inhibitors, simultaneous right heart catheterization, use of closure devices) covariables were considered. Major adverse cardiovascular and cerebrovascular events (MACCE: death, myocardial infarction, cerebrovascular event) were also assessed. Results. The overall access site complication rate was 2.6%. On multivariate regression analysis, the only two predictors of local complications were female gender (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.6-6.5) and femoral approach (OR 3.9, 95% CI 1.2-12.1). The rate of MACCE was 1.2%, mainly after percutaneous coronary interventions, with only 1 death overall (0.07%). Procedures performed by cardiology fellows were not associated with an increased incidence of either complication. Conclusions. Cardiology fellows can safely perform cardiac catheterization procedures without an increase in the rate of local and major cardiovascular complications. Of course, the presence and watchful supervision of an attending physician is still essential to ensure both patient safety and optimal training. J INVASIVE CARDIOL 2006;18(6):248-252. Aortic Stenosis Catheterization Revisited: A Long Sheath Single-Puncture Technique Janet Hays, MD, Michael Lujan, Robert Chilton, MD Objectives. To evaluate the accuracy of a new long sheath single-puncture technique in obtaining accurate transvalvular gradients in aortic stenosis. Background. Despite advances in echo Doppler, the evaluation of aortic stenosis continues to be a common procedure in the cardiac catheterization laboratory. Experts agree that simultaneous evaluation of the proximal aortic and left ventricular pressures yields the most accurate data; however, this is difficult to achieve unless two arterial punctures are performed. Methods. We postulated that using a 4 Fr pigtail catheter inside a 55-cm long 6 Fr sheath would provide accurate simultaneous pressure data, yet avoid the complications of two arterial punctures. We performed this technique in 13 male patients, and placed a second arterial catheter in the aortic root as a control aortic pressure. We then performed this technique in 55 other male patients without placing an additional control arterial catheter. Results. In the test population, correlation of aortic valve areas and transvalvular gradients was excellent. In the larger population, adequate hemodynamic data was obtained in 52 patients, with no difficulty engaging coronary arteries or grafts via the long sheath, and with an acceptable major complication rate of 1.5%. Conclusions. Using a 4 Fr pigtail catheter with a 55-cm long 6 Fr sheath is a safe, efficient way to obtain excellent hemodynamic data in an aortic stenosis catheterization procedure. J INVASIVE CARDIOL 2006;18(6):262-267. Percutaneous Coronary Intervention for Cardiac Arrest Secondary to ST-Elevation Acute Myocardial Infarction. Influence of Immediate Paramedical/Medical Assistance on Clinical Outcome Benigno Quintero-Moran, MD, Raul Moreno, MD, Sergio Villarreal, MD, et al. Background. Patients with cardiac arrest have been excluded from most randomized trials on percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). Objective. The aim of the study was to evaluate the outcome of patients undergoing primary PCI for acute myocardial infarction who suffered from cardiac arrest prior to the procedure, focusing the study on the influence of immediate paramedical/medical assistance on the outcome. Methods and Results. Sixty-three patients with ST-elevation AMI and previous cardiac arrest underwent primary PCI within 12 hours after symptom onset. Three groups of patients were defined: Group 1: Cardiac arrest before hospital admission, without immediate (Conclusions. Combining immediate initiation of resuscitation maneuvers and primary PCI yields a very good clinical outcome in patients with AMI suffering from cardiac arrest. J INVASIVE CARDIOL 2006;18(6):269-272. Clinical Outcomes after Percutaneous Coronary Intervention with Drug-Eluting Stents in Dialysis Patients Salah-Eddine Hassani, MD, William W. Chu, MD, PhD, Roswitha M. Wolfram, MD, et al. Objectives. We aimed to compare the clinical outcomes of dialysis versus nondialysis patients after coronary drug-eluting stent (DES) implantation. Background. The revascularization of ischemic heart disease in dialysis patients has remained controversial due to consistent exclusion of this population from major trials, especially in the context of percutaneous coronary interventions (PCI) with DES. Methods. We analyzed the data on 3,442 consecutive patients who underwent