Dollars and stents: A brave new world

• Reimbursement in the healthcare system is shifting from pure volume to a mixed volume/value‐based metric.
• Using complex statistical modeling to adjust for unknowns, the study provides real world data that the use of Co‐Cr EES is more cost effective than BMS assuming that clinicians select clopidogrel for P2Y12 inhibition.
• More cost‐effectiveness analyses should be conducted to guide the use of ever costlier novel medical devices and drugs.

     

Impact of Glycoprotein IIb/IIIa Inhibitors Use on Outcomes After Lower Extremity Endovascular Interventions From Nationwide Inpatient Sample (2006–2011)

• Anticoagulant and antiplatelet medications are necessary in peripheral endovascular intervention, but a standardized approach has not yet been established.
• Glycoprotein IIb/IIIa inhibitor use in endovascular lower extremity interventions decreased overall amputation rates.
• Glycoprotein IIb/IIIa inhibitor use in endovascular lower extremity interventions increased postprocedural bleeding and complications requiring intervention.

     

Looking for the bare necessities

• The authors suggest that the early durability of the CoreValve implant should not be in question based on the results of this modestly sized, but well‐done postmortem observational study.
• Given the ever‐expanding knowledge of valvular degeneration, one thing is clear: more research and study is needed before any routine change in clinical practice, such as change it antithrombotic therapy, can be recommended.
• Further autopsy studies of patients who die outside of typical healthcare settings and who have had a longer median implant time would aid greatly in furthering the understanding of the degeneration and natural history of bioprosthetic transcatheter heart valves.

     

Can our choice of contrast media impact renal and cardiovascular outcomes?

• Contrast media vary in their ionic status, viscosity, osmolarity—and these factors all play into clinical effects.
• Iso‐osmolar and low‐osmolar contrast media dominate clinical use today. The differences between these two agents in terms of kidney injury remain uncertain.
• Ionic agents have theoretical properties which may help prevent thrombus formation; however this phenomenon has not translated to differences in clinical outcomes.

     

The invisible scaffold…with invisible benefits?

• Authors suggest the use of an investigator‐owned and directed, prospective, non‐randomized, single‐arm multicenter registry at 23 Italian hospitals to follow 500 STEMI patients who receive BVS.
• Follow‐up of patients is out to 5 years to determine how a BVS which has been deployed according to the IFU performs in these ACS patients. There is no comparator arm.
• Mandate that patients included in this registry follow a strict BVS implantation protocol which is felt to mitigate the not insignificant stent thrombosis rates noted with BVS to date.

     

Coronary stent positioning under live IVUS guidance in low contrast percutaneous coronary interventions: The live IVUS stenting technique

In patients with renal insufficiency, advanced techniques have been described to achieve ultra-low contrast or zero contrast percutaneous coronary interventions (PCI). However, these techniques use intra-coronary imaging before stent placement to determine adequate landing zones, by correlating them with saved fluoroscopic landmarks. Still, this leaves the operator with a certain degree of uncertainty about the exact lesion coverage, which is checked with post-stent intra-coronary imaging. We hereby describe a novel technique which takes away the concern of uncertainty regarding stent-landing zones and allows for the highest amount of precision in stent positioning, arguably even better than with the use of angiography. This technique involves positioning coronary stents under the live guidance of an intravascular ultrasound (IVUS) catheter which is positioned simultaneously, side by side to a stent. This technique takes advantage of all the benefits of IVUS based PCI without losing the precision in stent positioning when compared to traditional angiography. It simplifies the application of low contrast PCI by the interventional cardiology community, while maintaining the confidence in precise stenting. It has also the potential to decrease the incidence of contrast-induced nephropathy, hence procedural morbidity, while allowing for optimal long-term image based PCI outcomes. Obviously, it applies to moderate or larger coronary segments, without significant tortuosity. It also comes at the expense of slightly larger guide catheters, which is compensated for by the use of thin walled sheaths or sheathless catheter systems. Finally, radial access is still applicable depending on radial artery size and available equipment.