AUCTORES
Globalize your Research
Case Report | DOI: https://doi.org/10.31579/2641-0419/134
1Department of interventional cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
2Department of interventional cardiology, Belfast City Hospital, Belfast, United Kingdom
*Corresponding Author: Jo Dens, MD, PhD Department of interventional cardiology Ziekenhuis Oost-Limburg Schiepse bos 6, 3600 Genk, Belgium
Citation: Ief Hendrickx, Bert Ferdinande, Colm Hanratty, Jo Dens, (2021) Algorithm for Recanalization of Chronic Totally Occluded (CTO) Native Coronary Arteries Through a Diseased or Occluded Saphenous Vein Graft in Post Bypass Patients.. J. Clinical Cardiology and Cardiovascular Interventions, 4(2); Doi:10.31579/2641-0419/134
Copyright: © 2021 Jo Dens, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 27 January 2021 | Accepted: 02 February 2021 | Published: 09 February 2021
Keywords: percutaneous coronary intervention; recanalization; chronic total occlusion; saphenous vein graft; coronary artery bypass graft
Chronic total occlusion (CTO) desobstruction of a native coronary artery in a post coronary artery bypass graft (CABG) patient can be a challenging procedure. In principle, the 3 basic approaches of recanalization of occluded native coronary arteries can be used: antegrade wire escalation (AWE), antegrade dissection re-entry (ADR) and a retrograde technique. On the other hand, a previous implanted saphenous vein graft (SVG) – even when occluded – can be used as a conduit for retrograde access. Moreover, access through a graft might be less complex compared to the use of septal or epicardial collaterals. If the graft is still open or has a tapered stump, this should be considered as a suitable conduit. Literature on recanalization of occluded native coronary arteries trough a diseased or occluded SVG is limited. A flowchart with an algorithm in post CABG patients is proposed and illustrated by 3 clinical cases.
Indexing words: angiography; coronary interventions; calcified stenosis.
Running title: Recanalization of chronic totally occluded native coronary arteries
About 30 years ago, Kahn and Hartzler performed the first percutaneous coronary intervention (PCI) through a saphenous vein graft (SVG) on a native coronary artery [1]. Although these landmark procedures were done a long time ago and many has changed regarding techniques and available materials, chronic total occlusion (CTO) desobstruction of a native coronary artery in a post coronary artery bypass graft (CABG) patient remains a challenging procedure [2,3].
Recanalization of an occluded coronary artery, by using a retrograde approach has significantly improved procedural success rates [4,5]. The most common retrograde conduits are septal collaterals followed by epicardial collaterals. Diseased or occluded SVGs are also suitable for retrograde access in CABG patients, but literature on these procedures is limited.
CTO desobstruction of a native coronary artery which is bypassed by a diseased or occluded SVG can be performed by the three conventional techniques: antegrade wire escalation (AWE), antegrade dissection re-entry (ADR) and by a retrograde technique (Figure 1).
In function of the lesion characteristics (ambiguous or non-ambiguous cap, occlusion length and quality of the landing zone) different techniques are applied. AWE is mainly used in short lesions (< 20 mm length) with a non-ambiguous cap. ADR is mainly used in longer lesions ( > 20 mm length) with a non-ambiguous cap and an appropriate landing zone, whereas a retrograde technique is preferred for lesions with an ambiguous cap in the presence of suitable interventional collaterals (septal or epicardial) or graft (both arterial and venous). If present, SVG gain preference above septal and epicardial collaterals because of easier crossability, less tortuosity, larger caliber and less risk of perforation [6].
In case the SVG is occluded, usually the distal segment is visualized by collaterals. In case a retrograde approach is needed, access through the diseased or even occluded SVG is an additional option (Figure 2), especially when the collaterals are poorly developed or non-suitable for crossing with a wire or a microcatheter. If the graft is still open or diseased (with tapered stump), this graft should be considered as a suitable conduit and therefore can be used as for facilitated ADR.
Case series
The first case is a 73-year old male who presented with peri-operative ischemia during transurethral resection of the prostate (TURP). The electrocardiogram (ECG) showed diffuse ST-depression in all leads and ST-elevation in aVR with mildly elevated high-sensitive troponine T (19 ng/L, cut-off < 14). Transthoracic echocardiography (TTE) showed preserved left ventricle function (visual estimation about 60%) with no regional contractility abnormalities.
The patient was known with diabetes mellitus, peripheral arterial disease and coronary artery bypass graft (CABG in 2002) with left internal mammary artery (LIMA) on the 2nd lateral branch of the circumflex (L2Cx), right internal mammary artery (RIMA) on the left anterior descending artery (LAD) and saphenous venous graft (SVG) originating from the aorta to the right coronary artery (RCA). Coronary angiography showed patency of the LIMA-L2Cx and RIMA-LAD. There was a CTO of the RCA and also a CTO of the SVG to the RCA (duration of occlusion of SVG unknown). There were epicardial collaterals originating from the Cx to the inferolateral (IL) branch from the RCA (Figure 3A).
