Umihiko Kaneko

BACKGROUND: The clinical utility of physiology-guided revascularization for decision-making in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) remains uncertain. The aim of this study is to evaluate the diagnostic performance and prognostic significance of fractional flow reserve (FFR) and nonhyperemic pressure ratios (NHPRs) according to the severity of CKD. METHODS: This subanalysis of the J-PRIDE registry, a prospective multicenter study conducted at 20 Japanese centers between September 2019 and February 2021, included 4296 lesions from 3194 patients who underwent both FFR and NHPR assessment. Patients were categorized by estimated glomerular filtration rate into non-CKD (≥60 mL/min per 1.73 m ² ; n=1639), CKD (15–59; n=1321), and ESRD (P P =0.001). The NHPR cutoff predicting FFR ≤0.80 was lower in ESRD compared with CKD and non-CKD (0.85 versus 0.89 versus 0.89). Although the overall prevalence of FFR/NHPR discordance was comparable (23.6%, 19.7%, and 19.7%; P =0.24), FFR−/NHPR+ discordance predominated in ESRD (18.6% versus 9.3% versus 7.0%; P <0.001). FFR−/NHPR+ lesions in the ESRD group exhibited an excess risk compared with other lesions. Revascularization was beneficial in non-CKD patients with FFR+/NHPR− lesions, whereas no clear benefit was observed in patients with CKD and ESRD. CONCLUSIONS: Patients with ESRD exhibited distinct physiological characteristics and substantially worse outcomes, highlighting the need for tailored coronary revascularization strategies in this population. REGISTRATION: URL: https://www.umin.ac.jp/ctr ; Unique identifier: UMIN000038403.

Antegrade percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) remains technically challenging. HydroDynamic contrast Recanalization (HDR) is a novel technique involving low‐pressure, low‐volume intraplaque contrast injection immediately distal to the proximal cap, with the goal of modulating plaque architecture and facilitating a polymer‐jacketed guidewire advancement toward the distal true lumen. Intravascular ultrasound (IVUS) is useful in two HDR‐related scenarios: first, to resolve proximal cap ambiguity and guide precise puncture; second, in cases of unsuccessful true lumen crossing, to identify extraplaque guidewire position and assist re‐entry into the true lumen. We report a case of proximal left anterior descending artery CTO treated using combined HDR and tip detection–antegrade dissection and re‐entry (TD‐ADR). Initial HDR produced patchy Type 1 staining, generally indicating intraplaque tracking. Second and third subsequent contrast injections again demonstrated Type 1 staining; however, true lumen crossing with polymer‐jacketed wires (Sion Black and Gladius EX) was unsuccessful. IVUS confirmed subintimal wire position. To avoid stiff wire escalation and maintain control, we switched to IVUS‐guided TD‐ADR. Spatial alignment enabled re‐entry into the distal true lumen with a Conquest Pro 12 Sharpened Tip wire. A drug‐eluting stent was implanted with excellent angiographic results and no complications. This case illustrates the complementary roles of HDR and TD‐ADR in antegrade CTO PCI. HDR promotes early plaque modification and facilitates wiring with minimal perforation risk, but does not ensure intraplaque tracking. IVUS‐guided TD‐ADR offers a safe bailout when true lumen crossing fails. A stepwise, imaging‐guided approach integrating both techniques may improve procedural success.

Percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) is a technically demanding procedure where successful guidewire navigation is critical. While intravascular ultrasound (IVUS) provides essential anatomical detail, its utility is often limited by the cognitive challenge of correlating the 2D IVUS image with the 3D angiographic view. A failure in this co‐registration can lead to procedural failure. To address this challenge, we detail the “Be‐The‐Wire” cognitive model, a simple, six‐step mnemonic‐based method for achieving intuitive 3D IVUS‐angiographic co‐registration. The technique requires the operator to adopt the perspective of being the IVUS‐carrying wire, with their head positioned on the proximal side of the coronary artery. Key steps include optimizing the angiographic view for gear separation, deducing the C‐arm's viewing angle, mapping this angle to a clock‐face position on the IVUS display, and physically rotating the screen to align it with the vessel's trajectory. The “Be‐The‐Wire” cognitive model provides a simple yet profound method to improve guidewire control by facilitating intuitive co‐registration without requiring complex software. Mastering this technique is a valuable step which may potentially contribute to improving safety and success rates in complex CTO PCI.

