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Revascularization of chronic total occlusions (CTO) with percutaneous coronary intervention is associated with favorable long-term clinical and echocardiographic outcomes. Whether bioresorbable vascular scaffolds (BVS) would be advantageous in the treatment of CTO is unknown as patients with these lesions were generally excluded from large BVS randomized trials. We performed a systematic review, which sought to summarize known data on mid- to long-term clinical outcomes for BVS in CTO. We searched MEDLINE, EMBASE, clinicaltrials.gov, and the Cochrane Library through April 2018 to look for studies on implantation of BVS in CTO. Outcomes of interest included myocardial infarction, cardiac death, all-cause mortality, major adverse cardiac events (MACE), vessel restenosis, scaffold thrombosis, and target lesion revascularization. A total of 13 articles met the inclusion criteria for analysis. All studies were observational with a total number of patients of 1,077. Only two studies included comparator groups which retrospectively compared BVS with drug-eluting stents (DES). The studies had variable size (21 to 537) and follow-up duration (3–23 months). The review showed favorable outcomes for BVS implantation in CTO with the reported incidence of MACE ranged from 0% to 6.7% with no significant differences between BVS and DES groups in double arm studies. Although data on the use of first-generation BVS in CTO are sporadic and limited by small sample observational studies, available evidence is promising and suggests of acceptable outcomes comparable with second generation DES. Further investigation with randomized clinical trials and use of newer generation scaffolds is required.
Introduction & Background
Chronic total occlusion (CTO) of the coronary artery is defined as a complete vessel occlusion with thrombolysis in myocardial infarction (TIMI) flow grade of 0 lasting for more than three months [1]. CTOs are present in up to 20% of patients with coronary artery disease undergoing elective angiography [2]. Revascularization of CTO with percutaneous coronary intervention (PCI) is associated with angina relief, improved left ventricular function, reduction in the rate of myocardial infarction, less need for subsequent coronary artery bypass grafting and better patient survival regardless of the presence of collateral circulation [3-5]. However, because multiple sequential long stents are frequently required (termed vessel "caging") to treat a chronically occluded vessel, the vessel is subject to risks of late stent thrombosis and restenosis [6-8]. Bioresorbable vascular scaffolds (BVS) offer an alternative treatment option, since their unique properties allow them to potentially promote vessel healing, permit vascular remodeling, avoid late lumen enlargement, and restore of normal vasomotion, which theoretically avoid the vessel caging issues and risk of late thrombosis [9,10]. Whether BVS would be advantageous in treatment of CTO is currently unknown as patients with these lesions were generally excluded from large BVS randomized trials. We performed a systematic review, which sought to summarize known data on mid- to long-term clinical outcomes for BVS in chronic total occlusion.
Materials and methods
This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [11]. We performed a systematic electronic search of MEDLINE (via PubMed), EMBASE, clinicaltrials.gov and the Cochrane library for case series, observational studies, clinical trials, and systematic reviews on the Absorb bioresorbable vascular scaffolds (Abbott Vascular, Santa Clara, CA) in chronic total occlusions published from inception until April 26, 2018. Two broad search themes, "bioresorbable vascular scaffold" and "chronic total occlusion" were used (see Appendix). These themes were combined using Boolean operator "AND". We also performed an additional search of references from included articles and articles that cited the included studies to identify additional publications. An experienced librarian was involved into the development of search strategy and search process to assure quality. Authors of included publications were contacted via e-mail in cases when additional information was required. Studies were included into review if they fulfilled the following inclusion criteria: 1) included implantation of bioresorbable vascular scaffolds; 2) included patients ≥ 18 years of age; 3) included patients having chronic total occlusion (CTO) of one or more coronary arteries; 4) reported on at least one of our safety and efficacy outcomes: myocardial infarction (MI), cardiac death, all-cause mortality, major adverse cardiac events (MACE), vessel restenosis, scaffold or stent thrombosis (ST), and target lesion revascularization (TLR); 5) reported at least three months of clinical follow-up data. Criteria for exclusion from the review were: 1) non-English language articles; 2) case reports and case series with fewer than 10 cases; 3) non-human studies. Screening of articles for eligibility and data extraction was performed by two independent reviewers (RM, SN). Any disagreements between reviewers were resolved by consensus using a third reviewer (AD). Extracted data included study type and design, year of publication, demographic and clinical characteristics, primary and secondary outcomes, duration of follow-up. Extracted outcomes were procedural success, cardiac and non-cardiac death, MI, TLR, target vessel revascularization (TVR), ST, and MACE. Results were documented as count data and reported as percentages of the total study population. Due to significant study design heterogeneity between the included studies, a meta-analysis was not performed. Included articles were evaluated for potential biases using Cochrane risk of bias assessment tool (ROBINS-I) which was performed independently by two authors (RM, SN), with discrepancies adjudicated by a third author (AD).