Because of the presence of ischemia and preserved contractility of the inferior wall on TTE, CTO desobstruction was planned. Double arterial access was implemented with use of supportive guiding catheters. Contrast injection of the LIMA was performed by 6 French (Fr) IMA guiding catheter through the left radial artery. Contrast injection of the RCA was performed by 7 Fr AR II through the right femoral artery. Because of unsuitable interventional epicardial collaterals from Cx to the IL-branch, we switched from the LIMA to the occluded SVG (the SVG was injected by 6 Fr AL 0.75 guiding catheter).
The first step is to “blindly” wire the SVG towards the native coronary artery (Figure 3B + C) by using a polymer jacket wire and MC. To confirm the wire being in the distal true lumen, visualization of the distal target via collaterals from the other branches is needed. This is confirmed by contrast injection in the donor artery (double access and in selected cases triple access is needed). Here, the SVG is wired using a Pilot 200 (Abbott, US) and Corsair MC (Asahi, Japan).
After this, the native coronary artery is wired retrogradely from the SVG. Sometimes the SVG connects with a sharp angle and the use of Supercross 120° (Teleflex, US) or double lumen MC is needed (Figure 4A). A double lumen catheter is advised if the SVG anastomosis is proximal from the distal cap. In this case, the native RCA was retrogradely wired through the SVG using a Gaia 3 (Asahi, Japan) and Corsair MC (Asahi, Japan).
If this is successful, the next step is retrograde wire escalation (RWE), reverse controlled antegrade and retrograde subintimal tracking (reverse CART) or CART. In this case, reverse CART was used (Figure 4B). First, balloon insufflation of the RCA was performed over the antegrade wire in the native RCA, followed by wiring of the created space with the retrograde wire. This wire enters the AR II guiding. The retrograde MC is also advanced into the AR II guiding, after which the retrograde wire is exchanged for a RG3 (Asahi, Japan) or R350 (Teleflex, US) wire (externalization) (Figure 4C).
Lesion preparation with antegrade ballooning is performed over the externalized system (Figure 5A + B).
The final step is to visualize and wire the distal vessel, either through collaterals or through contrast injection with a microcatheter/double lumen side port (Figure 6A). Once an antegrade system is in place and has reached the distal vessel, the retrograde gear has to be removed to avoid jailing the retrograde wire with a stent. A Corsair MC (Asahi, Japan) and Sion Black (Asahi, Japan) were used to wire the distal portion of the vessel (the anastomosis of the occluded SVG was close to the distal cap). Pre-dilatation was again performed, followed by stenting with drug-eluting stents (2.5 x 48 mm Xience Xpedition, Abbott, US in the distal portion of the RCA, 3.0 x 48 mm Xience Xpedition in the mid and proximal portion and a 3.5 x 15 mm Xience Xpedition in the ostium). The end result showed restoration of the antegrade flow in the RCA (TIMI III flow) (Figure 6B).
The second case is a 78-year old male who presented with unstable angina (UA). He was known with a double chamber pacemaker (because of 3th degree atrio-ventricular block), transient ischemic attack and CABG (in 1999) with LIMA-LAD and SVG-RCA. The SVG had already been stented 5 months before this episode of UA (Orsiro, Biotronik, US 3.0 x 13 mm in the mid segment + Orsiro 3.5 x 15 mm in the proximal segment). Coronary angiography showed patency of the LIMA-LAD CTO of the native RCA and occlusion of the SVG (occlusion of the stent in the proximal segment). There were collaterals originating from the septal branches to the posterior descending branch (PD) and inferolateral branch (IL) and also collaterals originating from the Cx to the IL branch (Figure 7).
TTE showed preserved left ventricle function without regional contractility abnormalities. Because of the unstable angina and preserved contractility of the inferior wall on TTE, CTO desobstruction was planned.
Triple arterial access was implemented. Contrast injection of the LIMA was performed by 6 Fr IMA guiding catheter through the left radial artery. Contrast injection of the left main was performed by 6 Fr EBU 3.75 through the left femoral artery and the occluded SVG was injected by 6 Fr AL 0.75 guiding catheter through the right femoral artery. During the procedure, we switched the EBU 3.75 to a 7 Fr AR II guiding catheter for injection of the native RCA.
Following the same steps in the flowchart, the first step is to “blindly” wire the SVG towards the native coronary artery with visualization of the collaterals (Figure 8A). The next step is to wire the native coronary artery retrogradely through the SVG, here by using Caravel (Asahi, Japan) MC and Gaia 3 (Asahi, Japan) wire (Figure 8B).
The next step was reverse CART (Figure 9A) and externalization (Figure 9B).
Lesions preparation (Figure 10A) and stenting of the mid and proximal segment (respectively 3.0 x 46 mm Cre8 Evo, Alvimedica, Italy + 3.0 x 26 mm Cre8 Evo) was performed with restoration of the antegrade blood flow in the RCA (TIMI III flow) (Figure 10B).