PCI and DES implantation since March 2003. Periprocedural events, 1- and 6-month clinical outcomes were then compared between dialysis (n = 72) and nondialysis patients (n = 3,370). Results. Baseline characteristics revealed a higher prevalence of female gender (p = 0.03), African Americans (p Conclusions. PCI with DES in dialysis patients is safe and feasible, with a similar reduction of repeat revascularization when compared with nondialysis patients. There was, however, a higher incidence of mortality in dialysis patients at 6 months, mostly influenced by contributing comorbidities and more severe conditions at presentation. J INVASIVE CARDIOL 2006;18(6):273-277. Immediate- and Short-Term Outcome following Recanalization of Long Chronic Total Occlusions (> 50 mm) of Native Coronary Arteries with the Frontrunner Catheter Akil Loli, MD, Rex Liu, MD, Ashish Pershad, MD Thirty percent of diagnostic angiograms have at least 1 chronic total occlusion (CTO). The 10-year survival of patients with a CTO is improved if they have the CTO successfully recanalized. The success of recanalization with conventional wires is 50% and the impact of new technology on recanalization is unknown. This abstract reports a single center experience with one such new device, the Lumend Frontrunner catheter in revascularization of this difficult lesion subset. A consecutive series of 18 patients with CTOs of native coronary arteries were enrolled in this single center, single operator series. The mean age of the CTO was 5.3 years. The indication for attempt at recanalization was ischemia in the territory of the CTO on SPECT imaging. Success was defined as TIMI flow restoration and The Use of Percutaneous Suture-Mediated Closure for the Management of 14 French Femoral Venous Access Ilias Mylonas, MD, Yoshihito Sakata, MD, Michael Salinger, MD, et al. Background. Little has been reported regarding the utility or outcomes of femoral venous vascular closure using arterial suture closure devices. We describe results using a pre-closure approach with a 6 French (Fr) Perclose Closer S device in patients who underwent antegrade aortic valvuloplasty using 14 Fr percutaneous femoral venous access catheters. Methods. Forty-five patients underwent antegrade aortic valvuloplasty and suture-mediated closure with a 6 Fr Perclose device. A 6 Fr Closer S suture device was preloaded into the femoral vein after 6 Fr sheath access, prior to insertion of a 14 Fr venous sheath. Upon completion of the procedure, the 14 Fr femoral venous sheath was removed through the existing sutures. Results. Of 45 patients (mean age 82.4 years; 17 males), immediate hemostasis was achieved with percutaneous suture closure in 43 (95.6%). Only 2 failures occurred which were subsequently successfully treated with manual compression. No late access site bleeding occurred from sutured sites. In all other patients, hemostasis using a 6 Fr Perclose suture-mediated device was successful and immediate. There was no need for transfusion, no clinical venous thrombosis, and no infections occurred at the access site. Two hospital deaths were documented from causes unrelated to suture-mediated closure. Conclusions. In conjunction with 14-Fr size percutaneous sheaths during antegrade aortic valvuloplasty, percutaneous suture-mediated closure is a highly effective method for achieving hemostasis. This has simplified postprocedural management in terms of early mobilization and diminished late access site bleeding. J INVASIVE CARDIOL 2006;18(7):299-302. Effects of Alcoholism on Coronary Artery Disease and Left Ventricular Dysfunction in Male Veterans Spyros Kokolis, MD, Jonathan D. Marmur, MD, Luther T. Clark, MD, et al. Background. Heavy alcohol consumption is a well-known cause of dilated cardiomyopathy and hypertension, but its effects on coronary atherosclerosis are less well understood. The objective of this study was to compare coronary anatomy and left ventricular dysfunction in patients with and without alcoholism associated with heavy consumption. Methods. We studied 100 consecutive alcoholic male patients presenting with chest pain to the Department of Veterans Affairs New York Harbor Healthcare System (VA) between 1994 and 2002. Alcoholism was defined as a history of either chronic alcohol-related pancreatitis or liver cirrhosis. Patients were compared to age-matched controls (n = 200) that were known to be nonalcoholic. All patients underwent coronary angiography. Results. Baseline demographic characteristics were similar between the two groups. The prevalence