The combination of acute ST-segment elevation myocardial infarction (STEMI) and gastric ulcers poses a challenge to primary percutaneous coronary intervention (PPCI), particularly for young patients. The role of drug-coated balloons (DCBs) in the treatment of de novo coronary artery lesions in large vessels remains unclear, especially for patients with STEMI. Our strategy is to implement drug balloon angioplasty following the intracoronary administration of low-dose prourokinase and adequate pre-expansion.

A 54-year-old male patient presented to the emergency department due to chest pain on June 24, 2019. Within the first 3 minutes of the initial assessment in the emergency room, the electrocardiogram (ECG) showed significant changes. There was atrial fibrillation with ST-segment elevation. Subsequently, atrial fibrillation terminated spontaneously and reverted to sinus rhythm. Soon after, the patient experienced syncope. The ECG revealed torsades de pointes ventricular tachycardia. A few seconds later, it returned to sinus rhythm. High-sensitivity tropon in I was normal. The diagnosis was acute STEMI. Emergency coronary angiography revealed subtotal occlusion with thrombus formation in the proximal segment of the left anterior descending artery. Considering the patient's age and history of peptic ulcer disease, after the intracoronary injection of prourokinase, percutaneous transluminal coronary angioplasty and cutting balloon angioplasty were conducted for thorough preconditioning, and paclitaxel drug-eluting balloon angioplasty was performed without any stents, achieving favorable outcomes.

A PPCI without stents may be a viable treatment strategy for select patients with STEMI, and further research is warranted.

It remains unclear which percutaneous coronary intervention (PCI) strategy is the most preferable in patients with small-vessel coronary artery disease (CAD). We sought to evaluate the clinical efficacy of various PCI strategies for patients with small-vessel CAD through a network meta-analysis of randomized controlled trials (RCTs). We searched multiple databases for RCTs investigating the efficacy of the following PCI strategies for small-vessel CAD (<3 mm in diameter): drug-coated balloons (DCB), early-generation paclitaxel-eluting stents and sirolimus-eluting stents (SES), newer-generation drug-eluting stents (DES), bare-metal stents (BMS), cutting balloon angioplasty, and balloon angioplasty (BA). The primary outcome was the trial-defined major adverse cardiovascular events (MACE), mostly defined as a composite of death, myocardial infarction, and revascularization. The secondary outcomes included each component of MACE and angiographic binary restenosis. We performed a sensitivity analysis for RCTs without BMS or first-generation DES. Our search identified 29 eligible RCTs, including 8,074 patients among the 8 PCI strategies. SES significantly reduced MACE compared with BA (hazard ratio 0.23, 95% confidence interval 0.10 to 0.54) with significant heterogeneity (I2 = 55.9%), and the rankogram analysis showed that SES was the best. There were no significant differences between DCB and newer-generation DES in any clinical outcomes, which was consistent in the sensitivity analysis. BMS and BA were ranked as the worst 2 for most clinical outcomes. In conclusion, SES was ranked as the best for reducing MACE. There were no significant differences in clinical outcomes between DCB and newer-generation DES. BMS and BA were regarded as the worst strategies for small-vessel CAD.

The toughness of femoral atherosclerotic tissue is of pivotal importance to understanding the mechanism of luminal expansion during cutting balloon angioplasty (CBA) in the peripheral vessels. Furthermore, the ability to relate this parameter to plaque composition, pathological inclusions and location within the femoral vessels would allow for the improvement of existing CBA technology and for the stratification of patient treatment based on the predicted fracture response of the plaque tissue to CBA. Such information may lead to a reduction in clinically observed complications, an improvement in trial results and an increased adoption of the CBA technique to reduce vessel trauma and further endovascular treatment uptake. This study characterises the toughness of atherosclerotic plaque extracted from the femoral arteries of ten patients using a lubricated guillotine cutting test to determine the critical energy release rate. This information is related to the location that the plaque section was removed from within the femoral vessels and the composition of the plaque tissue, determined using Fourier Transform InfraRed spectroscopy, to establish the influence of location and composition on the toughness of the plaque tissue. Scanning electron microscopy (SEM) is employed to examine the fracture surfaces of the sections to determine the contribution of tissue morphology to toughness. Toughness results exhibit large inter and intra patient and location variance with values ranging far above and below the toughness of healthy porcine arterial tissue (Range: 1330-3035 for location and 140-4560J/m(2) for patients). No significant difference in mean toughness is observed between patients or location. However, the composition parameter representing the calcified tissue content of the plaque correlates significantly with sample toughness (r=0.949, p<0.001). SEM reveals the presence of large calcified regions in the toughest sections that are absent from the least tough sections. Regression analysis highlights the potential of employing the calcified tissue content of the plaque as a preoperative tool for predicting the fracture response of a target lesion to CBA (R(2)=0.885, p<0.001).

