Cardiologia Croatica. 2020;15(3-4)

Borut Jug, Breda Barbič-Žagar, Mateja Grošelj, Darja Milovanović Jarh, Tjaša Lipušček

Cardiovascular (CV) diseases remain the leading cause of morbidity and mortality in the world and in Slovenia. According to the recommendations of the European Guidelines on Cardiovascular Disease Prevention in Clinical Practice, reducing LDL-cholesterol levels, especially with statins, is essential for prevention of CV events. A number of clinical studies and years of experience demonstrate the efficacy of statin therapy. Nevertheless, they are still rarely used in clinical practice or are used at insufficient doses. The clinical efficacy of all doses of Krka’s rosuvastatin (Roswera®) was monitored in FROZEN, a three-month non-interventional study. The results showed that patients at high or very high risk of a cardiovascular event were undertreated and were less likely to reach target LDL-C levels than moderate-risk patients. Treatment was evaluated as safe and effective during the follow-up period in patients at a moderate, high, and very high CV risk.

Renata Valenčak, Alenka Tuličić-Mihelčić

**Introduction**: A chronic total occlusion (CTO) of coronary arteries is an absence of blood flowing through the coronary arteries that lasts for over three months. (1) Advanced technology and equipment, the experience of an operator, as well as the entire team, presents a challenge in the revascularization of CTO coronary arteries with a percutaneous coronary intervention (PCI) with the growing procedural success of up to 90%. **Case report**: In the following case we will take a look at the successful opening of an in-stent chronic total occlusion of the right coronary artery. Firstly, an angiogram of the left coronary artery is done on the 59-year-old patient who has a documented coronary artery disease, and the symptoms of a stable angina pectoris. The angiogram of the left coronary artery is without significant pathological findings, with the appearance of collateral blood vessels on the right occluded coronary artery. On the right coronary artery (RCA), the angiographic readings of the middle segment show an occlusion of the stent that has been implanted eight years ago, and that has been auto collateralized. Due to the presence symptoms of angina and ultrasound-determined viability of the myocardium, CTO revascularization of the right coronary artery is justified. By the means of a standard anterograde technique, RCA is probed with a leading catheter using the right radial approach. By using additional advanced equipment in the sense of specialized coronary interventional wires and micro-catheters, the in-stent occlusion of the right coronary artery is rechanneled. Repeated dilatations with high-pressure balloons provide with a good angiographic result. Then, the drug-eluting stent is successfully implanted. Finally, the post-dilatation is facilitated – additional insertion of the stent into a stent using the TIMI 3 RCA flow. The success of an intervention implies a technically successful CTO revascularization with a <30% diameter of residual in-stent stenosis within the treated segment of the artery and the establishment of the TIMI 3 flow, with no complications during hospitalization (MACE: death, myocardial infarction, the occurrence of symptoms which require emergency PCI or surgical revascularization, tamponade which requires pericardiocentesis, or surgical intervention and a stroke).

Marija Romić, Tea Galić, Andrija Matetić

Rotational atherectomy (RA) is a type of percutaneous coronary intervention used to treat severely calcified coronary stenoses. While it offers a great therapeutic modality for complex coronary lesions, its complications could be devastating. Therefore, excellent theoretical knowledge of the possible complications and subsequent therapeutic approach by the entire interventional team is crucial for the successful procedure. (1-3) Here we introduce our 3-step nursing protocol for the main RA complications: 1. Preventive phase: The prevention of complications relies on adequate communication of the interventional team, competent equipment preparation (including flushing drug cocktail) and device set-up. Attention to timely raise concerns using a well-established PACE method (Probe, Alert, Challenge, Emergency) if the patient safety issues are endangered is crucial. Preprocedural system testing using a well-established DRAW method, understanding of the optimal RA technique and the potential rotablator system failure, as well as cautious ECG/angiogram monitoring is of high importance. 2. Emergency management phase: Supportive atmosphere, teamwork and effective communication with a feedback loop is crucial for successful management of complications. − Slow flow phenomenon: venous access re-assessment; preparation of BP optimization therapy; assistance in continuous ECG and BP monitoring; anticipation of pharmacologic therapy administration − Coronary dissection: adequate RA equipment withdrawal; assistance in wire position maintenance; preparation of angioplasty balloon and stent panel − Coronary perforation: warn an interventional team if on-going anticoagulation therapy; preparation of BP optimization therapy; adequate RA equipment withdrawal; assistance in wire position maintenance; continuous angiographic re-assessment of the perforation; preparation of angioplasty balloon, cover stent and coil panel; anticipation of emergent pericardiocentesis. 3. Follow-up phase − Clear communication with the nurse colleagues using a well-established SBAR communication model (Situation, Background, Assessment, Recommendation) − Reassessment of all procedural issues in the nursing reports including therapy and patient data.

Anita Miljas, Ivan Šakić, Kristina Pavlović

The drug coated balloons are evolution in treatment of clotted blood vessels. The era of interventional endovascular medicine began with balloon dilatation, further progress represented bare metal stents and after that drug eluting stents. In the last few years, interventional cardiology recognized the need for further evolution in treating clotted arteries. (1) The concept of DCB is distribution of cytostatic drug (most commonly Paclitaxel) locally through a balloon, which is blocking uncontrolled hyperplasia of the endothelium, most common cause of restenotic lesions. This is done to prevent implanting a permanent metal, and to shorten the usage of antiaggregation therapy. The main components of DCB are balloon drug and drug carrier. Drug carrier is very important in technical concept of successfully designed DCB. DCB is usually used as conventional balloon except avoiding hand contact with the surface of the balloon is necessary because it can damage the drug. The targeted drug delivery needs to be quick because the drug releases its substance at the moment when its entries in blood flow. Ideal drug delivery for coronary intervention to the vessel lesion is 60 seconds (time from entering in blood flow till finishing inflating the balloon). Indications for DCB usage in coronary interventions are in stent restenosis, coronary narrow lesions. DCB has wide usage in interventions of peripheral arteries. It’s more common usage of DCB in “de novo” coronary artery lesions after adequate preparation of the lesion with various methods (scoring balloons, cutting balloons, NC balloons). In now days DCB are unavoidable cardiac catheterization laboratory tool and whose usage is on the rise. For further expansion of indications and growing number of interventions additional study evaluations needs to be done.