of significant coronary artery disease (CAD) (defined as coronary arterial luminal diameter stenosis > 50%) was lower in the alcoholic group than in the control group (42% vs. 58%; p = 0.013). Among patients with CAD, those with a history of alcoholism had fewer vessels with stenoses (1.6 ± 0.6 vs. 2.3 ± 0.7; p Conclusions. In a group of male VA patients presenting with chest pain, alcoholism was associated with a lower incidence and a lesser severity of angiographically-defined CAD, but had greater left ventricular dysfunction. There appears to be an inverse relationship between CAD and left ventricular function in patients with a history of heavy alcohol consumption. J INVASIVE CARDIOL 2006;18(7):304-330. Twelve-Month Results of Percutaneous Endovascular Reconstruction for Chronically Occluded Superficial Femoral Arteries: A Quality-of-Life Assessment Eric Dippel, MD, Nicolas Shammas, MD, Vickie Takes, RT(R), CCRC, et al. Background. We report our experience on the technical feasibility and impact on quality of life (QOL) for angioplasty and primary stenting of chronic total occlusion (CTO) of the superficial femoral artery (SFA). Methods. Forty-four patients (51 legs) underwent attempted percutaneous revascularization for SFA CTO utilizing the self-expanding nitinol SMART® stent (Cordis Corp., Miami, Florida). The Walking Impairment Questionnaire (WIQ score range: 0 to 14,080) was used to assess quality of life and ankle-brachial indices (ABI) were obtained pre- and post-procedure. Results. Successful revascularization was achieved in 90.2% of the cases; Mean follow up was 374 ± 321 days. The mean occlusion length was 15.5 ± 9.9 cm; the mean stented segment length was 23.2 ± 12.2 cm. The minimum stent diameter averaged 7.0 ± 0.6 mm, and the maximum final balloon diameter averaged 5.9 ± 0.6 mm. The mean pre- and post-intervention WIQ scores were 722 ± 1,503 and 8,421 ± 5,741 (p Conclusions. Chronically occluded SFAs can be treated by percutaneous nitinol stenting techniques with a high degree of success that is durable at 12-month follow up. Patients have a significant improvement in QOL and ABI. Repeat revascularization rates are reasonably low, and parallel the historical surgical data. J INVASIVE CARDIOL 2006;18(7):316-321. Real-Time, Three-Dimensional Localization of a Brockenbrough Needle during Transseptal Catheterization Using a Nonfluoroscopic Mapping System Sumit Verma, MD and Mark Borganelli, MD We describe a new technique that allows real-time, three-dimensional (3-D) localization of the Brockenbrough needle tip during transseptal catheterization using the EnSite NavX system. Transseptal catheterization has been traditionally performed using fluoroscopy, and recently, with the use of intracardiac echocardiography. However, even intracardiac echocardiography has the limitation of providing only 2-D views limited to the ultrasound plane. By displaying the transseptal needle on the EnSite NavX system, we achieved real-time 3-D localization of the needle tip within the right atrial geometry and found accurate visual correlation between fluoroscopy, intracardiac echocardiography and nonfluoroscopic 3-D cardiac mapping. This study suggests that the EnSite NavX system is able to provide 3-D localization of the transseptal needle during transseptal catheterization, and may be a useful imaging modality in this procedure. J INVASIVE CARDIOL 2006;18:324-327. Improvement in Left Ventricular Function following Successful Rescue Percutaneous Coronary Intervention Is Independent of Time-to-Reperfusion Kanarath P. Balachandran, MBBS, MD, MRCP, Colin Berry, MBChB, BSc, PhD, MRCP, Alastair C. Pell, MBChB, BSc, MD, MRCP, et al. Objective. To study the influence of clinical and angiographic factors on global and regional left ventricular (LV) function after rescue percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI). Methods. We performed repeat cardiac catheterization in 102 patients who underwent rescue PCI at our centre. Eighty-two patients had suitable baseline and follow-up ventriculograms, which were analyzed offline by an automated edge detection technique. Results. The mean (standard deviation [SD]) follow-up period was 22 (15) months. PCI was completed in all patients between 3 to 24 hours following the onset of pain. Improved global and regional LV systolic function was observed in 55 (67%) patients, and deterioration in 27 (33%). On univariate analysis, baseline ejection fraction (p = 0.005) and coronary stenting (p = 0.05) were associated with improved LV systolic function. Preprocedure