This study addresses a gap in current knowledge regarding the influence of plaque location, composition and morphology on the toughness of human femoral plaque tissue. Such information is of great importance to the continued improvement of endovascular treatments, particularly cutting balloon angioplasty (CBA), which require experimentally derived data as a framework for assessing clinical cases and advancing medical devices. This study identifies that femoral plaque tissue exhibits large inter and intra patient and location variance regarding tissue toughness. Increasing calcified plaque content is demonstrated to correlate significantly with increasing toughness. This highlights the potential for predicting target lesion toughness which may lead to an increased adoption of the CBA technique and also further the uptake of endovascular treatment.

Because stent underdeployment occurs frequently, accurate minimal stent area (MSA) measurement during postdilatation is necessary. This study investigated the accuracy and repeatability for MSA determination using a novel conductance balloon (CB) catheter for peripheral vessels.

The CB catheter is a standard balloon catheter that measures electrical conductance (ratio of current/voltage drop) in real-time during inflation, which directly relates to the balloon cross-sectional area through Ohm's law. CB measurements were made in 4- to 10-mm phantoms on the bench, ex vivo in stents fully deployed in diseased human peripheral arteries, and in vivo in stents fully deployed in peripheral vessels in six swine. CB measurement accuracy and repeatability were calculated and compared with the known dimension (bench phantoms) or with intravascular ultrasound (IVUS) measurement after stent deployment (ex vivo and in vivo).

CB measurements were highly accurate (error: 1.8% bench, 5% ex vivo, and 5% in vivo) and repeatable (error: 0.9% bench, 1.8% ex vivo, and 1.3% in vivo), with virtually no bias (average difference in measurements: -0.05 mm bench CB vs known phantom diameters, -0.06 mm ex vivo CB vs IVUS, and -0.11 mm in vivo CB vs IVUS).

The CB sizing capability can be integrated within a standard balloon catheter (two-in-one function) to provide accurate, real-time assessment of MSA to ensure full stent apposition rather than the use of pressure as a surrogate for size.

The efficacy of cutting or plain balloon angioplasty (CBA or PBA) has not been analyzed for the treatment of drug-eluting stent (DES) restenosis vs bare metal stent (BMS) restenosis.

The 252 in-stent restenosis (ISR) lesions in 224 consecutive patients treated by CBA (n=167) or PBA (n=85) between July 2002 and December 2007 were analyzed. At 6-month angiographic and 12-month clinical follow-up, CBA and PBA showed similar efficacies: repeat-ISR (37.0% vs 37.8%, P=0.90), late loss (0.62+/-0.60 vs 0.61+/-0.47 mm, P=0.92), and target lesion revascularization (18.3% vs 22.4%, P=0.50). This comparable efficacy was maintained for treatment in the DES-ISR and BMS-ISR subgroups. However, target lesion-related myocardial infarction (n=9) occurred more frequently in the CBA than in the PBA arm (6.2% vs 0%, P=0.03), most of which developed early after ISR treatment (n=7; 54+/-26 days). Independent predictors of repeat-ISR were diffuse ISR and smaller pretreatment minimal lumen diameter, both of which might imply heavier plaque burden in the ISR group.