Using the search strategy described above, we identified a total of 251 potentially relevances (Figure 1). Ninety-five duplicate publications were identified and removed. The remaining 156 references were screened. Non-English language articles, conference abstracts, review articles, editorials, case reports and case series with less than 10 patients were excluded. A total of 13 articles met the prespecified inclusion criteria for analysis.
Study Characteristics
All studies included into review were observational in nature and were published between 2014 and 2018. Data were reported for a total of 1,077 patients with median study population size of 41 (Interquartile range (IQR): 29.5–67.5) with number of patients ranging from 21 to 537. The median follow-up duration ranged from 108 to 703 days. Patients in the studies were predominantly male (77.5%–98%) with mean age ranging from 56.9 to 65.7 years. Eleven out of 13 publications were retrospective cohort studies and therefore did not include a control group. Two others were double arm studies which included comparator groups which retrospectively compared BVS with drug eluting stents (DES). All studies defined CTO similarly as 100% vessel occlusion with TIMI 0 flow for more than three months. Primary and secondary end points slightly varied from study to study (Table 1) but were mainly focused on individual or composite of major adverse cardiovascular events such as cardiac death, myocardial infarction, and ischemia-driven target lesion revascularization.
Double Arm Studies
We identified only two double arm studies comparing BVS with DES that reported follow-up data (Table 2). The larger one was a multicenter retrospective registry which included a total of 537 patients by Azzalini et al. [20]. It compared outcomes for 153 patients who underwent first generation Absorb BVS implantation, and compared them to 384 patients treated with second generation DES. The primary endpoint was a target vessel failure (TVF) defined as the composite of cardiac death, target vessel myocardial infarction, and ischemia-driven TLR. Median follow-up duration was 703 (IQR: 426–989) days. There were no significant differences in rates of events between two groups including TVF (4.6% vs 7.7%; HR: 0.59, 95% CI: 0.26–1.35; p = 0.21), ischemia-driven TLR (4.0% vs 4.1%; HR: 0.95; 95% CI: 0.37–2.45; p = 0.92), or scaffold or stent thrombosis (0.6% vs 0.7%, p = 0.86). Further inverse probability of treatment weight-adjusted Cox regression analysis still did not demonstrate any significant differences in outcomes between groups. However, when clinical, angiographic, and procedural variables were simultaneously added to the model, it showed a non-significant increase in risk of TVF and ischemia-driven TLR in the BVS group (adjusted HR: 3.45; 95% CI: 0.87–13.66; p = 0.08). Another double-arm observational study was performed by Kugler et al. [15]. It was a small prospective registry which included 29 patients among which 14 underwent BVS implantation and 15 received DES. Twelve-month clinical follow-up showed similar results to those reported by Azzalini et al. and did not demonstrate any difference in outcomes between BVS and DES groups. Risk of TVF and ischemia-driven TLR as well as scaffold thrombosis were comparable between two groups.
Single Arm Studies
This group includes 11 publications among which the majority were small retrospective and prospective registries [6, 12-14, 16-19, 21-23]. Patient demographic and clinical characteristics were similar in all studies with similar reported outcomes (Table 3).
Median follow-up duration in this group varied from 108 to 556 days. A composite of cardiac death, target vessel MI, and target lesion revascularization was reported for five out of 11 studies and was 2.64% (95% CI: 1.04% to 4.24%). Only one study, performed by Yamac et al., reported a single cardiac death (3% of their total population) during the follow-up period [16]. Maeremans et al. were the only authors to report a non-cardiac death (2.4% of their study population) [14]. Incidence of non-fatal myocardial infarction was 1.07% (95% CI: 0.09% to 2.06%). Incidence of target lesion revascularization was 2.51% (95% CI: 0.86% to 4.16%) with the highest rate of 8.6% reported by Yamac et al. [16]. The incidence of probable or definite scaffold thrombosis was 1.3% (95% CI: -0.09% to 2.39%). Composite rate of restenosis reported in six studies was 4.45% (95% CI: 2.04% to 6.86%). Using ROBINS-I assessment tool for non-randomized studies, each publication underwent a thorough evaluation for potential risk of bias which demonstrated that 12 out of 13 studies had overall critical bias risk since at least one of the assessed domains in each study was judged as having critical bias risk. The double arm study published by Azzalini et al. was judged as having serious risk of bias (Table 4).