TIMI flow, postprocedure TMP grade, time-to-reperfusion, and use of glycoprotein (GP) IIb/IIIa inhibitors did not influence LV systolic function. On multivariate analysis, ejection fraction at the time of rescue PCI (odds ratio [95% confidence interval]: 0.427 [0.234, 0.780]; p = 0.006) and stenting 3.944 (1.182, 13.156; p = 0.026) were predictors of improved LV systolic function. Conclusion. Successful rescue PCI was associated with improved LV function at follow up in the majority of patients. Stenting, but not GP IIb/IIIa inhibitor therapy, predicted improved LV function in the area supplied by the infarct-related artery. These improvements in regional wall motion were independent of the time taken to establish reperfusion, provided the intervention was carried out between 3 to 24 hours from the onset of pain. J INVASIVE CARDIOL 2006;18(7):330-333. New Concept for CTO Recanalization Using Controlled Antegrade and Retrograde Subintimal Tracking: The CART Technique Jean-Francois Surmely, MD, Etsuo Tsuchikane, MD, PhD, Osamu Katoh, MD, et al. Objectives. To demonstrate the safety and feasibility of a new concept for CTO recanalization using a controlled antegrade and retrograde subintimal tracking technique (CART technique). Background. A successful percutaneous recanalization of chronic coronary occlusions results in improved survival, as well as enhanced left ventricular function, reduction in angina, and improved exercise tolerance. However, successful recanalization of CTOs is still not optimal, and needs further improvements. Methods. Ten patients with a CTO underwent the CART procedure. This technique combines the simultaneous use of the antegrade and retrograde approaches. A subintimal dissection is created antegradely and retrogradely, which allows the operator to limit the extension of the subintimal dissection in the CTO portion. A retrograde approach means that the occlusion site is approached in a retrograde fashion through the best collateral channel from any other patent coronary artery. Results. The occlusion site was located in the RCA in 9 patients, and in the LAD in 1 patient. CTO duration varied from 7 to 84 months. Vessel recanalization was achieved in all patients. In all cases, the subintimal dissection was limited to the CTO region. No complications occurred in the collateral channel used for the retrograde approach. There were no in-hospital major adverse cardiac events. Conclusions. The CART technique is feasible, safe, and has a high success rate. J INVASIVE CARDIOL 2006;18(7):334-338. Treatment of Stent-Jailed Side Branch Stenoses with Rotational Atherectomy Robert T. Sperling, MD, Kalon Ho, MD, David James, MD, et al. While debulking with rotational atherectomy (RA) prior to balloon angioplasty (BA) improves acute results by reducing elastic recoil, treatment of an ostial side branch lesion that is covered (jailed) by a stent represents a particular challenge. We report our experience with RA in conjunction with BA for the treatment of ostial stenosis in jailed side branches. Methods and Results. Thirty-two lesions in side branches jailed by a stent were treated with RA and BA 39 times in 30 patients. The mean age was 65.5 ± 11.5 years; 26.3% were women; 18.4% had diabetes mellitus; and 18.4% had a history of prior bypass surgery. Of the treated side branches, 53.9% were diagonals, 71.8% were jailed by a slotted-tube stent, and 86.5% were previously dilated prior to RA. The burr sizes used to treat the jailed side branch origin ranged from 1.25 to 2.25 mm, with a mean burr size of 1.62 ± 0.31 mm. An average of 1.53 ± 0.72 burrs were used per lesion. Quantitative coronary angiography was performed prior to, and after, intervention. The mean diameter stenosis of the side branch prior to revascularization was 77.8% ± 12.6%; this was reduced to a mean stenosis of 23.0% ± 17.9% following treatment with RA and BA. Angiographic success (residual stenosis /= 3 times normal) during the index hospitalization) was achieved in 33 of 38 cases (86.8%). One patient suffered a periprocedural myocardial infarction; another patient presented with stent thrombosis in the parent vessel requiring emergency revascularization 36 hours after the index procedure. Clinically-driven revascularization of either the side branch or the side branch or parent was performed in 44.8% and 46.4% of patients, respectively. The estimated freedom from any target lesion revascularization was 47.7% at 300 days. One patient died of unknown causes 253 days following the index procedure. Conclusions. RA