Focus on Intervention | SCAI 2024: Six Takeaways For Practice

SCAI 2024: Six Takeaways For Practice

The Society for Cardiovascular Angiography and Interventions (SCAI) 2024 conference presented impactful research that challenged traditional practices, introduced groundbreaking technology, offered novel tools for improved procedural decision-making, addressed disparities in peripheral arterial disease (PAD) treatment, and showcased a promising new option for treating pulmonary embolism and more. Here are my takeaways for what's likely to affect practice in the short and medium-term.

Fasting Before Cardiac Catheterization? The CALORI trial investigated a potential shift in preprocedural fasting practices for adult patients undergoing cardiac catheterization. Patients were randomized to either a standard fasting regimen (NPO after midnight) or unrestricted food and drink intake (ad libitum) before the procedure. Exclusions were limited to patients at high risk of aspiration and those undergoing complex interventions.

The trial focused on patient well-being through reports on preprocedural hunger, fatigue, anxiety and nausea. Additionally, postprocedural satisfaction and periprocedural complications were evaluated. With nearly 200 patients, the study found no significant differences in baseline characteristics or adverse event rates between the groups. Importantly, patients allowed to eat and drink before the procedure reported significantly higher satisfaction scores than those who fasted.

This comprehensive study, with its liberal approach to preprocedural intake in a diverse patient population, challenges traditional fasting practices. The findings suggest the potential for revising guideline recommendations towards prioritizing patient comfort and satisfaction while maintaining safety during cardiac catheterization procedures.

Promising Results With Novel Aortic Valve. The conference also showcased the first-in-human data with the Anteris DurAVR valve, a new technology in the transcatheter aortic space. This single-leaflet, balloon-expandable valve is designed to improve flow characteristics. The prospective, nonrandomized, single-center study evaluated the safety and feasibility of the DurAVR valve in patients with severe symptomatic aortic stenosis.

All 28 patients in the small study had successful implantation with no valve-related complications at one year. Flow characteristics remained stable for a year, as assessed by cardiac MRI, with no moderate or severe paravalvular leak. Additionally, transvalvular gradients remained consistent, and there were no valve-related complications, strokes, life-threatening bleeding, or reoperations. These promising early results suggest the DurAVR valve may offer a new option for patients needing aortic valve replacement.

Predicting Side Branch Occlusion Post LM Bifurcation PCI. Left main (LM) PCI carries a risk of side branch (SB) occlusion. Identifying high-risk patients for SB occlusion can guide interventional strategies and improve outcomes. A study presented at SCAI 2024 investigated the LM V-RESOLVE score, a novel angiographic scoring system designed to predict SB occlusion during LM bifurcation PCI.

JACC: Case Reports: More From SCAI 2024

JACC: Case Reports

A case series presented at SCAI 2024 and simultaneously published in JACC: Case Reports suggests exercise cardiac catheterization better characterized aortic valve hemodynamics in patients with paradoxical low-flow low-gradient aortic stenosis (AS), thus may be a potential novel diagnostic modality to differentiate true severe from pseudo-severe AS. Click here to read more.

The score considers three angiographic features: the main vessel (MV) to SB diameter ratio, MV plaque near the SB, and baseline SB diameter stenosis. The study found that these three factors were independent predictors of SB occlusion. Combining these features, the LM V-RESOLVE score demonstrated good accuracy (C-statistic of 0.830) in predicting SB occlusion after LM stenting during unprotected LM PCI. This scoring system can potentially optimize decision-making during LM bifurcation PCI by helping identify patients who may benefit from alternative stenting techniques or surgical intervention.

Endovascular Therapy in PAD Equally Effective in Women. PAD is a widespread condition affecting millions of people. Despite its prevalence, women are often underrepresented in PAD clinical trials, leaving the optimal revascularization strategy for women with femoropopliteal disease unclear.

This late-breaking trial research examined individual patient data from six prior randomized controlled trials comparing endovascular therapy (EVT) with stent implantation to surgical bypass in patients with PAD involving the femoropopliteal arteries. The study found that EVT, compared to bypass surgery, had similar rates of major adverse limb events and amputation-free survival at two years, regardless of sex.

Notably, the EVT group experienced significantly lower rates of early complications at 30 days and shorter hospital stays for both men and women. This pooled analysis provides further evidence for the safety and efficacy of EVT in femoropopliteal disease, and suggests its benefit extends equally to women.

New Technology For Treating PE. New to the venous space is a technology for managing patients with pulmonary embolism (PE). Current management of PE has shifted from the use of systemic thrombolysis and anticoagulation to catheter-directed thrombolysis and/or mechanical thrombectomy.

The current devices used for mechanical thrombectomy have challenges, such as ineffective/incomplete thrombus burden removal, vascular injury, significant blood loss due to the use of large-bore catheters, and difficulty in maneuverability of these catheters.

The safety and feasibility of the new dual-mechanism moderate-bore Hēlo PE thrombectomy system was examined in the multicenter first-in-human ENGULF study. In the prospective single-arm study with 25 patients from eight centers, all patients underwent successful mechanical thrombectomy for PE with the Hēlo system.

No significant adverse events were seen at 48 hours post procedure and no deaths at 30 days. Notably, no patients met the criteria for major life-threatening bleeding by VARC-2 criteria. The Hēlo PE thrombectomy system appears to be effective and safe for treating acute PE.

Radial Access Rising in PCI. A study designed to understand the use of guideline-recommended practice analyzed data on more than 2.2 million PCI procedures performed in the U.S. between 2013 and 2022. Over this period, there was a significant increase in the use of radial access, which is the preferred access site according to current guidelines. Radial access use climbed to 61.6% of PCI procedures, reflecting a 2.8-fold rise compared to a decade earlier.

This trend was most notable in cases of STEMI. Employing instrumental variable analysis to strengthen causal inference, researchers found the surge in radial access was associated with a significant decrease in in-hospital mortality, major access site bleeding and major vascular complications.

While a slightly higher risk of ischemic stroke was observed with radial access, the overall benefits of this approach for patient outcomes support its continued adoption as the preferred access site for PCI. Future research may delve into strategies to mitigate the potential increased risk of ischemic stroke associated with radial access while also investigating long-term outcomes following radial vs. femoral access for PCI.

M. Chadi Alraies, MD, FACC

This article was authored by M. Chadi Alraies, MD, FACC, medical director of the cardiac catheterization laboratory, cardiac rehabilitation, and interventional cardiology research at Detroit Medical Center, Harper University Hospital, in Michigan.

Clinical Topics: Anticoagulation Management, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Interventions and Vascular Medicine, Diet

Keywords: Cardiology Magazine, ACC Publications, Percutaneous Coronary Intervention, Cardiac Catheterization, Pulmonary Embolism, Anticoagulants, Fasting

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