Although DES remain devices of choice for percutaneous coronary interventions, BVS were designed as an alternative to DES with the theoretical advantages of full resorption of scaffolds after two years with resultant restoration of vasomotion, potentially avoiding the "caged vessel" phenomena leading to late stent thrombosis [9, 10]. Those properties in theory should be especially advantageous in CTO revascularization procedures where long segment stenting is often required. However, these theoretical advantages would need to be proven in trials before widespread adoption of this new technology. Our review identified 13 studies of overall low-quality evidence. The review of included articles showed favorable mid- to long-term outcomes for BVS implantation in CTO. Most of the studies showed relatively low incidence of composite as well as individual end points after a fairly long follow-up period. One large double-arm study performed by Azzalini et al. did not demonstrate any statistically significant difference in long-term outcomes between DES and BVS groups in unadjusted and primary adjusted analysis but showed some tendency toward a higher adjusted risk of ischemia-driven target lesion failure in BVS group compared with DES [20]. In contrast to the lower-quality evidence we have complied in CTO, three new randomized trials have identified an increased risk of stent thrombosis when compared to drug-eluting stents for patients undergoing routine PCI [24-26]. The differences in our findings from these RCTs might be explained by differing hemodynamics of stenting of CTOs, but could also be explained by patient selection, limited follow-up and reporting differences in our less rigorous study designs in this review. This trend might also be explained by comparison of first generation of BVS with second generation of DES, which have much thinner struts and as a result creates less turbulence of blood flow with less risk of thrombosis and restenosis [27]. As a result of described rheological disturbances, recently raised concerns about increased scaffold thrombosis (ST) were confirmed by several clinical trials and recently published meta-analysis which showed increased incidence of scaffold thrombosis compared with DES [24-26]. Interestingly, our systematic review did not demonstrate any difference in thrombosis rate between BVS and DES in CTO lesions and even in single arm observational studies thrombosis incidence was low. This again may be related to relatively small sample size but can also be explained by meticulous lesion selection for intervention, avoiding of small vessels with lower blood flow velocities, use of additional imaging modalities such as intravascular ultrasound or optical coherence tomography, more experienced performing operators given the complexity of CTO lesions. Lastly, recent concerns for potential subclinical nature of CTO lesion restenosis and even stent/scaffold thrombosis should also be considered [20]. For this reason, angiographic follow-up is important to uncover true restenosis/scaffold thrombosis incidence rates. In our systematic review, eight out of 12 studies performed an actual invasive or non-invasive follow-up angiography after BVS implantation, but in the vast majority of those studies, this imaging was done in less than 100% of patients, so the true rates of restenosis or scaffold thrombosis might be underestimated. For instance, Mitomo et al. reported that only 33.8% of patients underwent follow-up angiography [13] while Maeremans et al. reported about 83% of patients having follow-up multislice computed tomography angiography [14]. Regardless of these promising findings, the first generation BVS was recently removed from clinical practice due to safety alert for Absorb BVS (Abbott) recently issued by Food and Drug Administration due to confirmed higher rates of ST [28]. Next generation of BVS with thinner struts and improved rheological parameters are currently under investigation with some promising preliminary results [29]. At the same time, there are no published data on the use of second-generation scaffolds in CTO yet. Our systematic review has several limitations. First, all included studies were observational in nature with no published randomized controlled trials available to date and thus, the available data are subject to potential biases, such as selection bias and confounding, and as such were deemed to be of low quality in our quality review. Second, due to significant study heterogeneity, we were unable to meta-analyze our data across included publications and therefore we instead conducted qualitative systematic review. Third, median follow-up duration was less than two years for most of the studies, which limits the ability to assess theoretical BVS advantages after scaffold resorption. Fourth, all studies used first-generation BVS Absorb with its potentially unfavorable rheological properties.
Although data on the use of first-generation BVS in CTO are sporadic and limited by small sample observational studies, available evidence to date is promising and suggests of acceptable mid- and long-term outcomes comparable with second generation DES. Further investigation with randomized clinical trials and use of better-designed newer generation scaffolds is required in order to control for confounding variables and to determine if there is a significant difference between these devices.