in conjunction with BA can effectively treat stent-jailed ostial side branch stenosis with excellent acute angiographic and procedural results. However, the long-term efficacy is limited by a high rate of repeat revascularization. J INVASIVE CARDIOL 2006;18(8):354-358. Feasibility of a Pressure Wire and Single Arterial Puncture for Assessing Aortic Valve Area in Patients with Aortic Stenosis Jang-Ho Bae, MD, Amir Lerman, MD, Eric Yang, MD, Charanjit Rihal, MD Background. Determination of a transvalvular pressure gradient for measurement of aortic valve area (AVA) by hemodynamic cardiac catheterization usually requires 2 catheters and 2 arterial access sites. We assessed the feasibility of using a single arterial puncture and a 0.014 inch pressure wire for evaluation of aortic stenosis. Methods. Eighteen patients (mean age, 76 years; 10 men) underwent hemodynamic catheterization for assessment of AVA. Cardiac output was determined by thermodilution (using a pulmonary artery catheter), and the transvalvular pressure gradient was obtained from simultaneous pressure recordings (using a pressure wire to measure left ventricular pressure and a 5 Fr catheter to measure ascending aortic pressure). Results. This novel technique was technically feasible in all patients. Calibration of the pressure wire with the pressure of the fluid-filled catheter was possible and accurate in the left ventricle and aorta. The method required 36.4 ± 9.6 minutes from injection of a local anesthetic to completion of AVA measurement; 53.3 ± 18.6 minutes were required to finish all catheterization procedures, including coronary angiography. Measurements of AVA (mean, 1.01 ± 0.43 cm2) and pressure gradients (mean, 27.5 ± 10.5 mmHg) taken by a pressure wire were similar to measurements taken by Doppler echocardiography (1.07 ± 0.58 cm2 and 32.9 ± 12.1 mmHg, respectively); the correlation was significant (r = 0.856; p Conclusions. Our findings suggest that a single arterial approach using a pressure wire is feasible, safe, accurate and rapid for the invasive assessment of aortic stenosis. J INVASIVE CARDIOL 2006;18(8):359-362. Switching from Enoxaparin to Bivalirudin in Patients with Acute Coronary Syndromes without ST-Segment Elevation Who Undergo Percutaneous Coronary Intervention. Results from SWITCH A Multicenter Clinical Trial Ron Waksman, MD, Roswitha M. Wolfram, MD, Rebecca L. Torguson, BS, et al. Background. Enoxaparin is an established therapy for the treatment of patients with acute coronary syndrome (ACS), and bivalirudin is commonly used as the antithrombotic agent during percutaneous coronary intervention (PCI). This study was designed to examine the safety of switching from enoxaparin to bivalirudin in these patients. Methods. The Switching from Enoxaparin to Bivalirudin in Patients with Acute Coronary Syndromes without ST-segment Elevation Undergoing Percutaneous Coronary Intervention (SWITCH) trial was a prospective, open-label, multicenter study including 91 patients who presented with an ACS without ST-segment elevation, and who had received >/= 1 dose of enoxaparin (1 mg/kg SC) within the 12 hours prior to PCI. Patients were enrolled into 3 time categories: Group 1: 0-4; Group 2: 4-8; and Group 3: 8-12 hours from last enoxaparin dose to PCI. The primary endpoint of the study was major bleeding complications. Results. Baseline characteristics and average number of enoxaparin injections prior to PCI were similar in all 91 patients and among the groups. There was no occurrence of death, Q-wave myocardial infarction (MI), or acute revascularization in any group and no incidence of intracranial or retroperitoneal bleeding. The overall rate of major bleeding (7.7%) was comparable among groups (p = 0.39), as was the incidence of periprocedural non-Q-wave MI (overall 12%; p = 0.58), irrespective of the time interval between enoxaparin and bivalirudin administration. Conclusions. Switching from enoxaparin to bivalirudin for patients with ACS undergoing PCI appears to be clinically safe without increased risk of major bleeding complications, regardless of the time of enoxaparin administration, and is safe enough to warrant testing it in larger numbers. J INVASIVE CARDIOL 2006;18(8):370-375. High Incidence of Focal Left Ventricular Wall Motion Abnormalities and Normal Coronary Arteries in Patients with Myocardial Infarctions Presenting to a Community Hospital Brian Strunk, MD, Richard E. Shaw, PhD, Sally Bull, RN, et al. Background. Myocardial infarction with normal coronary arteries (MINCA) is a well-documented