Sara Milanović Litre, Adrijana Livaja

**Introduction**: Despite technological evolution and intervention techniques, complications resulting from vascular access still occur in patients undergoing percutaneous procedures in invasive laboratories. Brachial artery access, although little used by some specialties, is an option in peripheral vascular procedures and an alternative access in case of failure of other routes. Access site complications lead to longer periods of hospitalization, additional treatments, and higher costs, in addition to being associated with increased morbidity and mortality (1). **Case report**: In this case we have 58-year-old patient with diabetes mellitus and advanced micro and macrovascular complications, history of CABG, and peripheral artery disease was admitted with non-ST elevation myocardial infarction complicated with acute heart failure. After initial management a bedside echo was performed that show reduced LVEF of 25% and hypokinesia of the anterior wall. CT angio was performed which showed patent arterial grafts (LIMA LAD RIMA RCA). Diagnostic coronary angiography was performed using left brachial access which showed significant stenosis of the ostial subclavian artery. Patient was referred to our invasive radiologist, which performed PTA and implanted a stent at the site of stenosis using bi brachial arterial access. Two hours after procedure patient complained about tingling in the fingers of his right hand, with swelling. A CTA was performed and revealed a rupture of the right brachial artery, and a vascular surgeon was called, who sealed the place of bleeding. Patient was discharged 9 days after, and a follow up was performed after one year, with echo showing EFLV of 50% and patient being angina free.

Jelena Mikulan

Radial access is today the most popular approach in coronary angiography. It decreases risk of bleeding and complications of peripheral vessels. New type of radial approach is distal radial approach in anatomical snuff box region. The aim of this paper is to provoke discussion in the field of interventional cardiology. Distal radial artery access from the anatomical snuff box was described for the first time by Babunashvili in order to open occluded ipsilateral radial arteries in a retrograde fashion. It was then introduced for coronary catheterization as a new technique by Dr F Kiemeneij in April 2017 and in same year in December, Dr Shigeru Saito performed Kamakura live demonstration. The anatomical snuffbox is triangular deepening on the radial side of the wrist visible on extended thumb. (1) Most operators prefer the right radial approach. The main reason is the working position of the operator on the right side of the patient. Distal transradial access on the left arm is the most convenient for the patient and the operator. For the right-handed patient, the left radial access is more convenient because of the free use of the right hand after the procedure. In addition, this technique reduces the chance of radial artery occlusion at the site of the distal forearm. Possible advantages of this approach are more physiologic (pronation) and painless arm position on the catheterization laboratory table, especially for the left arm, with an easier reach of the left arm. Preservation of radial arteries for arterial grafts (coronary artery bypass surgery, etc.), convenience for right-handed patients, easy wrist flexion after the procedure. Faster postprocedural recovery, shorter time for compression, easy manual compression and lower rates of artery stenosis, thrombosis and bleeding. There is a less chance for vascular compromise (danger only for the deep palmar arch, superficial is intact). Limitation is that the distal radial artery is smaller, making puncture more challenging, it has a long learning curve. (2) Does the rise time follow for the distal radial approach?

Sandra Franjić, Zrinka Švec, Maja Jurec

In Croatia and throughout the world cardiovascular diseases represent a great public health problem as they are most common among diseases and the leading cause of death. Annually about 4 million people in Europe dies of cardiovascular disease (45% of all deceased). Acute coronary syndrome (ACS) is an acute complication of heart and blood vessels disease and is most commonly caused by atherosclerosis or coronary thrombosis. Types of ACS are unstable angina, ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI). (1) The purpose of this paper is to describe the role of the nurse in caring for patients suffering from acute coronary syndrome. Nurses in cardiac catheterization labs have gained immense knowledge through schooling and work. The role of nurses is not only participating in teamwork while caring for patients with ACS in cardiac catheterization labs, but also monitoring patients during their hospitalization. Teamwork is of great importance from the very beginning of the intervention procedure when blood vessels are opened, as well as during hemodynamic and rhythmological monitoring in the operating room. What is also important is the support given to the patient in the cardiac catheterization lab during the intervention when our patients are awake and fear for their life. Inasmuch as we are with them since the acute phase it is important to continue to support them during the entire hospitalization and throughout the following rehabilitation program. Good patient rehabilitation increases their chances of survival in case of reiterated coronary disease complications. Mortality rates for cardiovascular disease have been reduced in developed countries due to the increased number of educational programs for people, improved prehospital care, as well as improved monitoring and treatment methods. Continuous systemic education of contemporary methods of treatment are essential prerequisites of timely acute coronary syndrome treatment.

Mario Josipović, Ivan Horvat, Matea Podvorec, Lucija Lovreković, Jadranka Daskijević, Ivica Benko

**Introduction**: Although radiologic technologists have many responsibilities in the cardiac catheterization laboratory, the most important responsibility is to perform invasive cardiac surgery using radiological equipment in a safe manner, both for staff and for the patient. Very often, in addition to working with radiological equipment, radiologic technologists must have specific knowledge of specific interventional procedures in invasive. In order to monitor the complexity of today’s procedures and actively participate in an invasive team, ongoing and specific education is essential. The job of a radiologic technologist in the cardiology intervention room consists of a series of tasks such as: knowledge of the complexity of radiation protection, knowledge of heart anatomy, physiology, hemodynamics and all the technical capabilities of devices used in invasive cardiac methods. At the catheterization laboratory, radiologic technologists participate in preparing the patient for the procedure, which includes checking patient data, taking anamnestic data related to the procedure, placing the patient on the table, monitoring vital functions, etc. (1) The paper presents the experience of University Hospital Center „Sestre milosrdnice“, whereby after the establishment of the Clinic for Cardiovascular Diseases, the team settings at the Department of Invasive and Interventional Cardiology were changed. In earlier periods, practically from the moment the laboratory started with work, the radiological device was operated traditionally and habitually, but also due to a lack of staff, by invasive cardiologists and/or perioperative nurses. Goal: To compare radiation exposure before and after changes in team settings, and to determine the immediate impact of the work of radiologic technologists in the invasive cardiology laboratory. **Conclusion**: Radiologic technologists who directly control radiological equipment and accurately follow the instructions of the operator (interventional cardiologist), by standardizing procedures, can significantly affect the safety of the patient and team in the invasive laboratory.

