Technical characteristics of percutaneous coronary intervention in acute coronary syndromes at a Moroccan Military Tertiary Center: a retrospective descriptive case series

¹Department of Cardiology, Centre Hospitalier Universitaire Mohammed VI, Marrakech, Morocco, ²Department of Interventional Cardiology, Avicenne Military Hospital, Marrakech, Morocco

^&Corresponding author
Asma Ouaziz, Department of Cardiology, Centre Hospitalier Universitaire Mohammed VI, Marrakech, Morocco

Introduction    

Acute coronary syndromes (ACS) remain a leading cause of morbidity and mortality worldwide. Percutaneous coronary intervention (PCI) is the preferred reperfusion strategy in this setting, and its timely and appropriate execution is critical to reducing infarct size, restoring myocardial perfusion, and improving clinical outcomes [1,2]. Over the past two decades, the field of interventional cardiology has undergone substantial evolution, driven by the widespread adoption of drug-eluting stents (DES), optimization of vascular access (radial versus femoral), and refinement of procedural techniques, including the choice between predilatation and direct stenting, as well as the role of post-dilatation. Intravascular imaging modalities, including intravascular ultrasound (IVUS), have further improved stent sizing and deployment accuracy, thereby reducing the risk of stent underexpansion and long-term adverse events.

Despite the existence of international guidelines, real-world PCI practices vary considerably across regions and healthcare systems, owing to differences in operator experience, patient demographics, available resources, and institutional protocols. In Morocco, published data specifically addressing the technical aspects of PCI in the context of ACS remain limited, particularly regarding device characteristics, stenting strategies, and the selective use of adjunctive therapies. Understanding local practice patterns is essential for benchmarking against international standards and identifying areas for quality improvement in interventional cardiology.

The present study was conducted at the Avicenne Military Hospital in Marrakech, a tertiary referral center for interventional cardiology in southern Morocco. Its primary objective was to provide a detailed, real-world description of the procedural characteristics of PCI performed for ACS. A secondary objective was to place these findings in the context of data from international and regional ACS registries, in order to contribute to the growing body of evidence from low- and middle-income countries.

Methods     

Study design: this was a retrospective, descriptive, single-center case series of all patients who underwent PCI for ACS over a three-year period. It is reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines, as recommended by the journal for case series.

Setting: the study was conducted at the Cardiology Department of the Avicenne Military Hospital in Marrakech, Morocco, a tertiary referral center for interventional cardiology in southern Morocco. It involved patients who were admitted with a diagnosis of acute coronary syndrome (ACS) and underwent percutaneous coronary intervention (PCI) for ACS from January 1, 2021, to December 31, 2023.

Participants: inclusion criteria were age ≥18 years and performance of PCI for ACS during the study period. Patients whose medical records were incomplete or unexploitable were excluded. Patients were classified as having ST-elevation myocardial infarction (STEMI) or non-ST-elevation ACS (NSTE-ACS). Non ST-elevation acute coronary syndrome patients were further stratified into very high-risk, high-risk, and not high-risk categories according to the European Society of Cardiology (ESC) criteria [3]. In this classification, the very high-risk category is defined by clinical criteria (e.g., hemodynamic instability or cardiogenic shock, recurrent or refractory chest pain, life-threatening arrhythmias, mechanical complications, acute heart failure), whereas a Global Registry of Acute Coronary Events (GRACE) risk score >140 is one of the criteria defining the high-risk category.

Variables: the main outcome was procedural success, which was defined as optimal stent deployment (complete lesion coverage), restoration of normal coronary blood flow (thrombolysis in myocardial infarction (TIMI) grade 3), and no in-lab complications (e.g., acute vessel closure, stent thrombosis, or urgent surgical intervention). Procedural success was analyzed per treated lesion, whereas stenting rates were calculated per patient. When intravascular ultrasound (IVUS) was used, optimal stent deployment was defined as stent expansion >80%, complete stent apposition, and the absence of edge dissection. The following variables were collected: vascular access site, stenting strategy, stent features (type, length, diameter, deployment pressure), number of stents per treated artery, and adjunctive techniques (thrombus aspiration, glycoprotein IIb/IIIa inhibitors, and IVUS). Angiographic data collected included the number of diseased vessels, coronary lesion classification (American College of Cardiology/American Heart Association [ACC/AHA] lesion type), and final TIMI flow. Cardiovascular risk factors and clinical presentation were also recorded. In-hospital clinical outcomes, ischemic times, Killip class, culprit vessel, and detailed antithrombotic regimens were not systematically available in the procedural records and were therefore not analyzed. No exposure-outcome association was tested; clinical presentation (STEMI vs NSTE-ACS) was used only to describe subgroups.