syndrome often associated with global left ventricular wall motion abnormalities (LVWMAs). Recent literature has emphasized the occurrence of Takotsubo cardiomyopathy associated with MINCA. What has not been reported is the incidence of MINCA in the general population and the relative frequency of other types of associated LVWMAs. Methods and Results. Data were retrospectively collected on 165 consecutive patients with ST-elevation myocardial infarction (STEMI) and 244 patients with non-ST-elevation myocardial infarction (NSTEMI) who underwent cardiac catheterization at a single institution in Marin County, California. Thirty-two of the 409 (7.8%) patients had MINCA. Of the patients presenting with STEMI, 10.3% had MINCA, and 6.1% of the patients presenting with NSTEMI had MINCA. Females were more likely to present with MINCA than males, both for STEMI (21.6% vs. 5.3%; p Conclusions. An unexpectedly high incidence of MINCA with newly-described focal anterior and inferior LVWMAs as well as Takotsubo cardiomyopathy was observed in our community hospital. This syndrome occurred predominantly in females and was often associated with a recent stressful event. As these results were from a community, rather than a referral hospital, this finding challenges the current thought about the incidence of this syndrome in the general population. J INVASIVE CARDIOL 2006;18(8):376-381. Clinical Outcomes with Drug-Eluting Stents following Atheroablation Therapies Sunil V. Rao, MD, Emily Honeycutt, MD, David Kandzari, MD Background. Prior studies of atheroablation (directional atherectomy, rotational atherectomy and laser angioplasty) have demonstrated either no advantage or worse outcomes relative to conventional balloon angioplasty. Because these techniques are still required in a minority of patients, we hypothesized that the use of drug-eluting stents (DES) would minimize the rate of major adverse cardiac events (MACE) after atheroablation. Methods. From 2,252 percutaneous coronary intervention procedures, 212 patients were extracted using case control matching and were analyzed to compare the rate of MACE across four groups (DES with atheroablation, bare-metal stent (BMS) with atheroablation, DES without atheroablation, bare-metal stent without atheroablation). A Cox proportional hazards model was constructed to determine predictors of MACE after adjustment for potential confounders. Internal validation was performed with bootstrapping. Results. There were 36 patients, 42 patients, 63 patients and 71 patients in each of the groups, respectively. The incidence of 30-day and 6-month MACE was numerically lowest among patients who received DES after atheroablation, although the differences did not reach statistical significance (30-day MACE: 0% DES with atheroablation, 4.8% BMS with atheroablation, 3.2% DES without atheroablation, 8.5% BMS without atheroablation; 6-month MACE: 2.8% DES with atheroablation, 19.0% BMS with atheroablation, 6.4% DES without atheroablation, 16.9% BMS without atheroablation). After adjustment, the use of atheroablation was not a predictor of MACE. Conclusions. This study suggests that in situations where directional atherectomy, rotational atherectomy or laser angioplasty is required to optimize stenting, the use of DES can minimize MACE associated with atheroablation. J INVASIVE CARDIOL 2006;18(9):393-396. Temporal Trends in Target Vessel Revascularization in Clinical Practice: Long-Term Outcomes following Coronary Stenting from the Duke Database for Cardiovascular Disease David E. Kandzari, MD, Robert H. Tuttle, MSPH, James P. Zidar, MD, James G. Jollis, MD Objective. We examined outcomes of clinical restenosis and temporal trends in repeat target vessel revascularization (TVR) among a broad, unselected patient population undergoing percutaneous coronary revascularization. Background. The extent to which clinical trials involving protocol-specified follow-up angiography reflect real-world practice where interventions are driven by clinical restenosis is not completely understood. Whether clinical outcomes have varied over a long-term period that has paralleled substantial advances in stent design, balloon delivery catheter and adjunctive pharmacologic therapies is uncertain. Methods. To characterize the effectiveness of coronary stenting in routine practice, we examined 1-year clinical outcomes of death and repeat TVR among 5,765 patients enrolled in the Duke Database for Cardiovascular Disease who underwent stent placement between 1994 and 2002. To assess for temporal