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- Suh J, Park D-W, Lee J-Y, et al.: The relationship and threshold of stent length with regard to risk of stent thrombosis after drug-eluting stent implantation. JACC Cardiovasc Interv. 2010, 3:383-389. 10.1016/j.jcin.2009.10.033
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- Serruys PW, Ormiston JA, Onuma Y, et al.: A bioabsorbable everolimus-eluting coronary stent system (ABSORB): 2-year outcomes and results from multiple imaging methods. Lancet. 2009, 373:897-910. 10.1016/S0140-6736(09)60325-1
- Serruys PW, Ormiston J, Van Geuns R-J, et al.: A polylactide bioresorbable scaffold eluting everolimus for treatment of coronary stenosis: 5-year follow-up. J Am Coll Cardiol. 2016, 67:766-776. 10.1016/j.jacc.2015.11.060
- Liberati A, Altman DG, Tetzlaff J, et al.: The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009, 62:1-34. 10.1016/j.jclinepi.2009.06.006
- La Manna A, Miccichè E, D'Agosta G, et al.: Vascular response and healing profile of everolimus-eluting bioresorbable vascular scaffolds for percutaneous treatment of chronic total coronary occlusions: a one-year optical coherence tomography analysis from the GHOST-CTO registry. Int J Cardiol. 2018, 253:45-49. 10.1016/j.ijcard.2017.10.107
- Mitomo S, Naganuma T, Fujino Y, et al.: Bioresorbable vascular scaffolds for the treatment of chronic total occlusions: an international multicenter registry. Circ Cardiovasc Interv. 2017, 10:e004265. 10.1161/CIRCINTERVENTIONS.116.004265
- Maeremans J, Verhaert D, Pereira B, et al.: One-year clinical and computed tomography follow-up after implantation of bioresorbable vascular scaffolds in patients with coronary chronic total occlusions. Catheter Cardiovasc Interv. 2018, 92:488-496. 10.1002/ccd.27390
- Kugler C, Marovic S, Rottbauer W, Wöhrle J: Bioresorbable scaffolds compared with everolimus-eluting stents for the treatment of chronic coronary total occlusion: clinical and angiographic results of a matched paired comparison. Coronary Artery Disease. 2017, 28:120-125. 10.1097/MCA.0000000000000449
- Yamac AH, Yildiz A, Nasifov M, Tastan A, Bashirov N, Goktekin O: Clinical and angiographic outcomes at more than 1 year after treatment of chronic total occlusions with the everolimus-eluting bioresorbable vascular scaffold. Turk Kardiyol Dern Ars. 2016, 44:647-655. 10.5543/tkda.2016.21774
- Vaquerizo B, Barros A, Pujadas S, et al.: One-year results of bioresorbable vascular scaffolds for coronary chronic total occlusions. Am J Cardiol. 2016, 117:906-917. 10.1016/j.amjcard.2015.12.025
- Özel E, Taştan A, Öztürk A, Özcan EE, Kilicaslan B, Özdogan O: Procedural and one-year clinical outcomes of bioresorbable vascular scaffolds for the treatment of chronic total occlusions: a single-centre experience. Cardiovasc J Afr. 2016, 27:345-349. 10.5830/CVJA-2016-033
- Lesiak M, Lanocha M, Araszkiewicz A, et al.: Percutaneous coronary intervention for chronic total occlusion of the coronary artery with the implantation of bioresorbable everolimus-eluting scaffolds. Poznan CTO-Absorb Pilot Registry. EuroIntervention. 2016, 12:144-151. 10.4244/EIJV12I2A27
- Azzalini L, Giustino G, Ojeda S, et al.: Procedural and long-term outcomes of bioresorbable scaffolds versus drug-eluting stents in chronic total occlusions: the BONITO registry (bioresorbable scaffolds versus drug-eluting stents in chronic total occlusions). Circ Cardiovasc Interv. 2016, 9:e004284. 10.1161/CIRCINTERVENTIONS.116.004284
- Ojeda S, Pan M, Romero M, et al.: Outcomes and computed tomography scan follow-up of bioresorbable vascular scaffold for the percutaneous treatment of chronic total coronary artery occlusion. Am J Cardiol. 2015, 115:1487-1493. 10.1016/j.amjcard.2015.02.048
- Goktekin O, Yamac AH, Latib A, et al.: Evaluation of the safety of everolimus-eluting bioresorbable vascular scaffold (BVS) implantation in patients with chronic total coronary occlusions: acute procedural and short-term clinical results. J Invasive Cardiol. 2015, 27:461-466.