Sandra Franjić, Branka Horvatinec

Chronic total occlusion (CTO) is defined as the complete obstruction of coronary arteries in the duration of at least three months. In the last two decades interest in new techniques of percutaneous treatment of chronic total occlusion has increased and it has shown a greater rate of successful treatment compared to before. (1) Thanks to the new materials and techniques used in chronic total occlusion percutaneous coronary intervention (CTO PCI) the blood vessels can be opened in a higher percentage and even more importantly, the patient’s life quality is improved and mortality decreased. However, all scientific evidence backing this treatment come from observational studies, but a randomized controlled trial to compare the outcome of treatment of patients before and after CTO PCI has not yet been conducted. The main issue with this intervention is problematic visualization (flying blind), difficult passage of dilatation wire, length of procedure and high costs of material necessary for this intervention, as well as limited information considering the potential basic differences between successful and unsuccessful groups

Jadranka Daskijević

Croatian Primary Percutaneous Coronary Intervention Network, founded in 2005, is an internationally recognized system of well-organized urgent treatment of cardiology patients. (1) The project Croatian Interventional Treatment Network for Acute Myocardial Infarction is one of the most significant achievements in the field of contemporary cardiology in Croatia, but also in the field of medicine in general. Thousands of lives have been saved thanks to a network of heart attack interventions. The transfer of patients to another facility is arranged between the cardiologists on duty at both institutions. The patient is transported by ambulance accompanied by physician and a nurse/technician. Emergencies pose a specific challenge for the nurse/technician, where it is necessary to anticipate which complications can be avoided by good organization. In these emergencies, patients should be well prepared for the invasive and therapeutic procedure, as this results in a timely and effective revascularization of the lesion that caused the acute myocardial infarction. Health care of the patient, its prior continuity, as well as care during and after the procedure is extremely important for the patient’s recovery. The mental preparation of the patient reduces the level of fear and concern, and thus facilitates the intervention of team members. The information given to the patient must be understandable, detailed and simple. In the case of the physical preparation of patients, oral and parenteral therapy is required in addition to laboratory tests, according to the physician’s instructions and general condition of the patient, as well as mandatory informed consent to perform the examination which the patient must sign if capable. It is recommended to place two vein pathways, preferably cubital, to remove hair from both groin and wrists, to remove the denture if the patient has it, to remove all jewelry, glasses, lenses, nail polish, to relieve the patient of unnecessary clothing and footwear and to warm the patient. All team members work for the best possible outcome. Such a difficult and life-threatening condition requires immediate and instant interventions, as any delay lowers the chances of ultimate success of the procedure.

Ivica Benko, Gordana Hursa, Sanja Keleković, Tomislav Pijetlović

Percutaneous coronary interventions (PCI) have been the fastest-growing major invasive procedure in the past decade. Although PCI has many advantages, there are certain risks, including cardiac arrhythmias. It is known that myocardial ischemia and infarction leads to severe metabolic and electrophysiological changes that induce silent or symptomatic life-threatening arrhythmias. Both atrial and ventricular arrhythmias may occur during PCI procedure. (1-3) Arrhythmias and conduction disturbances are common during the early hours after myocardial infarction (MI) and a major cause of death in the pre-hospital phase. In STEMI patients undergoing primary PCI, ventricular arrhythmias, including non-sustained ventricular tachycardia (VT) in 26% of cases and sustained VT in 2-5% cases, have been reported. As the most lethal arrhythmia, ventricular fibrillation (VF) has been reported in 2-5% of cases. But on the other side, sustained VT occurs in 17-21% and VF even in 24-29% in patients with MI and cardiogenic shock undergoing pPCI. The occurrence of atrial fibrillation (AF) is frequently associated with severe left ventricular damage and heart failure. Episodes may last from minutes to hours and are often repetitive. In the case of cardiogenic shock, AF can quickly lead to a worsening of symptoms. High-grade AV block and asystole develop in about 23-35% of acute MI patients with cardiogenic shock, especially in the case of right coronary artery occlusion. Either ventricular or atrial arrhythmias or conduction disturbances occur as a complication of the PCI procedure, but many of them are related to reperfusion injury. The majority of the arrhythmias tend to revert spontaneously, but when necessary, special treatment must be given promptly. For nurses to be able to react properly, effective and early recognition of cardiac arrhythmias during PCI is crucial and beneficial. Also, it is important to identify changes in cardiac status and to early recognize high-risk patients for cardiac arrest, before the patient becomes symptomatic. Accuracy of cardiac rhythm interpretation improves with intermittent educational interventions. Moreover, cardiac rhythm recognition is crucial during Advance Life Support (ALS) training and it is recommended for all cardiac catheterization staff to undergo this type of training.

Ivica Benko

## Dear Friends and Colleagues! It is our pleasure to invite you to the 8th Meeting of the Working Group for Invasive and Interventional Cardiology of the Croatian Association of Cardiology Nurses (CACN) that will be held on March 21, during the 9th Conference on Interventional Cardiology with international participation in Hotel Westin in Zagreb, Croatia. The meeting is designed primarily for cardiology nurses and associated professions in invasive cardiology, but also for nurses from cardiology departments and coronary care units. This year, our aim is to provide insights into the progress and development that took place over the two years since the last meeting. Topics will include novelties in complex procedures and new imaging techniques. Particular attention will be given to PCI network issues and specific tips on how to make further improvements. This meeting promises to stimulate discussion among nurses and associated professionals and to provide mentorship to our young colleagues. On behalf of the CACN and the organizing committee, we look forward to welcoming you to Zagreb for CROINTERVENT 2020. Sincerely yours, ## PREDSJEDNICI 8. SASTANKA / PRESIDENTS OF THE 8th MEETING Marija Matoš, Ivica Benko ## Organizacijski odbor / Organizing Committee Ljubas • J. Daskijević • I. Ferjančić • M. Popić • M. Klasan • A. Kelecević M. Budetić • Z. Puljas K. Librenjak • B. Šego • S. Škifić • A. Miljas • A. Vujičić • R. Valenčak • R. Višnjovski • M. Čelković • B. Koren