A 57‐year‐old man presented with recurrent exertional angina 1 month after an unsuccessful PCI attempt elsewhere. Angiography revealed severe stenosis and a chronic dissection of the posterior lateral artery (PLA). PCI was performed via a 6 Fr right transradial guiding catheter. Initial intravascular ultrasound (IVUS) using OptiCross HD (Boston Scientific; 3.1 Fr outer diameter [OD], 20 mm transducer‐to‐tip distance [TTD]) confirmed guidewire placement in the subintimal space within the extensive chronic dissection. TD‐ADR was successfully performed using the OptiCross HD IVUS and a low‐profile Carnelian MARVEL microcatheter (1.9 Fr OD), both accommodated within the 6 Fr guide. True lumen re‐entry was achieved, followed by balloon dilatation, side branch management, and successful drug‐eluting stent deployment in the main vessel, confirmed by final angiography and IVUS.

Background: Since chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is mainly aimed at symptom relief, it should avoid placing patients at risk. Tip detection-antegrade dissection and reentry (TD-ADR), whose wiring time has been reported to be shorter compared to retrograde approach, do not need a dual access. Although the retrograde approach is effective, it is a significant risk factor for in-hospital adverse events after CTO PCI. We are advocating “Minimalistic Approach with Tip detection-antegrade dissection and reentry” (MAT) which positions antegrade wiring as the first, tip-detection IVUS-guided wiring as the second, and the retrograde approach as the third option. Case Summary: This case series describes three PCIs performed via a single radial access for right coronary artery CTOs characterized by a puncturable proximal cap and non-diffuse calcification. It was possible for TD-ADR to stick the CTO body and preserves side branches distal to the CTO. Discussion: MAT enables antegrade CTO treatment with a single radial access. While TD-ADR is difficult in diffusely calcified CTO, complications of TD-ADR are limited to those that can be adequately anticipated and managed, unlike those associated with the retrograde approach. MAT likely to reduce procedural risks and improve patient comfort.

Background: The number of transcatheter aortic valve implantation (TAVI) procedures has increased significantly and now includes younger and higher-risk surgical patients. As early-generation transcatheter heart valves (THVs) continue to degrade over time, the incidence of structural valve deterioration (SVD) is increasing, requiring more complex valve-in-valve (TAV-in-TAV) procedures. Case summary: We present a case of SVD of a THV, resulting in severe aortic regurgitation in an 88-year-old female with decompensated heart failure. Eight years prior, the patient had undergone TAVI with SAPIEN XT 23 mm via the transapical approach because of severe calcified stenosis of the lower extremity arteries and extreme tortuosity from the arch to the descending aorta and abdominal aortic aneurysm, right-sided aortic arch. Considering the patient’s condition and access route, we performed emergency transfemoral TAV-in-TAV using a 23 mm SAPIEN3 Ultra RESILIA. The endoconduit technique successfully facilitated sheath passage. The valve was implanted without complications. The procedure was successful, resulting in only trace paravalvular regurgitation. The post-operative effective orifice area was 1.80 cm² (indexed EOA: 1.32 cm²/m²). The Doppler Velocity Index was 0.59, suggesting no significant patient–prosthesis mismatch. Discussion: Vascular anomalies often restrict the choice of a safe access route in TAVI procedures. The endoconduit technique provides a minimally invasive solution for accessing complex iliac arteries. This case illustrates the importance of selecting the appropriate sheath, utilising endoconduit, and employing various procedural techniques to manage complex anatomies and ensure successful outcomes in TAV-in-TAV procedures.