Plain or cutting balloon angioplasty for ISR seems to be comparable, as the angiographic or clinical endpoints were not affected by initial stent type but by parameters related to the plaque burden of the ISR lesion. However, CBA might be associated with higher risk of myocardial infarction than PBA, suggesting more attention to dual-antiplatelet therapy after its use for ISR.

Cardiologists undertaking percutaneous coronary intervention (PCI) are excited by the combination of patient and physician satisfaction and technological advance occurring on the background of the necessary manual dexterity. Progress and applicability of percutaneous techniques since their inception in 1977 have been remarkable; a sound evidence base coupled with the enthusiasm and ingenuity of the medical device industry has resulted in a sea change in the treatment of coronary heart disease (CHD), which continues to evolve at breakneck speed. This is the third set of guidelines produced by the British Cardiovascular Intervention Society and the British Cardiac Society. Following the last set of guidelines published in 2000, we have seen PCI activity in the UK increase from 33,652 to 62,780 (87% in four years) such that the PCI to coronary artery bypass grafting ratio has increased to 2.5:1. The impact of drug eluting stents has been profound, and the Department of Health is investigating the feasibility of primary PCI for acute myocardial infarction. Nevertheless, the changes in the structure of National Health Service funding are likely to focus our attention on cost effective treatments and will require physician engagement and sensitive handling if we are to continue the rapid and appropriate growth in our chosen field. It is important with this burgeoning development now occurring on a broad front (in both regional centres and district general hospitals) that we maintain our vigilance on audit and outcome measures so that standards are maintained for both operators and institutions alike. This set of guidelines includes new sections on training, informed consent, and a core evidence base, which we hope you will find useful and informative.

PCI for long coronary lesions remains a challenge because of high incidence of early complications and late restenosis. Cutting balloon angioplasty may result in reduced procedural complications and late restenosis than angioplasty with conventional long balloons (LBA) due to minimized injury to the culprit arteries.

To compare the immediate and one-year outcomes of CBA and LBA for long coronary lesions.

169 consecutive patients were retrospectively identified who underwent CBA or LBA for de novo lesions 20 mm in length and 2.5 mm in diameter. The primary endpoint was immediate procedural outcomes and angiographic restenosis at one year.

CBA was performed in 54 patients (56 lesions) and LBA in 115 patients (151 lesions). Baseline characteristics were similar in both groups with a mean lesion length of 34.89+/-11.19 mm, and vessel diameter of 3.03+/-0.54 mm. CBA resulted in reduced incidence of side branch loss (23.2% versus 41.7%, P=0.022) which was associated with less peri-procedural infarction (OR: 11.39 (95% CI: 1.34-96.53), P=0.026). It also caused less dissection (23.2% versus 38.4%, P=0.048) leading to a trend of less provisional focal stenting (32.1% versus 41.1%, P=0.264). The rate of angiographic restenosis and clinically driven target lesion revascularization at one year (follow-up 91.1%) was similar (25% versus 21.2%, and 20.4% versus 20%, for CBA versus LBA, both P=NS). The mean event-free survival was also similar (10.15+/-0.45 months for CBA versus 9.50+/-0.39 months for LBA, P=NS).

CBA demonstrated better immediate results and equivalent late results than LBA, and therefore, it may be considered a reasonable firstline approach for PCI of long coronary lesions.

To evaluate the effect of cutting balloon (CB) angioplasty on the outcome of self-expanding coronary stent implantation, we compared the results of Radius stent implantation using two predilation strategies. Seventy de novo lesions in 70 patients (60 men) were included in the study. Stenting was performed after conventional angioplasty (n = 38, group 1) or CB angioplasty (n = 32, group 2). In-stent restenosis (ISR) rates of each group were 39 and 10% at 6-month follow-up (p = 0.02). Major adverse cardiac events occurred in 20 and 11%, respectively (p = 0.25). Multivariate analysis revealed that ISR was predicted only by lesion length > or = 20 mm. In conclusion, CB angioplasty did not reduce ISR after Radius stent implantation, when other independent risk factors, such as lesion length, were taken into consideration.