Zvonimir Ostojić, Jure Samardžić, Saša Pavasović, Dubravka Šipuš, Ivica Šafradin, Vlatka Rešković Lukšić, Jadranka Šeparović Hanževački, Boško Skorić, Davor Miličić, Joško Bulum

**Introduction**: Recent studies described changes in platelet reactivity (PR) in days following transcatheter aortic valve implantation (TAVI).**1** However, precise time course and duration of these changes have not been fully investigated. Aim of the study was to investigate PR changes during and after TAVI. **Patients and Methods**: Study included 40 consecutive patients with severe and symptomatic aortic stenosis undergoing transfemoral TAVI procedure. Patients’ clinical characteristics were collected from medical records. All patients who did not have chronic dual antiplatelet therapy received loading dose of aspirin and clopidogrel (300 mg) one day before the procedure followed by their standard maintenance doses. PR was measured in seven time points: before start of procedure (T1), after heparin administration (T2), 10 minutes after valve implantation (T3), at the end of procedure (T4), and on 3rd, 6th and 30th postoperative day (T5-7). PR was measured using impedance aggregometer in response to three platelet aggregation agonists using ASPI, ADP and TRAP test. **Results**: Mean patient age was 82.7 years with majority of patients being male 60% (N=25). All patients underwent successful transfemoral TAVI procedure using either self-expandable (N=25, 62.5%) or balloon-expandable valve. Mean postimplantation gradient was 9.97±4.44 mmHg. More than mild paravalvular regurgitation persisted in 2 (5%) patients. Values of PR in each tested time point are presented in **Table 1**. There was no significant difference in PR between T1 and T2. After the valve implantation significant reduction of PR in all 3 tests was observed. PR continued to decline on consecutive measurements, with lowest values reached on 3rd post-TAVI day (T5). On T6, value of ASPI test were not significantly different to the ones measured on T1, while values of ADP and TRAP test remained significantly lower. By 30th post-TAVI day PR values reached levels not significantly different compared to T1. ### TABLE 1: Results of platelet reactivity test using ASPI, ADP and TRAP test in tested time points. | | **T1** | **T2** | **T3** | **T4** | **T5** | **T6** | **T7** | **P** | | --- | --- | --- | --- | --- | --- | --- | --- | --- | | **ASPI** | 22.97±23.01 | 19.17±19.61 | 10.36±11.60 | 10.23±11.38 | 9.71±10.68 | 15.28±17.32 | 20.97±21.26 | < 0.001 | | **ADP** | 40.46±23.68 | 33.11±20.45 | 24.15±14.07 | 22.18±12.63 | 14.95±8.59 | 27.81±17.96 | 33.11±23.60 | < 0.001 | | **TRAP** | 91.69±32.50 | 93.42±27.71 | 69.31±26.57 | 64.05±24.20 | 40.97±17.71 | 69.09±29.08 | 88.06±35.51 | < 0.001 | [†] Values are presented in Units (U) **Conclusions**: Presented results indicate that transfemoral TAVI induces transient decrease in PR regardless of the platelet activation pathway. Significant reduction of PR is observed 10 minutes after valve implantation with continuous decrease until 3rd day post-TAVI after which it is gradually increasing to pre-TAVI values.

Iveta Merćep, Lukrecija Anzić, Ema Budimir

Statins reduce cardiovascular mortality and morbidity as well as cardiovascular events in patients with a very high risk of cardiovascular disease and also in subjects with a moderate or high risk by reducing the levels of low-density lipoprotein cholesterol. Although statins are considered to be drugs with a very good safety profile, their wide use seems to evoke concerns about the compromising adverse effects overpowering proven beneficial ones. Patients frequently discontinue statin therapy without medical advice due to unfavorable events, thereby substantially increasing their risk of cardiovascular events. Statin discontinuation is a great problem and appears to be growing. Complete statin intolerance is relatively rare. Step-by-step approach that includes careful examination of all possible statin-intolerance-increasing factors would help patients to continue statin therapy even if experiencing statin-associated side effects.

Boško Skorić, Joško Bulum, Hrvoje Jurin, Kristina Marić Bešić, Maja Čikeš, Ivo Planinc, Mia Dubravčić, Dubravka Šipuš, Renata Žunec, Marija Burek Kamenarić, Davor Miličić

**Introduction**: Cardiac allograft vasculopathy (CAV) is a common cause of late graft failure and mortality in heart transplant recipients. Concentric intimal proliferation that reflects immune-mediated vascular damage in the early post-transplant years is difficult to recognize by conventional coronary angiography. Optical coherence tomography (OCT) is a high-resolution intravascular imaging technique that has the potential to identify subtle early vessel wall changes and shape the therapeutic approach that may improve patients’ outcomes. (1) **Case report**: 68-year-old male patient underwent heart transplantation with positive lymphocyte crossmatch and Luminex that detected anti-HLA class I (A1, A25, B8, B57) donor-specific antibodies with MFI up to 2500. The patient was treated with steroid, antilymphocyte (rATG) induction, tacrolimus, and mycophenolate mofetil, in combination with IVIG and plasmapheresis. Graft function was preserved, biopsies showed no or mild cellular-mediated rejection (1R) with no signs of antibody-mediated rejection (AMR) with negativization of anti-A1 and -A25 antibodies. However, control biopsy after 6 months became positive for AMR. The patient was treated with steroid pulse, IVIG, plasmapheresis, and rituximab. The following biopsies were negative for AMR and the patient remained with preserved graft function. One year after transplantation we performed control coronary angiography with OCT. While coronary angiography was interpreted as normal, control OCT showed significant diffuse intimal thickening with maximal intimal thickness up to 920 µm and intima/media cross-sectional media of ≥1 (**Figure 1**). This finding prompted a change in therapy with the maximization of statin dose and introduction of everolimus in the maintenance immunosuppressive regimen. FIGURE 1. Control OCT cross-sectional frame of a left anterior descending artery 12 months after heart transplantation. OCT = optical coherence tomography; I/M CSA = intima/media cross-sectional area. **Conclusion**: This case report indicates the limitation of conventional coronary angiography in the early detection of transplant vasculopathy. OCT is able to establish the diagnosis and trigger specific therapeutic interventions like the introduction of everolimus before vascular changes become visible on conventional coronary angiography and resistant to treatment. Unfortunately, we still lack clearly defined OCT criteria for both diagnosis and treatment, but the progress in this field of transplant cardiology is promising.

