Surgical Turned-Downed CHIP Cases—Can PCI Save the Day?

Abstract

Current guidelines, rarely if at all, address decision-making for revascularization when bypass surgery is not a possibility for high-risk cases. Patients who are surgically turned down are routinely excluded from clinical trials, even though they remain symptomatic. Furthermore, the reasons for surgical ineligibility are often times not captured in standardized risk models. There is no data regarding health status outcomes following PCI procedures in these patients and the ultimate question remains whether the benefits of PCI outweigh its risks in this controversial subpopulation. When CHIP (Complex High risk Indicated Percutaneous coronary interventions) is selected for these very complex individuals, there is no unanimity regarding the goals for interventional revascularization (for instance, the ambition to achieve completeness of revascularization vs. more targeted or selective PCI). The recognition that, worldwide, these patients are becoming increasingly prevalent and increasingly commonplace in the cardiac catheterization labs, along with the momentum for more complex interventional procedures and expanding skillsets, gives us a timely opportunity to better examine the outcomes for these patients and inform clinical decision-making.

Impact of Diabetes Mellitus on Early Clinical Outcome and Stent Restenosis after Carotid Artery Stenting

“…Another limitation of our study is that HbA1c was not followed; so, an in-depth analysis of the restenosis rate in association with the baseline glycemic status could not be made. Similar mechanisms that demonstrate accelerated restenosis in diabetics have been described in other interventional fields [ 26 – 28 ]. It is assumed that the stenting of the coronary atherosclerotic plaque is different from the coronary plaque by the fact that in the case of CAS, the plaque is only pushed outwards, not cracked, and modified to the media, which would later stimulate intima proliferation [ 26 ].…”

“…The early phase of stent healing seems to be influenced by the poor glycemic state rather than the diabetic condition, with good glycemic control, [25]; so, it is understandable that aiming for strict hyperglycemic optimization prior to the procedure is important. Another limitation of our study is that HbA1c was not followed; so, an in-depth analysis of the restenosis rate in association with [26][27][28]. It is assumed that the stenting of the coronary atherosclerotic plaque is different from the coronary plaque by the fact that in the case of CAS, the plaque is only pushed outwards, not cracked, and modified to the media, which would later stimulate intima proliferation [26].…”

Radial Artery Calcification in Predicting Coronary Calcification and Atherosclerosis Burden

“…First, RUS may serve as a pre- and peri-procedural adjuvant tool for the interventionist, facilitating a “per primam” selection of coronary calcium debulking technique, intuiting stent underexpansion, and preparing the interventionist to expect a more difficult sheath placement or even radial access failure, with a longer, more complex procedure. Not losing the radial access advantages in complex PCIs of severe calcific disease is of paramount importance [ 14 ]. Second, RUS may be useful to cardiovascular surgeons, since the radial artery is commonly used as a conduit for coronary artery bypass and the presence of calcifications may reduce suitability of this graft.…”

Switching From Proximal to Distal Radial Artery Access for Coronary Chronic Total Occlusion Recanalization

“…Viable myocardium supplied by a CTO is a persistently ischemic zone ( 28 ). Moreover, with respect to complete revascularization, a trend was noted toward better in-hospital/30-day mortality and 6-month health status in patients with a lower residual Syntax Score ( 8 , 10 , 29 ). This is of particular importance when a patient with a coronary CTO suffers an acute MI in the donor vessel (“double jeopardy” effect).…”

“…In recent times, coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has become widely adapted and is currently being performed at large scale, with a significant positive clinical impact on malignant ischemic arrhythmias and adverse clinical outcomes in patients with acute myocardial infarction and incomplete revascularization ( 8 – 10 ). Dual arterial access is necessary in almost every case.…”