The third case is a 72-year old male who presented with stable angina. He had a normal ECG without elevated cardiac markers. He was known with CABG (SVG-RCA and LIMA-LAD). TTE showed mildly depressed left ventricle function due to hypokinesia from the inferior wall. Coronary angiography showed a CTO of the RCA with a severely diseased SVG and poor retrograde filling from septal branches (Figure 11).
Double arterial access was implemented. Contrast injection of the SVG was performed by 6 Fr AL I guiding catheter through the right radial artery. Contrast injection of the RCA was performed by 7 Fr EBU 3.5 guiding catheter through the right femoral artery. Also following the same steps in the flowchart, the first step is to wire the SVG towards the native coronary artery. To connect the proximal cap with the distal vessel, the technique of facilitated ADR was used. A knuckle wire was used to dissect from the proximal CTO cap of the RCA beyond the graft anastomosis (Figure 12).
Re-entry from the subintimal space towards the true lumen was performed using the Stingray LP (Boston Scientific, US) at the distal RCA landing zone (beyond the graft anastomosis, but before the crux) (Figure 13).
The re-entry was facilitated by a 3.0 mm compliant balloon via the SVG in the landing zone of the distal true lumen. This balloon is inflated to maximize the target for re-entry by using the Stingray wire (Boston Scientific, US) (Figure 14).
Next, the 3.0 mm balloon is deflated and the Stingray wire can puncture and be advanced through the tissue plane towards the true lumen. After penetration in the true lumen, this wire was exchanged for a Pilot 200 wire (Abbott, US) to wire the distal portion of the RCA (stick and swap technique). Finally, lesion preparation and stenting of the RCA was performed (3.0 x 48 mm + 3.5 x 30 mm, Synergy, Boston Scientific, US) (Figure 15).
Total coronary arterial bypass grafting (CABG) provides better outcome then internal mammary artery (IMA) in combination with saphenous vein grafts (SVGs) [7]. Nevertheless, CABG with SVGs is still widely applied. SVGs will develop over time more atherosclerosis and will be occluded in 50% of the cases in 10 years’ time post CABG [8]. Native coronary arteries also show accelerated atherosclerosis in post CABG patients [9] and therefore new CTOs could originate.
The three conventional techniques of CTO PCI remains the basis, but a retrograde approach through the SVG is suitable. Literature on retrograde CTO recanalization through a SVG is limited [10,11]. More recently, a larger United States (U.S.) registry was published [12].
Dautov et al [10] studied the outcome of CTO PCI through a SVG in 175 patients. Retrograde approach using a SVG was performed in 19% of the patients and through different collaterals in 36%. Antegrade approach was performed in 45% of the patients. The use of either patent of occluded SVGs was associated with a higher success compared with other collateral channels (97% vs 86%; p = 0.02). The final technical success was similar among the 3 different groups: 94%, 84% and 94% respectively for retrograde approach through SVGs, retrograde approach through other collateral channels and antegrade approach.
[11] Nguyen-Trong et al. retrospectively reviewed retrograde CTO PCI through SVG in 21 patients. Procedural success rate was 86% in patients in whom retrograde SVG crossing was successful.
Recently Xenogiannis et al presented their data of PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention). In this multicenter U.S. registry, 1615 patients were included with comparison of CTO PCI through a SVG (189 patients) versus other collaterals (1426 patients) [12]. The registry showed that the use of SVGs for retrograde crossing was associated with higher rates of procedural success (81% vs. 74%; p = 0.04) and no difference in in-hospital major adverse cardiac events (6.4% vs. 4.4%; p = 0.22) in comparison with retrograde CTO PCI through other collaterals. Moreover, they also report that SVGs are used as collateral conduits in 11.7% of the retrograde PCIs, which is less in Europe and Japan (3.9 % to 8.2%).
Post CABG patients represent an important portion of the CTO procedures. In Japan, these number is relatively low (9.7%) [13]. In Europa it is intermediate (17%) [14] and in the United States high (36.5 %) [15].
J-CTO score in post CABG patients is higher, making the procedure more complex. But, it’s worth of investment for treating the native coronary arteries because of the poor rate of patency success of SVG on the long term [8]. PCI of SVGs is associated with poor long-term results and higher event rates [16].
The ongoing multicenter and randomized PROCTOR (Percutaneous Coronary Intervention of the native coronary artery versus venous bypass graft in patients with Coronary Artery Bypass graft) study will provide new insights in recanalization of the native coronary artery versus recanalization of the SVG in post CABG patients.
Conclusion
Despite all the different techniques which can be used for CTO desobstruction in post CABG patients, the complexity remains. Retrograde crossing of a SVG for native CTO PCI is associated with high rates of success, but is challenging. Therefore we propose a flowchart with algorithm for practical guidance.
Declaration of conflict of interest:
No potential conflict of interest was reported by the authors.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
