Nicolas Boudou

Background: Aorto‐ostial chronic total occlusions (CTOs) of the right coronary artery (RCA) represent a particularly complex subset of CTO percutaneous coronary interventions (PCI), yet dedicated data remain limited. We aimed to evaluate technical outcomes of aorto‐ostial versus non–aorto‐ostial RCA CTO PCI and to identify predictors of failure in RCA aorto‐ostial lesions. Methods: Patients undergoing RCA CTO PCI between 2016 and 2024 and enrolled in the ERCTO (European Registry of Chronic Total Occlusion) registry were included in the present analysis. The primary end point was technical success. Multivariable logistic regression was used to identify independent predictors of technical failure. Results: A total of 26 374 patients undergoing RCA CTO PCI were included in the analysis, of whom 2850 had aorto‐ostial and 23 524 non–aorto‐ostial lesions. Technical success was lower in aorto‐ostial compared with non–aorto‐ostial lesions (79.6% versus 89.7%; P P P P P P <0.001) were independently associated with technical failure. In‐hospital major adverse cardiac and cerebrovascular events rates were low and did not differ significantly between groups. Conclusions: Aorto‐ostial RCA CTO PCI has a significantly lower technical success despite extensive use of advanced techniques. Technical failure is driven primarily by lesion‐specific anatomical features, underscoring the need for dedicated strategies and refined risk stratification tailored to aorto‐ostial anatomy.

Background: Long‐term outcome in patients with chronic total occlusions (CTO) depends on the target vessel and proximity of the lesion. Aims: To investigate of the target vessel was associated with procedural efficacy and safety in patients with proximal CTO lesions. Methods: Patients treated for a CTO lesion in the European CTO registry (ERCTO) between January 1, 2021, and December 31, 2023, were included in the study. Patients were categorized based on the treated vessel and the proximity of the lesion. The outcome was compared between proximal lesions in the three native vessels. The co‐primary endpoints were procedural success and 30‐day safety. Procedural success was defined as technical success without in‐hospital major adverse cardiac events. Results: A total of 14,744 patients were screened, and 7128 were included in the analysis of proximal CTO PCI. Technical success rates proximal in the three native vessel territories were 91.0% (left anterior descending [LAD]), 92.1% (left circumflex [LCX]), and 88.5% (right coronary artery [RCA]). In the adjusted analysis, the probability of procedural success was higher for LCX compared to RCA, but not for the LAD (OR (95% CI): LCX: 1.35, (1.05−1.75); LAD: 1.06 [0.86–1.31]). The adjusted 30‐day safety was better in the LAD, but not LCX, compared with RCA (LAD: OR 0.69, 95% CI: 0.50; 0.94, LCX: OR 0.77, 95% CI 0.54; 1.09). Conclusions: Modern CTO PCI for proximal lesions generally yields a very high success rate. The procedure tends to be more successful in the LAD and LCX territories compared to the RCA, with LAD lesion treatment being the safest option.

Background: High radiation exposure is a significant risk with recanalizations for chronic total coronary occlusions (CTO). Aims: To analyze the influence of radiographic equipment, radiation protocols, and operator experience on radiation exposure. Methods: We analyzed 17,769 procedures by 27 operators from a multicenter European Registry between 2015 and 2023. Thirteen operators had an experience > 10 years (Gen1), and 14 entered the registry after 2015 (Gen2). AirKerma (AK), dose area product (DAP), the dose rate index (DRI) as AK per fluoroscopy time (FT), and the collimation index (CLI) as DAP per AK were calculated to assess inter‐operator variability. Results: Despite increased lesion complexity (2015−17: CASTLE score 1.83 ± 1.10, 2021−23: 2.20 ± 1.19; p < 0.001), AK and DAP were reduced by 45%. Gen1 operators treated more complex lesions than Gen 2 (2.05 ± 1.13 vs. 1.85 ± 1.16; p < 0.001) at more extended FT (38.4 [23−61] vs. 34.0 [20−57]; p < 0.001) than Gen2 with slightly higher AK (1.6 [0.89−2.8] Gy vs. 1.4 [0.8−2.54]; p < 0.001), but DRI was similar (42.9 [27.7−64.3] vs. [28.0−62.1]). In 2015−17, operators with Philips Clarity had a lower median AK (1.7 Gy; p < 0.001) than other vendors (Siemens 2.1 Gy; General Electric 2.8 Gy), but with updated equipment, Philips systems had slightly higher AK (1.2 Gy) than Siemens systems (1.0 Gy; p < 0.001). Inter‐operator variability regarding DRI improved over time, but collimation did not change. Conclusions: Radiation exposure for CTO PCI was reduced for both long‐time and recent CTO operators during 9 years. Equipment updates were instrumental to improved radiation management, but inter‐operator differences remained regarding dose management and collimation.