- Wiebe J, Liebetrau C, Dörr O, et al.: Feasibility of everolimus-eluting bioresorbable vascular scaffolds in patients with chronic total occlusion. Int J Cardiol. 2015, 179:90-94. 10.1016/j.ijcard.2014.10.032
- Serruys PW, Chevalier B, Sotomi Y, et al.: Comparison of an everolimus-eluting bioresorbable scaffold with an everolimus-eluting metallic stent for the treatment of coronary artery stenosis (ABSORB II): a 3 year, randomised, controlled, single-blind, multicentre clinical trial. Lancet. 2016, 388:2479-2491. 10.1016/S0140-6736(16)32050-5
- Wykrzykowska JJ, Kraak RP, Hofma SH, et al.: Bioresorbable scaffolds versus metallic stents in routine PCI. N Engl J Med. 2017, 376:2319-2328. 10.1056/NEJMoa1614954
- Cassese S, Byrne RA, Ndrepepa G, et al.: Everolimus-eluting bioresorbable vascular scaffolds versus everolimus-eluting metallic stents: a meta-analysis of randomised controlled trials. Lancet. 2016, 387:537-544. 10.1016/S0140-6736(15)00979-4
- Pache J, Kastrati A, Mehilli J, et al.: Intracoronary stenting and angiographic results: strut thickness effect on restenosis outcome (ISAR-STEREO-2) trial. J Am Coll Cardiol. 2003, 41:1283-1288. 10.1016/S0735-1097(03)00119-0
- UPDATE on increased rate of major adverse cardiac events observed in patients receiving Abbott Vascular's Absorb GT1 bioresorbable vascular scaffold (BVS) - Letter to health care providers. (2017). Accessed: February 15, 2018: https://www.fda.gov/MedicalDevices/Safety/LetterstoHealthCareProviders/ucm582728.htm.
- FUTURE-I: six-month clinical, angiographic IVUS, and OCT results with a thin-strut PLLA-based sirolimus-eluting bioresorbable vascular scaffold in patients with coronary artery disease. (2016). Accessed: March 04, 2018: https://www.tctmd.com/videos/futurei-sixmonth-clinical-angiographic-ivus-and-oct-results-with-a-thinstrut-pllabased-s....
Search strategy for PubMed
("bioresorbable vascular" OR "bioresorbable scaffold" OR "bioresorbable scaffolds" OR "bioresorbable stent" OR "bioresorbable vascular scaffolds" OR "absorb bioresorbable vascular scaffold" OR "bioresorbable coronary scaffold" OR "bioresorbable scaffolds coronary" OR "BVS" OR "BRS" OR "naturally dissolving stents") AND ("chronic total occlusion" OR "chronic total occlusions" OR "coronary chronic total occlusion" OR "CTO" OR "chronic total coronary occlusion").
Search strategy for Embase
('bioresorbable scaffold'/exp OR 'absorb (device)' OR 'absorb gt1' OR 'acute (device)' OR 'amaranth (device)' OR 'avatar (device)' OR 'desolve' OR 'dreams (device)' OR 'fortitude (device)' OR 'fantom (device)' OR 'ideal biostent' OR 'meres (device)' OR 'rezolve' OR 'xinsorb' OR 'zorion' OR 'bioresorbable scaffold' OR 'bioresorbable vascular stent'/exp OR 'igaki-tamai' OR 'bioresorbable vascular stent' OR 'bvs' OR 'brs') AND ('chronic total occlusion'/exp OR 'chronic total occlusion' OR 'chronic total coronary occlusion'/exp OR 'chronic total coronary artery occlusion'/exp OR 'chronic total occlusion percutaneous coronary intervention'/exp OR 'cto').
Clinical Outcomes of Successful Revascularization of Chronic Total Coronary Occlusions with Bioresorbable Vascular Scaffolds: A Systematic Review
Ethics Statement and Conflict of Interest Disclosures
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.
Article Information
Cite this article as:
Marchenko R, Nazir S, Malla S, et al. (November 28, 2018) Clinical Outcomes of Successful Revascularization of Chronic Total Coronary Occlusions with Bioresorbable Vascular Scaffolds: A Systematic Review. Cureus 10(11): e3647. doi:10.7759/cureus.3647
Publication history
Received by Cureus: October 22, 2018
Peer review began: October 31, 2018
Peer review concluded: November 23, 2018
Published: November 28, 2018
© Copyright 2018
Marchenko et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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.
Clinical Outcomes of Successful Revascularization of Chronic Total Coronary Occlusions with Bioresorbable Vascular Scaffolds: A Systematic Review
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Mr. Johnny Frank Thompson, age 52, of Andalusia, passed away Sunday, May 5, 2019, at his residence.