Conventional angioplasty of stenoses at the venous anastomosis has been demonstrated to be an important endovascular adjunct to mechanical thrombectomy of clotted arteriovenous dialysis grafts. In some cases, however, severe venous anastomosis stenosis is resistant to angioplasty. Cutting balloon angioplasty may have an advantageous role in these difficult situations in order to avoid surgical revision. In this series of 350 patients receiving percutaneous, endovascular declotting procedures, 9 patients had high-grade venous anastomotic stenoses (opening less than 2 mm) that could not be remedied with either conventional or high-pressure noncompliant peripheral angioplasty balloons. These nine patients had the lesions opened with the use of 4 mm x 10 mm cutting balloons and placement of self-expanding nitinol stents at the venous anastomosis during the same angiography procedure. Patients were followed for patency and functionality of the graft. In all cases, immediate technical success occurred. Among these patients, the vessels have remained patent for as long as 20 months of follow-up and grafts have remained functional. Cutting balloon angioplasty may have a potential therapeutic role in resistant venous anastomotic stenoses.

The aim of this study is to demonstrate initial results and long-term outcomes of patients after receiving cutting balloon angioplasty (CBA), balloon angioplasty (BA), or stenting for small vessel diseases. We studied a total of 327 lesions of small coronary disease treated either by CBA (n=87), BA (n=130), or stenting (n=110) in two affiliated institutes. A small coronary artery was defined as a reference vessel <2.5 mm using quantitative coronary angiography (QCA). Angiographic restenosis was encountered in 31% of the CBA, 46.5% of the BA, and 43.9% of the stent (p=0.048). Major adverse cardiac events (death, myocardial infarction, and target lesion revascularization) at follow-up were significantly lower in the CBA compared to other groups (CBA, 20.3%; BA, 37.3%; stent, 33.3%; p=0.036). The CBA procedure provided superior angiographic and clinical outcomes to the stenting or BA. The CBA may be a cost-effective and reasonable approach for the treatment of lesions in small coronary diseases.

Infrainguinal angioplasty has less initial and long-term success compared with more proximal sites. These suboptimal initial technical results may be related to the heavy calcific burden in the femoral and popliteal arteries and, subsequently, higher incidence of distal dissection. Cutting balloon angioplasty (CBA) is a newer technique that is thought to limit distal dissection in heavily calcified vessels; although CBA has been evaluated in the coronary circulation, there are few reports of its use in peripheral vessels. This study evaluates our initial experience with CBA for the management of femoropopliteal disease. Eleven patients underwent infrainguinal CBA for symptomatic limb ischemia at a community hospital. Ten procedures (91%) were technically successful, with no distal dissections, iatrogenic vessel perforations, or surgical target vessel revascularizations. In eight patients available for follow-up, the limb salvage rate was 100% and of seven and eight CBA sites (88%) were still widely patent (mean follow-up, 3 months; range, 2-12 months). This preliminary study suggests that CBA is safe and feasible for electively performed femoropopliteal chronic occlusive disease with acceptable success rates on short-term follow-up. Long-term results and comparison with other endovascular modalities require evaluation.

We conducted a systematic overview (meta-analysis) of randomized trials of balloon angioplasty versus coronary atherectomy, laser angioplasty, or cutting balloon atherotomy to evaluate the effects of plaque modification during percutaneous coronary intervention.

Several mechanical approaches have been developed that ablate or section atheromatous plaque during percutaneous coronary interventions to optimize acute results, minimize intimal injury, and reduce complications and restenosis.

Sixteen trials (9,222 patients) constitute the randomized controlled experience with atherectomy, laser, or atherotomy versus balloon angioplasty with or without coronary stenting. Each trial tested the hypothesis that ablative therapy would result in better clinical or angiographic results than balloon dilation alone.

Short-term death rates (<31 days) were not improved by the use of ablative procedures (0.3% vs. 0.4%, odds ratio [OR] 0.94 [95% confidence interval 0.46 to 1.92]), but periprocedural myocardial infarctions (4.4% vs. 2.5%, OR 1.83 [95% CI 1.43 to 2.34]) and major adverse cardiac events (5.1% vs. 3.3%, OR 1.54 [95% CI 1.25 to 1.89]) were increased. Angiographic restenosis rates (6,958 patients) were not improved with the ablative devices (38.9% vs. 37.4%, OR 1.06 [95% CI 0.97 to 1.17]). No reduction in revascularization rates (25.2% vs. 24.5%, OR 1.04 [95% CI 0.94 to 1.14]) or cumulative adverse cardiac events rates up to one year after treatment were seen with ablative devices (27.8% vs. 26.1%, OR 1.09 [95% CI 0.99 to 1.20]).

