James W. Choi M.D.

Kandzari, D.E., Kirtane, A.J., Windecker, S., Latib, A., Kedhi, E., Mehran, R., Price, M.J., Abizaid, A., Simon, D.I., Worthley, S.G., Zaman, A., Choi, J.W., Caputo, R., Kanitkar, M., McLaurin, B., Potluri, S., Smith, T., Spriggs, D., Tolleson, T., Nazif, T., Parke, M., Lee, L.C., Lung, T.H. and Stone, G.W. (2020). “One-Month Dual Antiplatelet Therapy Following Percutaneous Coronary Intervention With Zotarolimus-Eluting Stents in High-Bleeding-Risk Patients.” Circ Cardiovasc Interv 13(11): e009565.

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BACKGROUND: Despite treatment guidance endorsing shortened dual antiplatelet therapy (DAPT) duration in high bleeding risk (HBR) patients after drug-eluting stents, limited evidence exists to support these recommendations. The present study was designed to examine the safety and effectiveness of 1-month DAPT duration following percutaneous coronary intervention with zotarolimus-eluting stents in HBR patients. METHODS: Onyx ONE Clear was a prospective, multicenter, nonrandomized study evaluating the safety and effectiveness of 1-month DAPT followed by single antiplatelet therapy in HBR patients undergoing percutaneous coronary intervention with Resolute Onyx drug-eluting stents. The primary analysis of cardiac death or myocardial infarction between 1 month and 1 year was performed in the prespecified one-month clear population of patients pooled from the Onyx ONE US/Japan study and Onyx ONE randomized controlled trial. One-month clear was defined as DAPT adherence and without major adverse events during the first month following percutaneous coronary intervention. RESULTS: Among patients enrolled in Onyx ONE US/Japan (n=752) and Onyx ONE randomized controlled trial (n=1018), 1506 patients fulfilled one-month clear criteria. Mean HBR characteristics per patient was 1.6 with 44.7% having multiple risks. By 2 months and 1 year, respectively, 96.9% and 89.3% of patients were taking single antiplatelet therapy. Between 1 month and 1 year, the rate of the primary end point was 7.0%. The 1-sided upper 97.5% CI was 8.4%, less than the performance goal of 9.7% (P<0.001). CONCLUSIONS: Among HBR patients who were event free before DAPT discontinuation at 1 month, favorable safety and effectiveness through 1 year support treatment with Resolute Onyx drug-eluting stents as part of an individualized strategy for shortened DAPT duration following percutaneous coronary intervention. Registration: URL: https://www.clinicaltrials.gov; Unique identifier NCT03647475.

Xenogiannis, I., Alaswad, K., Krestyaninov, O., Khelimskii, D., Khatri, J.J., Choi, J.W., Jaffer, F.A., Patel, M., Mahmud, E., Doing, A.H., Dattilo, P., Koutouzis, M., Tsiafoutis, I., Uretsky, B., Jefferson, B.K., Patel, T., Jaber, W., Samady, H., Sheikh, A.M., Yeh, R.W., Tamez, H., Elbaruny, B., Love, M.P., Abi Rafeh, N., Maalouf, A., Fadi, A.J., Toma, C., Shah, A.R., Chandwaney, R.H., Omer, M., Megaly, M.S., Vemmou, E., Nikolakopoulos, I., Rangan, B.V., Garcia, S., Abdullah, S., Banerjee, S., Burke, M.N., Karmpaliotis, D. and Brilakis, E.S. (2020). “Impact of adherence to the hybrid algorithm for initial crossing strategy selection in chronic total occlusion percutaneous coronary intervention.” Rev Esp Cardiol (Engl Ed) Nov 12;S1885-5857(20)30410-2. [Epub ahead of print.].

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INTRODUCTION AND OBJECTIVES: The hybrid algorithm was designed to assist with initial and subsequent crossing strategy selection in chronic total occlusion (CTO) percutaneous coronary interventions (PCIs). However, the success of the initially selected strategy has received limited study. METHODS: We examined the impact of adherence to the hybrid algorithm recommendation for initial CTO crossing technique selection in 4178 CTO PCIs from a large multicenter registry. RESULTS: The initial crossing strategy was concordant with the hybrid algorithm recommendation in 1833 interventions (44%). Patients in the concordant group had a similar age to those in the discordant group but a lower mean J-CTO score (2.0 ± 1.4 vs 2.8 ± 1.1; P < .01). The concordant group showed higher technical success with the first crossing strategy (68% vs 48%; P < .01) and higher overall technical success (88% vs 83%; P < .01) with no difference in the incidence of in-hospital major adverse events (1.8% vs 2.3%; P = .26). In multivariable analysis, after adjustment for age, prior myocardial infarction, prior PCI, prior coronary artery bypass grafting, J-CTO score, and scheduled CTO PCI, nonadherence to the hybrid algorithm was independently associated with lower technical success of the initial crossing strategy (odds ratio, 0.55; 95% confidence interval, 0.48-0.64; P < .01). CONCLUSIONS: Adherence to the hybrid algorithm for initial crossing strategy selection is associated with higher CTO PCI success but similar in-hospital major adverse cardiac events.

Kandzari, D.E., Kirtane, A.J., Windecker, S., Latib, A., Kedhi, E., Mehran, R., Price, M.J., Abizaid, A., Simon, D.I., Worthley, S.G., Zaman, A., Choi, J.W., Caputo, R., Kanitkar, M., McLaurin, B., Potluri, S., Smith, T., Spriggs, D., Tolleson, T., Nazif, T., Parke, M., Lee, L.C., Lung, T.H. and Stone, G.W. (2020). “One-Month Dual Antiplatelet Therapy Following Percutaneous Coronary Intervention With Zotarolimus-Eluting Stents in High-Bleeding-Risk Patients.” Circ Cardiovasc Interv 13(11): e009565.

