Alessandro Di Giorgio

Background: Excimer laser coronary atherectomy (ELCA) is a technology used to treat a wide spectrum of complex coronary lesions, such as thrombotic lesions, severe calcific lesions, non‐crossable or non‐expandable lesions, chronic total occlusions, stent under‐expansion, and stent restenosis. Aims and Methods: This prospective multicenter observational study aims at examining procedural, in‐hospital and long‐term clinical outcomes in a consecutive cohort of patients treated with ELCA for complex coronary lesions. The primary end point was the rate of procedural success, defined as PCI success plus the absence of in‐hospital MACE. Results: From July 2018 to May 2024 a total of 320 consecutive patients (age 71 ± 9 years) with 429 lesions treated with ELCA were enrolled. The most common clinical presentation was chronic coronary syndrome (48%), and the left anterior descending artery was the target vessel in 47% of cases. The subsets of lesions treated were stent restenosis (48%), de novo lesions (46%), and stent underexpansion (6%). Procedural success was achieved in 97% of patients. In‐hospital MACE occurred in 1.2% of cases, mainly driven by death (0.9%) and no reflow (0.9%). After multivariate analysis, left ventricular function was recognized as independent predictor of procedural failure (OR 0.9, 95% CI 0.84−0.97, p = 0.006). During a median clinical follow‐up of 841 days (interquartile range: 395−1414) the survival free from MACE was 94.7%. Death was 2.9%, MI 1.5%, TLR 3.4%, and the composite was 4.7%. Conclusion: ELCA demonstrates a high rate of angiographic and clinical success in treating complex coronary lesions in a real‐world cohort of high‐risk patients.

Aims: The CLIMA study, on the relationship between coronary plaque morphology of the left anterior descending artery and twelve months clinical outcome, was designed to explore the predictive value of multiple high-risk plaque features in the same coronary lesion [minimum lumen area (MLA), fibrous cap thickness (FCT), lipid arc circumferential extension, and presence of optical coherence tomography (OCT)-defined macrophages] as detected by OCT. Composite of cardiac death and target segment myocardial infarction was the primary clinical endpoint. Methods and results: From January 2013 to December 2016, 1003 patients undergoing OCT evaluation of the untreated proximal left anterior descending coronary artery in the context of clinically indicated coronary angiogram were prospectively enrolled at 11 independent centres (clinicaltrial.gov identifier NCT02883088). At 1-year, the primary clinical endpoint was observed in 37 patients (3.7%). In a total of 1776 lipid plaques, presence of MLA <3.5 mm2 [hazard ratio (HR) 2.1, 95% confidence interval (CI) 1.1–4.0], FCT 180° (HR 2.4, 95% CI 1.2–4.8), and OCT-defined macrophages (HR 2.7, 95% CI 1.2–6.1) were all associated with increased risk of the primary endpoint. The pre-specified combination of plaque features (simultaneous presence of the four OCT criteria in the same plaque) was observed in 18.9% of patients experiencing the primary endpoint and was an independent predictor of events (HR 7.54, 95% CI 3.1–18.6). Conclusion: The simultaneous presence of four high-risk OCT plaque features was found to be associated with a higher risk of major coronary events.

SOUHRN S anomáliemi koronárních tepen se lze setkat přibližně u 1 % pacientů, u nichž je indikována koronarografi e. Většina těchto anomálií se neprojevuje žádnými známkami, symptomy ani komplikacemi a obvykle jsou zjištěny až náhodně během katetrizace. V urgentních situacích mohou pro intervenčního kardiologa anomálie koronárních tepen představovat značný problém, protože je lze obtížně nalézt a následně selektivně kanylovat. Základem úspěšné perkutánní intervence na anomálních koronárních tepnách v urgentních situacích je znalost anatomie a volba vhodných technických prostředků.