The combined experience from randomized trials suggests that ablative devices failed to achieve predefined clinical and angiographic outcomes. This meta-analysis does not support the hypothesis that routine ablation or sectioning of atheromatous tissue is beneficial during percutaneous coronary interventions.

Small vessel size represents a critical risk factor for an adverse outcome after both conventional balloon angioplasty (POBA) and stenting. Gradual and prolonged balloon angioplasty (GPBA) has been shown to cause less arterial trauma, which results in higher procedural success rates and fewer in-hospital complications than POBA. The aim of this study was to assess the clinical and angiographic benefits of primary GPBA with a perfusion balloon in small coronary arteries, as compared with cutting balloon angioplasty (CBA) and POBA.

A total of 263 patients with symptoms and reference diameters <3.0 mm were randomly assigned to undergo GPBA (n = 85), CBA (n = 88), or POBA (n = 90). The cumulative inflation time must be >10 minutes in GPBA. Crossover to stent was allowed for inadequate results. Follow-up angiography was performed after 6 months. The primary end point was angiographic restenosis at follow-up.

Compared with POBA, GPBA resulted in a lower final residual diameter stenosis (27.3% vs 34.2%, P =.01) and decreased the need for stent placement (8.0% vs 22.2%, P =.031). At follow-up, the restenosis rates were lower with GPBA (31.3%, P =.034) and CBA (32.9%, P =.059) than POBA (50.6%). Target lesion revascularization was less frequently needed with GPBA (20.5%, P =.043) and CBA (20.0%, P =.033) than POBA (37.6%). Additionally, the event-free survival rate was higher with GPBA (77.1%, P =.033) and CBA (76.4%, P =.047) than POBA (58.8%).

In small coronary arteries, both GPBA and CBA resulted in favorable angiographic and clinical outcomes. With a lower restenosis rate and target lesion revascularization rate, GPBA may be a superior strategy for small vessels compared with POBA.

The appropriate regimen of platelet inhibitors that should be used in patients with immune thrombocytopenia purpura (ITP; formerly called idiopathic thrombocytopenic purpura) who are undergoing percutaneous coronary intervention is unclear. We report the case of a patient with ITP who underwent two separate coronary interventions. The first involved the use of aspirin and a cutting balloon to treat obstructive disease of the left circumflex. When the patient presented with restenosis, he received eptifibatide, clopidogrel, and an intracoronary stent. He is currently 16 months removed from his second procedure and remains physically active without any anginal symptoms. Percutaneous revascularization in patients with ITP remains a challenge and this therapeutic approach, while ultimately successful in the patient, requires further validation.

Treatment for peripheral pulmonary artery stenosis is challenging, and conventional balloon angioplasty has not proved to be universally effective. Evaluated was the efficacy of bladed balloon (BB) dilation to address vessels resistant to conventional high-pressure (10-15 atm) balloon angioplasty (BA). Thirty-one procedures were performed on 14 children with age range 1 month to 15 years. The diameter of the BB ranged from 3 to 8 mm. After BB dilation, all children had subsequent conventional BA (balloon size range, 3-10 mm). The minimal lumen diameter (MLD) before and after the procedure, whether there was a waist at initial BA, and BB diameter-to-MLD ratio before the procedure were measured. A > 50% increase in MLD was considered successful. Four children had Williams syndrome, two children Alagille syndrome, five children Fallot's tetralogy, and three miscellaneous lesions. The resistant stenosis was located in the right central pulmonary artery in 6, right branch pulmonary artery in 7, left central pulmonary artery in 6, and left branch pulmonary artery in 12 lesions. Median BB diameter was 253% (117-440%) of the MLD and increased from 2.0 +/- 0.7 to 3.2 +/- 0.8 mm (P < 0.0001), with a mean increase of 73% +/- 62%. There was an inverse relationship between the MLD before and increase after the procedure (r = 0.75; P < 0.001). The BB diameter-to-MLD ratio before procedure was significantly associated with the increase in MLD (r = 0.70; P < 0.001). After the procedure, 18 of the 31 procedures were considered successful. In all successful procedures, the BB diameter was greater than twice the MLD before the procedure. Comparing children with Williams and Alagille syndrome with the remaining eight children, there were no significant differences in the increase in MLD. A small aneurysm and thrombus were noticed in two and three children, respectively, but no fatal complications were reported. BB angioplasty is effective for resistant peripheral pulmonary artery stenosis when conventional BA fails. The diameter of the BB should be larger than twice the minimal luminal diameter of the stenotic lesion.

