Coronary artery disease (CAD) is highly prevalent in patients with severe aortic stenosis (AS). The management of CAD is a central aspect of the work-up of patients undergoing transcatheter aortic valve implantation (TAVI), but few data are available on this field and the best percutaneous coronary intervention (PCI) practice is yet to be determined. A major challenge is the ability to elucidate the severity of bystander coronary stenosis independently of the severity of aortic valve stenosis and subsequent impact on blood flow. The prognostic role of CAD in patients undergoing TAVI is being still debated and the benefits and the best timing of PCI in this context are currently under evaluation. Additionally, PCI in the setting of advanced AS poses some technical challenges, due to the complex anatomy, risk of hemodynamic instability, and the increased risk of bleeding complications. This review aims to provide a comprehensive synthesis of the available literature on myocardial revascularization in patients with severe AS undergoing TAVI. This work can assist the Heart Team in individualizing decisions about myocardial revascularization, taking into account available diagnostic tools as well as the risks and benefits.

Background. Coronary artery disease (CAD) is a common finding among patients undergoing trans-catheter aortic valve implantation (TAVI), who often present severely calcified coronary lesions. Evidence is scarce about the use of rotational atherectomy (RA) in this setting, in particular regarding long-term outcome. Methods. RA was performed on severely calcified coronary lesions concomitant with TAVI in a consecutive series of patients treated between 2010 and 2020. Immediate and long-term clinical outcomes are reported. Results. A concomitant CAD (coronary stenosis visually > 50%) was observed in 402/845 (47.6%) consecutive patients undergoing TAVI at the University Hospital of Verona. Angioplasty was performed in 104 patients (12.3%). Among these, 19 patients (18.3%, 20 coronary arteries), were treated with RA after TAVI: 10 after implantation of a balloon-expandable trans-catheter valve and 9 after a self-expandable valve. All procedures were successful. Hypotension occurred in 3 patients (15.8%), with rapid recovery after the procedure; CI-AKI (contrast-induced acute kidney injury) in 3 patients (15.8%), of which two recovered within discharge. At a median follow-up of 21.5 months (Q1–3: 6–36) event free survival was 83.3%. Only one patient suffered a target vessel failure >2 years after RA. Neither stroke nor peri-procedural infarctions were detected. Conclusions. RA concomitant with TAVI was feasible and safe in patients treated with implantation of either self-expandable, or balloon-expandable trans-catheter aortic valves. Long-term clinical events related to the coronary procedure were extremely infrequent and the survival rate at median follow-up of 21.5 months was 83.3%.

Background: Accurate evaluation of stent implantation during percutaneous coronary intervention (PCI) is essential to reduce both early and late adverse events. Conventional coronary angiography, although routinely used, has limited spatial resolution and may fail to detect subtle mechanical abnormalities in implanted stents. Enhanced stent visualization (ESV) is an X-ray-based post-processing technique that improves delineation of stent struts without additional contrast or intracoronary instrumentation. Methods: We report a retrospective case series of five patients who underwent complex PCI where ESV was used as an adjunctive imaging modality. Clinical scenarios included left main interventions, bifurcation lesions, multivessel disease, and acute coronary syndromes. The ability of ESV to detect mechanical complications not evident on angiography was assessed. The impact of ESV on procedural decision-making was also assessed. Results: ESV enabled identification of mechanical complications in all cases, including stent fracture, stent loss, stent dislodgement, stent underexpansion, and geographical miss. These findings were not clearly appreciable when using angiography alone. In each case, ESV directly influenced intraprocedural management, prompting immediate corrective actions such as additional stent implantation, stent retrieval, or further optimization with post-dilatation or intravascular lithotripsy. This resulted in improved procedural outcomes and optimized stent deployment. Conclusions: In this small retrospective case series, ESV provided incremental diagnostic value over conventional angiography by detecting otherwise unrecognized mechanical complications and guiding real-time procedural optimization. While these findings suggest a potential role for ESV in complex PCIs, larger prospective studies are required to confirm its clinical impact.

Accurate evaluation of stent implantation during percutaneous coronary intervention (PCI) is essential to reduce both early and late adverse events, including stent thrombosis and in-stent restenosis. Although conventional coronary angiography remains the standard imaging modality, its spatial resolution is often insufficient to detect subtle mechanical abnormalities of implanted stents. Enhanced stent visualization (ESV) is an X-ray-based post-processing technique that enhances delineation of stent struts using routine fluoroscopic images, without requiring additional contrast administration or intracoronary instrumentation. We describe a case series of five patients undergoing complex PCI in whom ESV proved crucial for the detection of mechanical complications that were not readily evident on angiography alone. The procedures involved challenging anatomical and clinical settings, including left main coronary artery treatment, bifurcation lesions, multivessel coronary disease, and acute coronary syndromes. In each case, ESV offered incremental diagnostic insight, enabling prompt identification of complications. These findings directly influenced procedural strategy and facilitated appropriate bailout interventions. This case series underscores the potential clinical utility of ESV as an adjunctive imaging tool to standard angiography and intravascular imaging techniques. Given its simplicity, broad accessibility, and negligible effect on procedure duration, ESV represents a feasible option during PCI. In selected complex interventions, its use may enhance mechanical optimization and procedural safety. Further large-scale prospective investigations are needed to corroborate the implementation of ESV in clinical practice.

Background: Unusual aortic arch variants such as the bovine arch configuration can complicate carotid revascularization, often limiting the effectiveness of standard femoral access. Radial access is an established alternative, but data on ulnar access in neurovascular interventions remain scarce. We report a case of urgent left internal carotid artery angioplasty successfully performed via the ulnar artery after failed radial and femoral attempts, highlighting the feasibility of this approach in challenging anatomy. Case Presentation: A 63-year-old man initially presented with suspected right-sided hemiparesis, with a normal supra-aortic Doppler ultrasound. One month later, he was readmitted for headache; brain CT revealed a right frontal hemorrhagic lesion, and CT angiography showed left internal carotid sub-occlusion due to a soft plaque, critical right internal carotid stenosis, and a type 2 bovine aortic arch. Due to hostile neck anatomy and high carotid bifurcation, percutaneous endovascular treatment was chosen over surgery. Initial radial access was not feasible, and femoral access provided inadequate support. Ulnar access was therefore obtained, enabling favorable navigation and deep catheter engagement. A dual-layer micromesh stent was deployed with distal filter protection, achieving successful revascularization and preserved hand perfusion. The patient showed neurological recovery during follow-up. Conclusions: This case illustrates the ulnar artery as a safe and effective alternative vascular access for carotid angioplasty when both radial and femoral approaches fail, even in the absence of a palpable radial pulse. It emphasizes the potential of ulnar access to expand treatment options in complex arch anatomies and supports its consideration in selected urgent neurovascular interventions.