Quantitative coronary angiography (QCA) is the gold standard for evaluating correct stenting, despite its limitation in recognizing features indicative of suboptimal deployment. This subanalysis of the CLI-OPCI II registry addressed the role of optical coherence tomography (OCT) to verify whether suboptimal OCT deployment occurs in the presence of an optimal angiographic result. We retrospectively analyzed 125 lesions in the 105 patients with major adverse cardiac events of the CLI-OPCI II. Every lesion was evaluated with OCT and angiography, including visual and QCA assessment. Optimal angiographic result was defined as residual stenosis of less than 30% at QCA and absence of haziness at visual angiography. The following OCT features of suboptimal stenting were considered: edge dissection (linear rim of tissue with a width >200 μm), reference lumen narrowing (lumen area <4.5 mm2 in the presence of significant residual plaque adjacent to stent endings), and in-stent narrowing (minimum lumen area<4.5 mm2). Among the 125 lesions, 105 showed an optimal angiographic result. At OCT, a suboptimal positioning was common (56%). In the group of optimal angiographic results, OCT showed a suboptimal deployment in 54% of cases. Minimum lumen area of less than 4.5 mm2, distal and proximal reference narrowing, and distal edge dissections were found in 30, 25, 15, and 7% of cases, respectively. This substudy of the CLI-OPCI II showed that in patients with major adverse cardiac events, the presence of an optimal postintervention angiographic appearance with suboptimal OCT metrics is a frequent finding. Our data further support the effectiveness of OCT, which provide valuable information even in the presence of optimal poststenting angiographic results.

Objectives: Assess clinical consequences of acute stent malapposition (ASM) in the context of the multicenter Centro per la Lotta Contro l'Infarto‐Optimization of Percutaneous Coronary Intervention (CLI‐OPCI) registry.Background: ASM as important determinant of stent thrombosis (ST) risk remains controversial.Methods: From 2009 to 2013, we retrospectively analyzed postprocedural optical coherence tomography (OCT) findings in 864 patients undergoing percutaneous coronary intervention, assessing prevalence and magnitude of ASM and exploring correlation with outcome, especially ST.Results: Postprocedural OCT revealed a variable grade of ASM in 72.3% of stents without correlation between maximal strut‐vessel distance and longitudinal extension (R = 0.164, P < 0.01). At a median follow up of 302 (IQ 127–567) days, ASM did not affect risk of following major cardiac adverse events (MACE); residual ASM was comparable in terms of thickness (median [quartiles] 0.21[IQ 0.1–0.4] vs. 0.20[IQ 0.0–0.3], P = 0.397) and length (2.0[IQ 0.5–4.1] vs. 2.2[IQ 0.0–5.2], P = 0.640) in patients with versus without MACE. The predictive accuracy for outcome was low (C‐statistic 0.52, CI 95% 0.47–0.58, P = 0.394) as well for target lesion revascularization (HR 0.80, CI 95% 0.5–1.4) and ST (HR 0.71, CI 95% 0.3–1.5). Likewise, timing to MACE was not influenced by presence of such an ASM with similar rate of acute‐subacute (HR 1.09, CI 95% 0.6–1.9), late (HR 0.91, CI 95% 0.5–1.8), and very late (HR 1.23, CI 95% 0.5–2.9) events.Conclusions: Limited ASM was a common finding after stent implantation, but was not associated to increased risk of stent failure or ST during mid‐term follow‐up.

Article: Coronary aneurysm formation following bare-metal stent implantation: an optical coherence tomography evaluation - Minerva Cardioangiologica 2017 April;65(2):196-8 - Minerva Medica - Journals

Background—: Clinical consequences of optical coherence tomographic (OCT) high-definition visualization of plaque/stent structures in acute patients remain undefined. In this retrospective substudy, we assessed the prognostic impact of postprocedural culprit lesion OCT findings in patients with acute coronary syndrome undergoing percutaneous coronary intervention. Methods and Results—: In the CLI-OPCI (Centro per la Lotta Contro L’Infarto-Optimization of Percutaneous Coronary Intervention) database collecting cases from 5 independent OCT-experienced centers, we retrospectively analyzed postprocedural OCT findings in acute coronary syndrome patients and explored its possible impact (specifically that of residual intrastent plaque/thrombus protrusion) on outcome. From 2009 to 2013, 507 patients (588 lesions) were evaluated. Patients experiencing device-oriented cardiovascular events showed more frequently the features of suboptimal stent implantation defined as the presence of significant residual intrastent plaque/thrombus protrusion (hazard ratio [HR], 2.35; P 2 (HR, 2.72; P 200 µm at distal stent edge (HR, 3.84; P 2 at either distal (HR, 6.07; P P P P =0.002) and the residual intrastent plaque/thrombus protrusion (HR, 2.83; P =0.008) were confirmed as independent predictors of device-oriented cardiovascular events. Conclusions—: In this retrospective study of acute coronary syndrome patients undergoing percutaneous coronary intervention, a composite of OCT-defined suboptimal stent implantation characteristics at the culprit lesion and residual intrastent plaque/thrombus protrusion was associated with adverse outcome.