Data sources/measurement: data were obtained retrospectively from catheterization reports, PCI documentation, and hospital medical records. A standard data collection sheet was used to document all the variables described above.

Bias: as a retrospective single-center study, this work was exposed to information and selection bias. To limit information bias, data were extracted from catheterization reports and PCI documentation using a standard data collection sheet. Patients with incomplete or unexploitable records (n = 15) were excluded, which may have introduced selection bias. The non-randomized, operator-dependent use of adjunctive techniques (thrombus aspiration, glycoprotein IIb/IIIa inhibitors, IVUS) may also have introduced selection bias, which could not be controlled for in this descriptive study.

Study size: no formal sample size calculation was performed. During the study period, 257 patients underwent PCI for ACS; 15 (5.84%) were excluded because of incomplete or unexploitable records, and the remaining 242 patients were included (Figure 1).

Quantitative variables: age was analyzed as a continuous variable. Stent length, stent diameter, stent deployment pressure, lesion length, and vessel diameter were recorded and analyzed as categorical variables using the following categories: stent length ≤15 mm or >15 mm; stent diameter ≤3 mm or >3 mm; deployment pressure 14 bar, <14 bar, or >14 bar; lesion length 10-20 mm; and vessel diameter ≥2.75 mm. Exact continuous values were not consistently available in the retrospective records; medians and interquartile ranges could therefore not be reported.

Statistical methods: data were entered into SPSS software for statistical analysis. Continuous variables were expressed as means with standard deviations, while categorical variables were summarized as counts and percentages. Procedural characteristics are described for the overall ACS population, with results also presented separately for the STEMI and NSTE-ACS subgroups for descriptive purposes. No inferential statistical tests were performed. Patients with incomplete records were excluded, and no missing data were imputed. The comparison with other registries (Table 1) was descriptive.

Ethical considerations: this retrospective study was conducted under the supervision of Professor Abdelmajid Bouzerda, Department of Interventional Cardiology, Avicenne Military Hospital, co-author of this article, who authorized access to the medical records. It was based exclusively on anonymized data extracted from existing records, without any intervention or contact with patients, and was conducted in accordance with the principles of the Declaration of Helsinki. Patient confidentiality and data protection were respected; patient records were kept anonymous and used solely for research purposes. Because of the retrospective design and the use of anonymized data, individual informed consent was not required, and no identifiable patient information is reported in this article.

Results     

Participants: during the study period, 257 patients underwent PCI for ACS. Fifteen patients (5.84%) were excluded because of incomplete or unexploitable records, and 242 patients were included in the analysis (Figure 1). Of these, 143 (59.1%) presented with ST-elevation myocardial infarction (STEMI) and 99 (40.9%) with non-ST-elevation ACS (NSTE-ACS). Among the 99 NSTE-ACS patients, 25 (25.25%) were classified as very high risk, 65 (65.66%) as high risk, and 9 (9.09%) as not high risk according to ESC criteria.

Descriptive data: the mean age was 63 ± 7 years, with a male predominance of 76.45% (sex ratio 3.25). Cardiovascular risk factors were highly prevalent: smoking (51.65%), dyslipidemia (63.22%), hypertension (34.71%), and diabetes mellitus (42.56%). Coronary angiography revealed single-vessel disease in 55.37% of patients, double-vessel disease in 28.10%, and triple-vessel disease in 16.53%. The left anterior descending artery was the most frequently affected (65.29%), followed by the right coronary artery (42.98%) and the circumflex artery (34.71%). Type B and C lesions (ACC/AHA classification) accounted for 86% of the 280 treated lesions, 71% of lesions measured 10-20 mm in length, and 75.12% of vessels had diameters ≥2.75 mm. A TIMI flow grade of 0-1 was noted in 74% of patients before PCI.

Outcome data: the overall procedural success of coronary angioplasty was 96.07% (269/280 treated lesions), calculated per treated lesion rather than per patient, since some patients underwent treatment of more than one lesion. Success was slightly higher in the NSTE-ACS subgroup (97.39%) than in the STEMI subgroup (95.15%). The 11 procedural failures (3.93%) were attributable to technical difficulties, including inability to cross the lesion, stent malposition, or suboptimal stent expansion in the setting of severe calcification (Table 2).