Background: Because rotational atherectomy (RA) is associated with arterial trauma and platelet activation, patients treated with RA may benefit from more potent antiplatelet drugs. The aim of this trial was to assess the superiority of ticagrelor over clopidogrel in reducing post procedure troponin release. Methods: TIRATROP (TIcagrelor in Rotational Atherectomy to reduce TROPonin enhancement) is a multicenter double-blind randomized controlled trial that included 180 patients with severe calcified lesions requiring RA who received either clopidogrel (300 mg loading dose, then 75 mg/d) or ticagrelor (loading dose 180 mg then 90 mg twice daily). Blood samples were collected at the beginning (T0), and 6, 12, 18, 24 and 36 h after the procedure. Primary end point was troponin release within the first 24 h using area under the curve analysis (troponin level as a function of time). Results: The mean age of patients was 76 ± 10 years, 35% had diabetes. RA was used to treat 1, 2 or 3 calcified lesions in 72%, 23% and 5% of patients, respectively. Troponin release within the first 24 h was similar in both the ticagrelor (adjusted mean ±SD of ln AUC 8.85 ± 0.33) and the clopidogrel (8.77 ± 0.34, p = 0.60) arms. Independent predictors for troponin enhancement were acute coronary syndrome presentation, renal failure, elevated C-Reactive protein and multiple lesions treated with RA. Conclusion: Troponin release did not differ among treatment arms. Our results suggest that greater platelet inhibition does not affect periprocedural myocardial necrosis in the setting of RA.

Objectives: To evaluate the rate of procedural success and long‐term outcomes of the PK Papyrus (PKP) covered stent (CS).Background: CS are essential in the treatment of coronary artery perforation (CAP). They have also been used to treat coronary artery aneurysms. Limited evidence is available on clinical outcomes with the PKP.Methods: This was a multicenter, observational, retrospective, and prospective study. Consecutive patients undergoing intentional PKP implantation in 22 centers in France were included. The primary endpoint was the rate of procedural success. Secondary endpoints included rates of death, myocardial infarction (MI), target lesion revascularization (TLR), in‐stent restenosis (ISR), and stent thrombosis (ST).Results: Data from 130 patients were analyzed (mean age 72.5 ± 10.5 years; 71% men). The main indication for PKP was CAP, in 84 patients (65%). Delivery success was achieved in 95% and procedural success in 91%. During the in‐hospital stay, 15 patients died (12%) and 7 (5%) presented with ST. Data from 127 patients were available at 19.2 ± 12.8 month follow‐up. Thirty‐three patients died (26%), 15 (12%) had an MI and 21 (17%) presented with TLR. TLR was due to ISR in 12 patients (9%), 10 had definite ST (8%) and 1 patient for stent under‐expansion.Conclusions: The principal indication for PKP was CAP. PKP had high rates of delivery and procedural success. At long‐term follow‐up, there was a high rate of TLR, mainly due to ISR and ST. These results are consistent with previously reported data in these clinical settings.