The objective of this study was to evaluate the safety and efficacy of cutting balloon angioplasty (CBA) for the treatment of in-stent restenosis prior to intracoronary brachytherapy (ICB). Cutting balloon angioplasty may reduce the incidence of uncontrolled dissection requiring adjunctive stenting and may limit "melon seeding" and geographic miss in patients with in-stent restenosis who are subsequently treated with ICB. We performed a retrospective case-control analysis of 134 consecutive patients with in-stent restenosis who were treated with ICB preceded by either CBA or conventional balloon angioplasty. We identified 44 patients who underwent CBA and ICB, and 90 control patients who underwent conventional percutaneous transluminal coronary angioplasty (PTCA) and ICB for the treatment of in-stent restenosis. Adjunctive coronary stenting was performed in 13 patients (29.5%) in the CBA/ICB group and 41 patients (45.6%; P < 0.001) in the PTCA/ICB group. There was no difference in the injury length or active treatment (ICB) length. The procedural and angiographic success rates were similar in both groups. There were no statistically significant differences in the incidence of death, myocardial infarction, recurrent angina pectoris, subsequent target lumen revascularization, or the composite endpoint of all four clinical outcomes (P > 0.05). Despite sound theoretical reasons why CBA may be better than conventional balloon angioplasty for treatment of in-stent restenosis with ICB, and despite a reduction in the need for adjunctive coronary stenting, we were unable to identify differences in clinical outcome.

The cutting balloon (CB) is a specialized device designed to create discrete longitudinal incisions in the atherosclerotic target coronary segment during balloon inflation. Such controlled dilatation theoretically reduces the force needed to dilate an obstructive lesion compared with standard percutaneous transluminal coronary angioplasty (PTCA). We report a multicenter, randomized trial comparing the incidence of restenosis after CB angioplasty versus conventional balloon angioplasty in 1,238 patients. Six hundred seventeen patients were randomized to CB treatment, and 621 to PTCA. The mean reference vessel diameter was 2.86 +/- 0.49 mm, mean lesion length 8.9 +/- 4.3 mm, and prevalence of diabetes mellitus in patients was 13%. The primary end point, the 6-month binary angiographic restenosis rate, was 31.4% for CB and 30.4% for PTCA (p = 0.75). Acute procedural success, defined as the attainment of <50% diameter stenosis without in-hospital major adverse cardiac events, was 92.9% for CB and 94.7% for PTCA (p = 0.24). Freedom from target vessel revascularization was slightly higher in the CB arm (88.5% vs 84.6%, log-rank p = 0.04). Five coronary perforations occurred in the CB arm only (0.8% vs 0%, p = 0.03). At 270 days, rates of myocardial infarction, death, and total major adverse cardiac events for CB and PTCA were 4.7% versus 2.4% (p = 0.03), 1.3% versus 0.3% (p = 0.06), and 13.6% versus 15.1% (p = 0.34), respectively. In summary, the proposed mechanism of controlled dilatation did not reduce the rate of angiographic restenosis for the CB compared with conventional balloon angioplasty. CB angioplasty should be reserved for difficult lesions in which controlled dilatation is believed to provide a better acute result compared with balloon angioplasty alone.