Main results: the radial approach was used in 56.61% of patients (55.94% in STEMI, 57.58% in NSTE-ACS). Balloon angioplasty alone was performed in 9 patients (3.72%). Stenting was performed in 96.28% of patients (233/242), with new-generation drug-eluting stents accounting for 97.31% of the 260 stents implanted. Predilatation was preferred over direct stenting (77.69% versus 22.31% of stents). Of the 235 stented arteries, 213 (90.64%) were treated with a single stent, 19 (8.09%) with two stents, and 3 (1.28%) with three stents. Thrombus aspiration and glycoprotein IIb/IIIa inhibitors were used in 3.72% and 10.74% of patients, respectively, both more frequently in the STEMI subgroup. The remaining procedural characteristics are summarized in Table 2.

Other analyses: Intravascular ultrasound (IVUS) was used in 15 patients (6.2%; 9 STEMI, 6 NSTE-ACS). In all of these cases, post-stent IVUS showed optimal stent deployment according to the criteria defined above. Given the small number of cases and the non-randomized, operator-dependent use of IVUS, no comparison with angiography-guided procedures was made. Subgroup findings by clinical presentation (STEMI vs NSTE-ACS) are detailed in Table 2; procedural characteristics were broadly similar between the two subgroups.

Discussion     

Statement of principal findings: this case series provides a detailed real-world description of the clinical, angiographic, and procedural characteristics of patients with acute coronary syndromes undergoing percutaneous coronary intervention at a tertiary military center in Morocco. Practice in our cohort was largely consistent with contemporary international PCI standards, with widespread use of new-generation drug-eluting stents (97.3%), a stenting rate of 96.28%, and a per-lesion procedural success rate of 96.07%, despite a high proportion of complex (type B/C) lesions (86% of treated lesions). Radial access (56.61%) remained below the rates reported in major contemporary registries.

Strengths and weaknesses of the study: the main strength of this study lies in its detailed, granular description of procedural technical characteristics-stent type, length, diameter, deployment pressure, and adjunctive techniques-which are rarely reported together in North African PCI datasets. The main weaknesses are its retrospective, single-center design and a sample size that limited statistical power for subgroup comparisons; the non-randomized, operator-dependent use of adjunctive techniques (thrombus aspiration, glycoprotein IIb/IIIa inhibitors, IVUS) may also have introduced selection bias.

Strengths and weaknesses in relation to other studies: the demographic profile of our population, with a mean age of 63 ± 7 years and a male predominance (76.45%), is congruent with regional and international data, including the ACCESS registry [4,5], the EPICOR [1], and FAST-MI [2] studies. Cardiovascular risk factors were highly prevalent in our population, including dyslipidemia (63.22%), smoking (51.65%), and type 2 diabetes mellitus (42.56%), with similar rates observed in other studies involving North African and Middle Eastern populations. The prevalence of hypertension (34.71%) was lower than that of diabetes, which is unusual. This pattern may reflect the specific profile of our population, composed of military personnel and their beneficiaries who undergo periodic medical fitness assessments. In terms of angiographic findings, single-vessel disease was the most prevalent pattern (55.37%), and the left anterior descending artery was involved in 65.29% of cases, consistent with FAST-MI [2] and FES-AMI [6]. Lesion complexity was notable, with 86% of treated lesions classified as type B or C (ACC/AHA), a factor associated with lower success rates and higher complication risk.

Table 1 compares the vascular access route, stenting rate, drug-eluting stent (DES) use, and predilatation rate of our cohort with those reported in international and regional ACS registries and series. Radial access was used in 56.61% of our patients, lower than in FAST-MI [2] (87.0%) and DIOCLES [7] (75.53%). Current ESC guidelines recommend radial access as the standard approach in ACS [3], based on large trials such as RIVAL [8] and MATRIX [9], which showed reduced vascular complications, bleeding, and mortality with radial access. Our radial access rate was higher than in the early series of Valsecchi et al. [10] (22.45%) and in the recent Cairo registry [11] (26.9%), and close to that reported by Kim et al. [12] (62.5%). Stenting rates in our cohort (96.50% in STEMI, 95.96% in NSTE-ACS) were comparable to FAST-MI [2] and DIOCLES [7], as well as to the ACCESS registry [13] and ACCESS-Maghreb [4] (94% and 97%, respectively).