Mihajlo Kovačić, Dario Dilber

**Introduction:** Drug-coated balloon (DCB, PACCOCATH® technology) is recognized from 2014 ESC Guidelines on myocardial revascularization in treatment of DES/BMS ISR (IA recommendation) (1) and its indications are expanding. DCB in “de-novo” lesions is validated mostly in Small Vessel Disease (PEPCAD I, PICCOLETO, BASKET-SMALL 2, International SVD Register). Information on Large Vessel Disease are scarce and based on preparation of the lesion with DCB followed with BMS implantation: PEPCAD IV and OCTOPUS I, PEPCAD V (Bifurcations), DEBAMI (Acute Myocardial Infarction) and PEPCAD CTO, but “de-novo DCB–only” concept is still practically “off label”. (2) Available conclusions on “de-novo DCB-only” concept can be drawn from the World-wide “all comer” Registry and single center studies such as Potsdam Heart Center, trials such as OCTOPUS II (Stabile CAD), DCB Bifurcation Study (Side Branch Treatment), study on Primary Percutaneous Coronary Intervention (3) and works of Kleber and coworkers which studied Late Lumen Enlargement in DCB-only concept, but again, mainly in small vessels. “De-novo DCB-only” in complex coronary interventions is practically “off label”, especially in CTO PCI. In this paper we present a complex PCI based on “de-novo DCB-only” concept and a novel approach to CTO PCI based on this method. **Case 1**: 85-years-old female patient was admitted due to acute coronary syndrome. Diffuse coronary disease was found, occlusion of LCx, CTO of ostial PD. Heart team decided for PCI. Procedure was done via bilateral radial approach with support of dual lumen microcatheter, and AWE technique. Final angioplasty (**Figure 1**) was done with DCB 3.0x30 Sequent Please NEO (B. Braun). FIGURE 1. Angiogram before and after angioplasty with drug-coated balloon. **Case 2**: 78-years-old male patient with multiple previous PCIs was admitted for elective PCI of in-stent restenosis CTO of OM1. Previously, ostial lesion of OM2 was also p treated with DCB. CTO procedure was done via right transradial approach with support of microcatheter and AWE technique. Final procedure (**Figure 2**) was done with 2 DCBs covering ostial and distal OM1, and 1 DES covering fractured microcatheter tip. FIGURE 2. Angiogram before and after the procedure. **Case 3**: 78-years-old male patient with multiple comorbidities and previously done CABG was admitted for elective PCI after verification of vein grafts degeneration. CTO PCI of LAD (**Figure 3**) was done with AWE technique and finalized with angioplasty with DCB 2.0x30. FIGURE 3. Angiogram before and after angioplasty with drug-coated balloon. **Case 4**: 85-years-old male patient was admitted for elective PCI CTO of RCA. Procedure was done via left transradial approach and single guiding catheter. AWE technique was done, after which CTO body was treated with DCBs 2.0x25 and 2.5x25 and mid segment of the RCA was treated with DES 2.75x33 (**Figure 4**). FIGURE 4. Angiogram before and after the procedure. **Case 5**: 78-years-old female patient was admitted for elective PCI CTO of LAD. Procedure was done with AWE technique, and finalized with two DCBs, 2.0x30 in mid and 2.5x30 in distal segment of the LAD, and 1 DES at the bifurcation of LAD-D1 (**Figure 5**). FIGURE 5. Angiogram before and after the procedure. **Conclusion**: “De-novo DCB-only” concept in complex coronary interventions in chronic coronary syndrome as well as in the setting of primary PCI shows promising results, especially for ostial lesions and by simplifying bifurcations techniques without compromising final result. Concept of de-novo DCB-only CTO procedure depicted here, with “true-to-true crossing” and optimal lesion preparation, shows excellent results, but follow-up and further studies are warranted.

Klara Klarić, Zvonimir Ostojić, Kristina Marić Bešić, Boško Skorić, Ivan Škorak, Hrvoje Jurin, Maja Strozzi, Eduard Margetić, Joško Bulum