Full text of this article.

BACKGROUND: Despite treatment guidance endorsing shortened dual antiplatelet therapy (DAPT) duration in high bleeding risk (HBR) patients after drug-eluting stents, limited evidence exists to support these recommendations. The present study was designed to examine the safety and effectiveness of 1-month DAPT duration following percutaneous coronary intervention with zotarolimus-eluting stents in HBR patients. METHODS: Onyx ONE Clear was a prospective, multicenter, nonrandomized study evaluating the safety and effectiveness of 1-month DAPT followed by single antiplatelet therapy in HBR patients undergoing percutaneous coronary intervention with Resolute Onyx drug-eluting stents. The primary analysis of cardiac death or myocardial infarction between 1 month and 1 year was performed in the prespecified one-month clear population of patients pooled from the Onyx ONE US/Japan study and Onyx ONE randomized controlled trial. One-month clear was defined as DAPT adherence and without major adverse events during the first month following percutaneous coronary intervention. RESULTS: Among patients enrolled in Onyx ONE US/Japan (n=752) and Onyx ONE randomized controlled trial (n=1018), 1506 patients fulfilled one-month clear criteria. Mean HBR characteristics per patient was 1.6 with 44.7% having multiple risks. By 2 months and 1 year, respectively, 96.9% and 89.3% of patients were taking single antiplatelet therapy. Between 1 month and 1 year, the rate of the primary end point was 7.0%. The 1-sided upper 97.5% CI was 8.4%, less than the performance goal of 9.7% (P<0.001). CONCLUSIONS: Among HBR patients who were event free before DAPT discontinuation at 1 month, favorable safety and effectiveness through 1 year support treatment with Resolute Onyx drug-eluting stents as part of an individualized strategy for shortened DAPT duration following percutaneous coronary intervention. Registration: URL: https://www.clinicaltrials.gov; Unique identifier NCT03647475.

Xenogiannis, I., Choi, J.W., Alaswad, K., Khatri, J.J., Doing, A.H., Dattilo, P., Jaffer, F.A., Uretsky, B., Krestyaninov, O., Khelimskii, D., Patel, M., Mahmud, E., Potluri, S., Koutouzis, M., Tsiafoutis, I., Jaber, W., Samady, H., Jefferson, B.K., Patel, T., Megaly, M.S., Hall, A.B., Vemmou, E., Nikolakopoulos, I., Rangan, B.V., Abdullah, S., Garcia, S., Banerjee, S., Burke, M.N. and Brilakis, E.S. (2020). “Outcomes of subintimal plaque modification in chronic total occlusion percutaneous coronary intervention.” Catheter Cardiovasc Interv 96(5): 1029-1035.

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BACKGROUND: When crossing into the distal true lumen fails during chronic total occlusion (CTO) percutaneous coronary intervention (PCI), subintimal plaque modification (SPM) is often performed to restore antegrade flow and facilitate subsequent lesion recanalization. METHODS: Between January 2012 and May 4, 2019, 4,659 CTO PCIs were included in the PROGRESS-CTO registry, of which 935 (20%) had a prior unsuccessful attempt. Of those 935 patients, 119 (13%) had prior SPM. We analyzed the outcomes of the 58 SPM procedures for which data were available, as well as the outcomes of the 60 subsequent CTO PCI attempts. RESULTS: Mean patient age was 67 ± 9 years and 86% were men. Patients had high prevalence of cardiovascular risk factors such as dyslipidemia (91%), hypertension (93%) diabetes (48%), prior PCI (61%), and prior coronary artery bypass graft surgery (47%). The target CTO lesions often had proximal cap ambiguity (54%), moderate/severe calcification (73%), moderate/severe tortuosity (63%), and high J-CTO score (mean 3.2 ± 1.1). The technical and procedural success of subsequent CTO PCI were high (83% for both) with an acceptable rate of in-hospital major adverse cardiovascular events (3.3%). Technical and procedural success were higher for repeat attempts that were performed ≥60 days after the index CTO PCI (94% vs. 69%, p = .015). Median (interquartile range) subsequent procedure time was 147 (100, 215) min, contrast volume was 185 (150, 260) ml, and air kerma radiation dose was 2.5 (1.4, 4.2) Gray. CONCLUSION: Repeat CTO PCI attempts after SPM are associated with high likelihood for successful revascularization with acceptable risks.

Sudhakaran, S. and Choi, J.W. (2020). “Coronary Chronic Total Occlusion Antegrade Wire Technique to Successfully Cross a Common Iliac Chronic Total Occlusion from Retrograde Access.” Am J Cardiol 129: 118-119

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Percutaneous endovascular intervention is the preferred modality of revascularization for iliac arterial obstructive disease. Chronic total occlusions (CTO) of the iliac arteries can be uniquely challenging, as typically utilized polymer jacketed 0.035 in wires have a tendency to enter subintimal planes within the iliac artery or aorta, which consequently require complicated re-entry wire techniques. We present a case of a common iliac chronic total occlusion, initially unable to be crossed with a traditional 0.035 in polymer jacketed guidewire due to subintimal entry. Instead, using an antegrade coronary CTO wire escalation technique with a 0.014 in coronary CTO guidewire, the iliac occlusion was successfully crossed via the true lumen.