Drug-eluting stent use in our study (98.03% in STEMI, 96.30% in NSTE-ACS) was higher than in the ACCESS [13], IPACE2 [5], FAST-MI [2], and ACCESS-Maghreb [4] registries; as these registries were conducted several years earlier, when DES availability was more limited, this difference largely reflects the temporal evolution of practice and improved access to modern devices at our center. Predilatation was preferred over direct stenting (77.69% versus 22.31% of stents), broadly similar to Kocum et al. [14] (69.5%) and Wilson et al. [15] (80.34%). In our cohort, 213 of the 235 stented arteries (90.64%) received a single stent, accounting for 81.92% of all stents implanted; the 50.3% reported in a Cairo registry [11] should be compared with caution, as the denominators may differ. Thrombus aspiration was used in 3.72% of patients, consistent with the Cairo registry [11] (3.6%) and with current ESC guidelines, which recommend against routine thrombus aspiration [3] following the neutral results of the TASTE [16] and TOTAL [17] trials. Glycoprotein IIb/IIIa inhibitor use (13.99% in STEMI, 6.06% in NSTE-ACS) was comparable to the ACCESS-Maghreb registry [4] (10% and 9%) and the ACCESS registry [13] (19% and 16%), but lower than in the SPACE [18] (37.1% and 33.3%) and Polish [19] (24.9% and 13.5%) registries, in line with the current restriction of these agents to bailout situations or high thrombotic burden [3].

Discussion of important differences in results: the overall procedural success rate in our cohort (96.07%) was consistent with outcomes reported in FAST-MI [2] and the Polish registry [19] (95%-97%), although definitions of procedural success vary between studies. Procedural failures (3.93%) were attributable to technical limitations such as severe calcification, stent malposition, or inadequate expansion, consistent with prior interventional cardiology literature [20]. Intravascular ultrasound was used in only 6.2% of patients. In all of these cases, post-stent IVUS showed optimal deployment (expansion >80%, complete apposition, no edge dissection); this is a descriptive observation that does not allow any causal inference regarding the effect of IVUS on stent deployment or clinical outcomes. Current ESC guidelines recommend considering intravascular imaging to guide PCI, particularly in complex lesions [3], and the low rate of IVUS use in our cohort therefore represents a target for improvement.

Meaning of the study: taken together, these findings suggest that PCI practice at this Moroccan military tertiary center is largely consistent with contemporary international standards in terms of device selection and stenting technique, with a high procedural success rate despite a high burden of anatomically complex lesions. They also suggest that, with adequate training and equipment, high-quality interventional cardiology can be delivered in a resource-variable North African setting, and they contribute real-world data from a region that remains underrepresented in the international PCI literature.

Unanswered questions and future research: larger, prospective, multicenter studies across Moroccan and North African centers are needed to confirm these findings, better power subgroup comparisons, and clarify the drivers of the persistent gap in radial access adoption and IVUS utilization relative to major international registries. Future work should also report continuous device characteristics, temporal trends in vascular access, in-lab complications, and in-hospital and longer-term clinical outcomes (e.g., target lesion revascularization, stent thrombosis, mortality).

Limitations: this study has several limitations. First, its retrospective, single-center design and the exclusion of 15 patients with incomplete records may have introduced information and selection bias. Second, the sample size limited the precision of subgroup estimates. Third, the non-randomized, operator-dependent use of adjunctive techniques (thrombus aspiration, glycoprotein IIb/IIIa inhibitors, IVUS) may have introduced selection bias. Fourth, stent length, diameter, and deployment pressure were available only as categories, and yearly trends in vascular access could not be analyzed. Finally, in-lab complications other than procedural failure, ischemic times, and in-hospital and long-term clinical outcomes (e.g., stent thrombosis, target lesion revascularization, mortality) were not assessed.

Conclusion     

This case series provides a detailed description of the technical aspects of PCI in ACS (stenting strategy, device selection and adjunctive techniques) at a Moroccan tertiary military center. Practice was largely consistent with contemporary guidelines, with near-systematic use of new-generation drug-eluting stents, selective use of thrombus aspiration and glycoprotein IIb/IIIa inhibitors, and a high procedural success rate despite a high proportion of complex lesions. Radial access and intravascular imaging remain underused relative to current recommendations and represent concrete targets for local quality improvement.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Mariam Ouaziz: data collection, statistical analysis, interpretation of data and drafting of the manuscript. Asma Ouaziz: study conception and design, interpretation of data, drafting and critical revision of the manuscript. Mouad Kasmi: data collection and critical revision of the manuscript. Abdelmajid Bouzerda: supervision, provision of access to the data, and critical revision of the manuscript for important intellectual content. All authors have read and approved the final version of the manuscript.

Tables and figure     

Table 1: comparison of vascular access, stenting rate, drug-eluting stent use, and predilatation rate between our study and international/regional acute coronary syndromes registries and series

Table 2: procedural characteristics and outcomes of percutaneous coronary intervention in the acute coronary syndromes population

Figure 1: flow diagram of patient selection; ACS: acute coronary syndrome; ESC: European Society of Cardiology; NSTE-ACS: non-ST-elevation acute coronary syndrome; PCI: percutaneous coronary intervention; STEMI: ST-elevation myocardial infarction

References