**Aim**: Aim of the study was to compare angiographic and clinical outcomes after percutaneous coronary interventions (PCI) using drug coated balloons (DCB) between patients treated for “de novo” lesions and in-stent restenosis (ISR) in acute coronary syndrome (ACS). **Patients and Methods**: Study included 128 ASC patients treated with DCB between 2012 and 2019. All coronary angiographies were reviewed to determine indication, lesion complexity, vessel size and procedural success. Baseline and follow up clinical data were extracted from hospital digital database. **Results**: Mean patient age was 63.8 years, with the majority being men (75.8%, N=97). In total, 24 (18.8%) patients were treated for ISR. Comparison of clinical, angiographic and procedural characteristics between groups is presented in **Table 1**. Patients in the non-ISR group had more often multivessel disease (56.7 vs 25.0%, p=0.005), bifurcation PCI (45.0 vs 20.8%, p=0.042) and more DCB used in the index event (1.1±0.3 vs 1.0±0, p=0.004). Furthermore, they had more concomitant PCI with stent implantation in other lesions (75.9 vs 33.3%, p<0.001) with consequent higher number of stents implanted per person (1.2 vs 0.5, p=0.002). Both mean DCB diameter and length were larger in the ISR group (2.85±0.59 mm vs 2.48±0.49 mm, p=0.007 and 23.38±3.23 vs 21.24±5.24 mm, p=0.012, respectively). In the non-ISR group 8 (7.7%) patients had “bail out” stent implantation, while none was done in ISR group. Mean angiographic and clinical follow up was not significantly different between groups (**Table 2**). Altogether 75 (58.6%) patients underwent repeated coronary angiography, more often in the non-ISR group (64.4% vs 33.3%, p=0.005) but most of those were elective (73.1%). There was no significant difference in the composite endpoint consisted of death, unplanned rehospitalisation, target vessel revascularization and target lesion failure (ISR vs non-ISR; 29.2% vs 26.9%, p=0.82), nor in any of its components (**Table 2**). ### TABLE 1: Differences in clinical, angiographic and procedural characteristics between groups. | | **ISR (N=24)** | **Non-ISR (N=104)** | **P value** | | --- | --- | --- | --- | | **Clinical characteristics** | | | | | Patient age | 68.36±6.85 | 62.85±11.37 | 0.002 | | Family history | 7 (29.2) | 44 (42.3) | 0.23 | | Active smokers | 3 (12.5) | 40 (38.5) | 0.015 | | Diabetes mellitus | 7 (29.2) | 35 (33.7) | 0.67 | | Arterial hypertension | 21 (87.5) | 90 (86.5) | 0.90 | | Hyperlipidaemia | 21 (87.5) | 88 (84.6) | 0.72 | | Previous myocardial infarction | 20 (83.3) | 16 (15.4) | < 0.001 | | Atrial fibrillation | 3 (12.5) | 6 (5.8) | 0.24 | | Ejection fraction | 51.4±21.1 | 54.3±18.2 | 0.33 | | **Angiographic and procedural characteristics** | | | | | Vascular access - femoral | 6 (25) | 36 (34.6) | 0.36 | | Multivessel disease | 6 (25) | 59 (56.7) | 0.005 | | Bifurcation | 5 (20.8) | 45 (43.3) | 0.042 | | Number of used DCB | 1.0±0 | 1.1±0.3 | 0.004 | | Length (mm) | 23.38±3.23 | 21.24±5.24 | 0.012 | | Diameter (mm) | 2.85±0.59 | 2.48±0.49 | 0.007 | | Bail out PCI | 0 | 8 (7.7) | 0.16 | | Concomitant PCI | 8 (33.3) | 79 (75.9) | <0.001 | | Total number of stents per person | 0.5 | 1.2 | 0.002 | [†] Results are presented as mean ± standard deviation or absolute number (%). ISR = in-stent restenosis; DCB = drug coated balloons; PCI = percutaneous coronary intervention. ### TABLE 2: Comparison of clinical and angiographic outcomes between groups. | | **ISR (N=24)** | **Non-ISR (N=104)** | **P value** | | --- | --- | --- | --- | | Angiographic follow up (years) | 1.59±1.45 | 0.87±1.38 | 0.22 | | Clinical follow up (years) | 2.51±2.02 | 2.52±2.36 | 0.98 | | Repeated coronarography | 8 (33.3) | 67 (64.4) | 0.005 | | Elective | 6 (25) | 85 (55.8) | 0.006 | | Target lesion failure | 4 (16.7) | 9 (8.6) | 0.32 | | Target vessel revascularization | 2 (8.3) | 7 (6.7) | 0.78 | | Unplanned hospitalization | 6 (25) | 18 (17.3) | 0.38 | | Death | 1 (4.2) | 5 (4.8) | 0.89 | [†] Results are presented as mean ± standard deviation or absolute number (%). ISR=in-stent restenosis. **Conclusions**: DCB in treatment of native coronary arteries provides similar angiographic and clinical outcomes compared to DCB for ISR in patients presenting with ACS in real-world settings. (1) Furthermore, the prevalence of target lesion failure after DCB treatment was smaller in native coronary arteries compared to ISR.

Krešimir Gabaldo, Božo Vujeva, Katica Cvitkušić Lukenda, Marijana Knežević Praveček, Domagoj Vučić

**Background**: Provisional stenting is a favorable option for most bifurcation lesions, while two stent techniques show benefits in true bifurcation performed by experts. Using one stent and DCB in true bifurcation lesions still remains questionable. (1, 2) **Case report**: 76-year-old male presented with persisting chest pain. ECG showed no specific ischemic changes, while hsTnI was highly elevated. He had gone PCI LAD 14 years ago. Diagnosis: right coronary angiography revealed occlusion of RCA, while left coronary angiography revealed LLS of 20% in proximal LAD stent, 70% stenosis of mid LAD, and acute occlusion of secondary OM branch on bifurcation level, while CxA was stenosed 70-80%. Management: PCI CxA-OM2 was performed with DES Xience expedition 2,75/33mm in CxA-OM2 with POT 3,25/12mm proximally, then after rewiring and adequate lesion preparation a DEB Sequent please 2,5/25mm in CxA distally was performed. After two months we performed an elective PCI LAD and checked out the result of CxA bifurcation which was optimal. **Conclusion**: Using one stent and DCB in true bifurcation lesions still remains questionable. There are no data from a prospective study, while there are data from the observational study which enrolled 130 patients. DCB-only strategy was performed in 54% patients, 34.6% had at least one stent in the main branch, 8.5% had at least one stent in the side branch and 3.1% at least one stent in the main branch and side branch. Study follow up lasted for 9.8 months. The TLR rate was 4.5%, MACE was 6.1%, and no stent thrombosis was detected. This study suggested that the DCB+one stent, and DCB-only strategy was safe and effective in selected bifurcations, possibly allowing for an abbreviated antiplatelet regimen.

