IntroductionPreviously, we have demonstrated that significant proportions of patients with various cardiovascular diseases have active tissue factor and active factor XIa in their plasma. In the current study, we evaluated active tissue factor and active factors (F)XI and FIX in plasma from patients with atrial fibrillation.Material and methodsIn 110 consecutive patients with permanent atrial fibrillation receiving warfarin, we determined active tissue factor, together with plasma FIXa and FXIa, using clotting assays by measuring the response to inhibitory monoclonal antibodies.ResultsSixteen (14.5%) patients had detectable active tissue factor and active FXIa, including 11 subjects with both factors, while FIXa was observed in 28 (25.7%) patients. The three positive groups did not differ from the patients without these factors with regard to demographic and clinical characteristics. Von Willebrand factor was higher in the active tissue factor-positive group (p < 0.0001) and FXIa-positive group (p = 0.0037). Individuals positive for active tissue factor and FXIa had higher plasma interleukin-6 levels (p = 0.0014 and 0.0322, respectively). The presence of active tissue factor, FXIa and FIXa in anticoagulated patients with permanent atrial fibrillation correlated with elevated von Willebrand factor and interleukin-6. During a 3-year follow-up, ischemic stroke (n = 12, 10.9%) occurred more commonly among atrial fibrillation patients who had circulating TF (p = 0.002) or FXIa (p = 0.013).ConclusionsThese data suggest that circulating active coagulation factors, in particular TF and FXIa, can be detected despite oral anticoagulation in a significant proportion of patients with atrial fibrillation, and could represent novel markers of persistent prothrombotic alterations predisposing to ischemic stroke.

Recanalisation of chronic total occlusion (CTO) is still a challenge in invasive cardiology, requiring operator experience, equipment, and techniques dedicated to CTO. Due to difficulties in crossing the lesion by wire and by balloon (both responsible for 98% of the procedure's failures), many helpful techniques have been described. We report the case of both Tornus system and anchor technique in successful recanalisation of a right coronary artery.

Using novel equipment with adequate experience allowed high rates of successful revascularisation. The retrograde technique for CTO revascularisation showed good overall success and was safe.

Chronic total occlusions (CTO) remains a challenge in invasive cardiology. It requires not only a very experienced opera tor, but also a variety of equipment (dedicated to CTO) to be available in the operating room. The most common causes of procedure failure are an inability to: cross the lesion by wire (89%), to cross the lesion by balloon (9%), and to implant the stent (2%). However, the development of the new procedure's techniques and equipment have increased the rate of successful interventions in reference centres up to 90%, although the mean success rate is only about 60% in non specialised centres. We report the case of a 44-year-old man with hyperlipidaemia, hypertension, coronary artery disease and CTO of circumflex coronary artery (Cx). In 2005, the patient underwent elective coronary angioplasty of right coronary artery (RCA) and left anterior descending artery (LAD) with the implantation of two bare-metal stents (BMS). In February 2012, a second coronary angioplasty of the RCA was performed with implantation of two BMS, and the Cx was already closed. Because of restenosis in a RCA stent, in May 2012 balloon angioplasty was performed. Due to persistent symptoms, the patient was referred to our centre which specialises in CTO angioplasty. The artery was closed in proximal segment (segment 11), and the peripheral part of the vessel was visualised from RCA to segment 13 and the marginal branch. The length of the occlusion was assessed to be about 30 mm (Fig. 1). Two femoral accesses were used, one (6 FR) for visualising the distal part of the Cx from the RCA, and the second one (7 FR) for the angioplasty. A 7 FR Launcher EBU4.0 was used to engage the left coronary artery. The Fielder XT wire (ASAHI) managed to cross the occlusion. However, after many attempts it was unable to cross the 1.5 × 15 mm OTW Apex Push balloon and 1.5 × 15 mm Maverick Monorail balloon. Using a special system Tornus 2.1 FR (ASAHI), we were able to create enough room in the occlusion that it was only possible to cross the lesion by small balloon (Fig. 2). First we used a 1.5 × 15 mm Maverick Monorail balloon, then a 2.5 × 15 mm Maverick Monorail. After successful opening of the artery, a drug-eluting stent (2.75 × 32 mm -14 atm, Promus Element) was implanted, with optimal effect. Control contrast medium injection revealed very good effect of the procedure, with good filling of the peripheral part of the Cx and the marginal branch (Fig. 3). Angiographic images showed a reduction of the contrast flow to the Cx from the RCA. The total time of fluoroscopy was 43.4 min, the patient received 4.246 Gy of radiation, and the total amount of contrast medium was 400 mL. Today, 12 months after the procedure, the patient is asymptomatic.