trends in outcomes, patients were further divided into tertiles according to the year of initial revascularization. Results. Overall, the 1-year occurrence of TVR and death was 11.4% and 4.9%, respectively. Rates of repeat TVR increased at 3-month intervals, with most events occurring prior to 9 months. In an adjusted analysis over an 8-year period, 1-year survival did not significantly differ across patient tertiles (p = 0.95), although rates of recurrent TVR significantly decreased (1994-1996, 11.1%; 1997-1999, 11.5%; 2000-2002, 9.3%; p = 0.003). Conclusions. In a broad patient population in whom repeat angiography is not protocol-specified, most events occur within the initial months following revascularization, yet late clinical restenosis continues. Although survival has not improved since the introduction of coronary stents, overall rates of repeat revascularization have modestly, but significantly, declined. J INVASIVE CARDIOL 2006;18(9):398-402. Coronary Angiography and Angioplasty Using the Aberrant Radial Artery as an Access Site Rajpal K. Abhaichand, MD, K.A. Sambasivam, MD, P.R. Vydianathan, MD, et al. Objective. To study the suitability of the aberrant radial artery (ARA) as an access site for coronary angiography and angioplasty. Background. In certain situations, the radial artery operator finds that the right radial artery in its usual location is unsuitable for a transradial procedure (TRP). In such cases, the ARA should be considered as an alternate access site. Methods. Between January 2002 and December 2004, all patients considered suitable for a TRP with a clinically absent radial artery, or a small radial artery and a palpable ARA, underwent a TRP using this vessel as an access site. We describe the technical aspects and the differences that this approach entails, in comparison to the standard radial artery approach to TRPs. Results. Of the 3,610 patients considered suitable for a TRP, 22 patients underwent 29 procedures using the ARA as an access site [22 angiograms and 7 percutaneous transluminal coronary angioplasty procedures (PTCAs)]. The median age of the patients was 55 years, with 19 males and 3 females. All procedures using the aberrant radial artery were successful. None of the patients developed spasm or an access site complication. The mean fluoroscopy time for angiography in the right radial artery group was 4.6 minutes, and 4.8 minutes for the ARA group. The procedure timed were 24 minutes and 32 minutes, respectively. Conclusion. The aberrant radial artery can be used as a safe alternate access site for coronary angiography and angioplasty when the right radial artery at the usual site is not suitable. J INVASIVE CARDIOL 2006;18(9):412-416. Directional Coronary Atherotomy Experimental Use of Single-Blade Cutting Balloon Yoshihisa Kinoshita, MD, Yoshifumi Kashima, MD, Takahiko Suzuki, MD Background. In the drug-eluting stent era, minimum stent diameter is one independent predictor of restenosis. Some plaque modification is necessary before stenting to obtain the minimum stent diameter, but plaque modification using current devices is difficult in certain lesions, such as those in eccentric small vessels. As a potential solution to this problem, we investigate the usefulness of a single-blade Cutting Balloon (SCB) in this study. Methods. We used the SCB in 5 porcine coronary arteries (2 LAD, 1 LCx and 2 RCA) to investigate the feasibility of directional atherotomy. We also tried the kissing balloon technique (KBT) with the SCB in 3 bifurcations from the same arteries. We used intravascular ultrasound (IVUS) guidance to position and direct the atherotome using the side holes of the guiding catheter as a marker. We also assessed plaque modification with IVUS before and after percutaneous coronary intervention and took coronary sections to inspect tissue pathology after the procedures. Results. In all 5 porcine models, we were able to view and confirm the success and accuracy of our incision on IVUS. We were successfully able to control the direction of the blade without balloon rupture during KBT. We were also able to verify the directional incisions afterwards from examination of tissue pathology. Conclusion. Our investigation suggests that this SCB may be used effectively for directional atherotomy. We can accurately modify the plaque with this device by correctly positioning the blade to choose the direction of the incision. The next challenge is to improve the reliability of the device and to move on to in vivo trials. J INVASIVE CARDIOL 2006;18(8):428-431.