Mihajlo Kovačić, Dario Dilber

**Introduction:** The “Tip-In” method is a technique first described in 2015 and is developed to overcome some limitations of commonly used methods in retrograde approach in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). (1, 2) The most commonly applied retrograde technique is placing a guidewire just distal to the distal cap using collateral vessels, with subsequent retrograde crossing of the occlusive segment which is followed by advancement of a microcatheter and externalization of a long guidewire to allow PCI, but sometimes the microcatheter fails to advance into the antegrade guide, obstructing attempts at guidewire externalization. (3) The “tip-in” technique involves the advancement of an antegrade microcatheter over the retrograde guidewire enabling subsequent antegrade wiring of the CTO segment and facilitates successful completion of a retrograde CTO procedure. Wiring can be completed by threading an antegrade wire through the retrograde microcatheter and crossing the CTO which is named rendezvous method. To our knowledge there are no published reports of a use of this technique as a primary strategy in retrograde CTO. Here we present a case where the “tip-in” technique was used not as a “bail-out” method after an unsuccessful completion of an applied retrograde technique, but as a first line strategy of retrograde approach. **Case report:** 57-year-old male patient was presented with angina class III. Echocardiography shoved good ejection fraction of the left ventricle with viable myocardium. Coronary angiography showed occlusion of the mid-segment of the right coronary artery (RCA) with J-CTO 3 score (ambiguous cap, length, calcium). With bilateral vascular access, left snuffbox and right transulnar, Amplatz left 0.75 7F, and Extra backup 3.5 6F guiding catheters were engaged to the right and left coronary arteries respectively. Several methods were tried in an anterograde manner with the support of Corsair Pro 135 microcatheter (Asahi Intecc). First, anterograde wire escalation (AWE) technique, with wires Sion, Gaia first, Gaia second, Gaia third, was attempted with many redirections, always subintimal. (**Figure 1A**). Second, the parallel wire technique was tried unsuccessfully (**Figure 1B**), and also anterograde fenestration technique (AFR) with Sion Black wire, and 2.5x15 SC balloon on Gaia third was unsuccessful, due to probably too small balloon (**Figure 1C**). The bigger balloon was planned, but with retrograde injection, the subintimal hematoma was compressing the distal vessel. Switch to the retrograde procedure was done with Corsair Pro 150 microcatheter and septal surfing with Sion and finally Suoh03 wire through long septo-epicardial collateral (**Figure 1D**). Retrograde wire escalation (RWE) was not succesfull after that reverse CART method was used to externalize wire towards the anterograde guiding catheter (**Figure 1E**). Rather than the externalization wire technique, the „tip-in“ maneuver was done with retrograde wire positioning into anterograde microcatheter on the convex part of the anterograde guiding catheter (**Figure 1F**). After that, anterograde microcatheter was advanced over the retrograde guidewire distal to the CTO, to convert the procedure to the anterograde method. Finally, a good result was achieved with the implantation of 3 drug-eluting stents. (**Figure 1G**). FIGURE 1. Anterograde wire escalation (AWE) (A). Parallel wire technique (B). Anterograde fenestration technique (AFR) (C). Retrograde microcatheter position through septoepicardial collateral with selective contrast injection (D). Reverse controlled anterograde and retrograde tracking (rCART)(E). “Tip-in“ maneuver (F). Final result (G). **Discussion:** Tip-in or rendezvous techniques with fast conversion to the anterograde procedure are suggested as a first approach because of some pitfalls of classic externalization wire technique. First, there is no need for long externalization wires like RG3 from Asahi Intecc, or R350 from Teleflex. Second, in many cases of the retrograde procedure, there are difficulties in microcatheter crossing over the collaterals, bandings and calcified lesions or due to a shortage of microcatheter length. Third, excessive rotation and pushing of the microcatheter increase the risk of vessel injury. Fourth, prolonged duration of retrograde gear position is producing donor vessel ischemia, which can lead to left system injury, like left main trauma, etc. Fifth, with retrograde equipment in situ, there is a need for more meticulously activated clotting time (ACT) controlling, with much higher ACT needed, which can result in more bleeding. Sixth, in some cases, especially when snaring of the wire is performed, the spring coil segment of the externalized wire is disrupted, which can compromise navigation of the materials to the wire. Seventh, the externalized wire can be stuck in the system, and extraction can produce serious complications like left main and ostial right coronary artery lesion, collaterals trauma/dissection, „cutting“ of the interventricular septum, and some examples of so-called „chocking heart“ phenomenon. Accordingly, tip-in and rendezvous methods cannon provide strong support in delivering balloons and stents as the externalization method can, which is the main advantage of this technique. Another main pitfall of tip-in and rendezvous is that one can easily lose anterograde wire position and with that putting the whole procedure to the beginning. **Conclusion:** In this case report, we demonstrated that the “tip-in” technique can be successfully obtained as a first-line strategy in retrograde CTO with lower cost and rate of possible complications of the procedure as this technique doesn’t require an “externalization” wire, with fast extraction of retrograde equipment and movement towards the straightforward anterograde procedure.

Marijana Knežević Praveček, Krešimir Gabaldo, Katica Cvitkušić Lukenda, Božo Vujeva, Ivica Dunđer, Antonija Raguž, Tomislav Krčmar, Boris Starčević

**Introduction**: There are limited study data available of the effects of peripheral artery disease (PAD) on patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI). According to the PROGRESS-CTO Registry results patients with PAD undergoing CTO PCI have more comorbidities, more complex lesions and lower procedural success. (1-3) We present the case of successful opening in-stent CTO lesion of right coronary artery (RCA) in patient with PAD. **Case report**: 59-year-old man with a known history of a coronary vessel disease and PAD presented to our department due to frequent episodes of chest pain under minimal exercise and claudication and pain in the buttocks. The coronary angiography showed unchanged exam in left coronary basin. The RCA was completely occluded in segment two right in the area of the stent that was implanted eight years before. We found collaterals from the left coronary artery system and signs of calcification and autocollaterals for the distal segment of RCA, so the diagnostically criteria of a CTO were fulfilled. Because of the present symptoms of the patient and evidence for vital myocardium by echocardiography and myocardial scintigraphy revascularization of the CTO was performed. An AL 0.75 6F guidance catheter was used and the standard antegrade wire escalation technique attempted. A Turnpike Spiral catheter was inserted with the help of a ASAHI Fielder XT-A wire which was exchanged to an ASAHI Gaia Second which allowed the successful recanalization. Balloon angioplasty was performed with Abbot Traveler 1.5/15mm, Medtronic Euphora 2.57/15mm. Two sirolimus eluting stents (Terumo Ultimaster 3.0/38 mm and Ultimaster 3.0/30 mm) were successfully implanted with very good angiographic result. Three months later, chronic total occlusion of the left external iliac artery was treated successfully by percutaneous intervention and control coronary angiography showed unchanged exam in RCA. **Conclusion**: Our experience in this case demonstrates the feasibility of recanalization of an in-stent CTO in the patient with PAD and three months follow up showed improved of angina and quality of life. There is a definite and strong correlation between PAD and CAD. A concurrent PAD diagnosis is associated with higher rates of adverse outcomes following CTO PCI which requires additional monitoring.