Objective. To determine short-term and mid-term prognosis in patients with calcified ostial coronary lesions who underwent rotational atherectomy (RA). Background. RA was developed to facilitate stenting in complex lesions. Treatment of calcified aortoostial coronary lesions with RA appears to have poorer procedure outcomes than nonostial lesions; yet the literature on this topic is scarce. Methods. Of 498 consecutive patients who underwent RA, a total of 80 (16.1%) presented with aortoostial lesions. A comparative, monocentric study was performed between patients with aortoostial and nonaortoostial stenosis, in a retrospective registry. The primary endpoint was the procedural success rate. Secondary endpoints were the rates of major adverse cardiac and cardiovascular events (MACE) at 30 days and 24 months. Results. The procedural success rate was high and similar in patients with and without ostial lesions (96.3% vs 94.7%, p=0.78), as was the rate of angiographic complications (7.5% vs 8.4%, p=0.80). However, the 30-day mortality rate was significantly higher in the aortoostial group (11.3% vs 4.8%, p=0.04), as was the 24-month rate of MACE (43.8% vs 31.8%, p=0.04). The aortoostial location of the lesion was an independent factor associated with the occurrence of cardiovascular events at 24 months (HR = 1.52, 95% CI, 1.03-2.26, p=0.035). Conclusion. Procedural success and complication rates were similar in patients with and without aortoostial lesions. Despite a poor short- and mid-term prognosis, rotational atherectomy appears to be a feasible and safe treatment option for calcified aortoostial coronary lesions.

Drug eluting stent (DES) decrease the risk of restenosis by reducing the neointimal response. However, DES may impair strut coverage, and this has been associated with late stent/scaffold thrombosis. Bioresorbable vascular scaffold (BVS) may overcome the risk of stent/scaffold thrombosis when completely resorbed. The purpose of this randomised trial was to compare the arterial healing response in the short term, as a surrogate for safety and efficacy, between the metallic everolimus-eluting stent (Synergy; Boston Scientific, Marlborough, MA, USA) and the everolimus BVS (Absorb; Abbott Vascular, Santa Clara, CA, USA) in the particular setting of acute myocardial infarction (AMI). This pilot study sought to compare the neointimal response of metallic everolimus DES (Synergy) with polymeric everolimus BVS (Absorb) by optical coherence tomography (OCT) 3 months after an AMI. COVER-AMI was a single-centre, single-blind, non-inferiority, randomised controlled trial. Patients with ST segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention were randomly allocated (1:1) to treatment with the Synergy DES or Absorb BVS. The primary endpoint was the 3-month neointimal response assessed as the percentage of uncovered struts, neointimal thickness, in-stent/scaffold area obstruction, and pattern of neointima. The main secondary endpoint included the device-oriented composite endpoint according to the Academic Research Consortium definition. Twenty patients without clinical and/or angiographic complications (Synergy (n = 10) or BVS (n = 10); mean age 59.0 years; 20% female) were enrolled in our centre. The stent diameter was higher in the Synergy group (3.7 ± 0.4 mm vs 3.4 ± 0.4 mm in the BVS group, p = 0.01). At 3 months, no significant differences in angiographic lumen loss were observed between the everolimus DES and everolimus BVS (0.04 mm (IQR 0.00–0.07) vs 0.11 mm (IQR 0.04–0.31), p = 0.165). OCT analysis of 420 cross-sections showed that the total neointimal area and in-stent obstruction were lower in the Synergy group, while OCT analysis at the strut level (n = 3942 struts) showed that the rate of uncovered struts was lower in the BVS group. Stenting of culprit lesions in the setting of STEMI resulted in a nearly complete arterial healing for both the Synergy and the BVS devices. Lower neointimal thickness and in-stent obstruction but a higher rate of uncovered struts were observed in the Synergy group. These findings provide the basis for further exploration in clinically oriented outcome trials.