Marin Vučković, Sandra Makarović, Zorin Makarović, Damir Kirner

Atherosclerotic disease predominantly occurs in the position of the biggest blood turbulations. Pathophysiologicaly this position is prone to shear stress. In interventional cardiology this position is called coronary bifurcation. Bifurcation stenting depends on distribution of atherosclerotic burden and anatomical structure of main and side branches. The problem lies in wright conformation of delivered stents and wright anatomical structure that should mimic natural blood flow. Because of this physical law debate is on how to adequately form positioned stents through postdilatation. One common way is doing kissing balloons. We will show the importance of these techniques through medical literature data (1, 2), that were published in last 5 years, and try to propose recommendation for kissing balloons in one stent, and two stents techniques. We will show several examples of one and two stent techniques and our solutions. In conclusion, based on literature review and our practice, we think that kissing balloon could be optional in provisional stenting, but desirable, not mandatory, in two stents techniques.

Marin Pavlov, Zdravko Babić, Matias Trbušić, Vjekoslav Radeljić, Petra Radić, Diana Delić Brkljačić

**Aim**: To evaluate clinical, interventional and outcome data of patients treated for left main (LM) stenosis. **Patients and Methods**: Study was conducted in University Hospital Centre „Sestre milosrdnice“, Zagreb. We retrospectively analyzed all coronary angiographies from June 20, 2017 until February 12, 2020. Cases were identified by a nation-wide database (Stenos). Patients with percutaneous coronary intervention (PCI) involving LM were analyzed, regardless of Medina stenosis class. **Results**: Out of 5537 procedures (3255 interventions, 1775 non-elective), 400 procedures involved LM stenosis. PCI was performed in 235 patients. In 25 cases LM interventions were protected (excluded from further analysis). Centre yearly LM volume was 79.7, average operator LM volume was 9.9/year. Male sex was predominant (72.4%), average age was 68.6±10.3. Total of 63.8% patients presented with acute coronary syndrome (elevation 16.7%, non-elevation 33.3%, unstable angina 13.8%). Ad-hoc PCI was performed in 70.0% of cases. Stenoses involved LM in 92.4%, ostial left anterior descending artery in 59.5%, ostial circumflex artery in 44.3% patients. Bifurcation was stented in 80.5%, while 2 or more stents were used in 20.5% of all cases. Dominant bifurcation technique was provisional stenting (74.6%), followed by T and protrusion (15.4%). Proximal optimization (POT) was performed in 96.4%, which was followed by kissing in 34.7%, or strut dilatation in 10.3%, and re-POT in 57.8% of eligible patients. Intravascular ultrasound (IVUS) was used in 16.7%, coronary flow physiology in 1.4% patients. Radial access was most commonly used (83.1%; 58.6% right-sided), followed by femoral (14.9%, right-sided in 84.6%). Shock was present in 7.3% on admission, while 9.6% of the patients were resuscitated. Mechanical circulatory support (MCS) was used in 1.4%. Two patients (0.9%) required emergent surgery. In-hospital mortality was 6.2%. Follow-up was available for 75.7% patients (294 [100-474] days). Major adverse cardiovascular event was observed in 7.0% patients. **Conclusion**: Patient preferences, operator and centre experience, and availability of cardiac surgery impacts the decision to interventional treat LM stenosis. (1) Acute presentation, radial access, ad-hoc procedures, and simple stenting technics predominate. IVUS and MCS are still underutilized.

Sandra Makarović, Marin Vučković, Zorin Makarović, Damir Kirner

Coronary artery aneurysm is a rare disorder, which occurs in 0.3-4.9% of patients undergoing coronary angiography and atherosclerosis is the main cause in this disorder in adult population. There are different pathophysiological mechanisms of coronary aneurysm formation and classification. According to the available dana in the literature, the best treatment is unknown. (1) Case reports in literature, have presented surgical, medical and interventional forms of coronary aneurysms treatment, but the comparison of interventional forms of treatment has not shown the superiority of either method. The question remains regarding the duration of dual antithrombotic therapy. In our case reports, we show two patients who are resolved by different interventional tools, precisely because of anatomical formation of the aneurysm. Both patients were admitted for acute coronary syndrome, and diagnostic coronary angiography revealed that these were complex lesions that contained large aneurysms within their body. The right coronary artery in one patient was stented with covered stent, while in another patient the interventional treatment of the ostial circumflex artery was done with open cell design drug-eluting stent. Both patients are clinically monitored, and both are in satisfactory clinical condition. Based on our cases we conclude that the possible solution lies in the anatomical position and size of the coronary aneurysm.

Eduard Margetić

## Dear Colleagues, It is a great pleasure and honor to cordially invite you to the 9th Croatian conference on interventional cardiology – CROINTERVENT 2020, which will take place in Zagreb, Croatia, on March 19-22, 2020. Since the last congress, new diagnostic and therapeutic procedures have emerged and existing ones have been improved. All this was made possible by advances in the utilized instruments and materials and the continuous advancement of the skills of interventional cardiologists. Much of the congress will be devoted to pharmacotherapy, which has become a vital part of interventional cardiology and has proven its value in the field of primary or secondary prevention of cardiovascular disease in improving the primary outcomes and reducing the incidence of complications of cardiovascular interventions. CROINTERVENT 2020 is designed not only for cardiologists and cardiology fellows but also for other medical specialists and people professionally associated with this important part of modern medicine. The aim of this event is, in addition to demonstrating current clinical practice in interventional cardiology, to reflect on concerns and difficulties encountered in our daily practice. The conference program will contain invited lectures as well as oral and moderated poster presentations. As usual, a significant part of the conference will be devoted to practical side of interventional cardiology, both through displaying “live procedures” and presentation of already completed interventions with analysis, comments, and evaluation. This Supplement of Cardiologia Croatica – the official journal of the Croatian Cardiac Society – consists of selected original contributions from our participants in the form of abstracts, which will be presented at the meeting in the form of oral presentations and moderated posters. Sincerely yours,