Mr. Thompson is survived by his wife of 12 years, Amy King Thompson; four children, Justin (Heather) Thompson of Andalusia, Bryan (Amber) Gay of Andalusia, Chris (Allie) Gay of Andalusia, and Cortney (Jordan) Pettie of Babbie, AL; eight grandchildren: Brayden, Rylan, and Jackson Pettie , Trinity, Judah, and Michelle Thompson, Bryan Gay Jr., and Parrish Gay of Andalusia; his father and mother, Bennie (Sherry) Thompson of Opp; one brother, Jody (Tina) Thompson of Opp; mother-in-law and father-in-law, Faye and Eugene Lee of Opp; and father-in-law and mother-in-law, Richard and Debbie King of Opp. He was preceded in death by his mother, Genelle Grice Thompson; sister, Michelle Leigh Thompson; an infant sister, and an infant brother.
Mr. Thompson worked as a welder for a majority of his life. In his spare time, he enjoyed fishing and working in his yard. He also had a love for camping; although, his favorite pastime was spending time with those he loved most, his family and friends.
A memorial service will be held in his honor 2:00 P.M. June 8, 2019, at Mt. Pisgah Church of God. All family and friends are invited to attend.
Please join us in remembering Mr. Thompson by visiting his memorial page at www.keaheyfuneralhome.com. We invite you to share your memories and words of comfort with his loved ones there.
To send flowers to the family or plant a tree in memory of Johnny Thompson, please visit our floral store.


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My favorite room is our outdoor living room. We have coffee there every morning, it is so peaceful.
The patio, water feature and landscaping attract so much wildlife. It is like a bird sanctuary. The photo of the hummingbird still amazes me! Yes, it is real and a beautiful little guy who comes by regularly to visit.
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- Carole Swiergoszon May 5, 2016
Hummingbirds are magical; you've created an truly inviting space; thanks for sharing!
- Drd4223999on Jul 25, 2016
Very lovely, so peaceful. I have an outdoor space and am working with keeping my cushions dry when it rains. Do you remove your cushions when it rains or do u have them waterproofed?
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text: Hi everyone! Wow, that summer flew by, but now we enter the fall soccer season! Registration will take place at the beginning of each of the sessions for the first two weeks. Sessions will begin the week of Sept 9. *******NOTE CHANGE: Goalie practice will now take place on Wednesdays from 7pm – 8pm


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One of the greatest annoyances to teachers is students not bringing the appropriate equipment to lessons with them. It delays the lesson, hampers the learning of the students and results in the school having to loan out equipment that is often not returned. Most schools will issue instructions with regards to what a student is required to bring to school with them. However, there are still many students who fail to do so. Here is an overview of essential equipment that all students should take to the classroom.
Writing equipment
There are very few lessons that will not require writing in some form. Whether this be taking notes, highlighting, writing an assignment or drawing, there will be at least some part of a lesson that will need a student to have equipment for writing. Typically, equipment that would be expected includes pens, pencils, coloring pencils, a ruler, an eraser and a highlighter. It can be helpful to have several of each of these so that if one doesn't work, the student has a reserve.
Mathematical equipment
For maths lessons, there is a whole set of equipment needed that is specific to this subject. Some of these can also come in useful for other subjects, such as graphics, science and technology. Suggestions of what to include are a scientific calculator, a protractor, compasses, a ruler and a set square. If any other equipment is needed, students will generally be loaned the equipment form school or be given advance notice of the necessity to bring additional equipment to school.
Other equipment
There are sometimes subject specific pieces of equipment that are needed for lessons. This may depend on the subjects covered in particular schools or on the lesson choices of the students. Another factor can be the level of study that a student is doing. Examples are a student studying art being required to bring additional pencils and paints, or a student studying French being required to bring a French dictionary to school with them.
It is essential that students are properly equipped for their lessons as not being so leads to delays and disruption to learning. Although schools generally provide a list of the required equipment, if you are unsure it is wise to seek the advice of the school. Common sense will generally tell you what is required for each of the lessons. Much of the equipment will be used in most lessons, although there are some subject specific items of equipment that may also be required.


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Emily Button is designed by excellent supplier of cross stitch kits; Anchor crafts. Her adorable character and friendly cat Bobble are featured in a charming selection of cross stitch kits including baby birth samplers, perfect for welcoming a new baby to the world!
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Read The Winner Stands Alone Online
Authors: Paulo Coelho
Tags: #Fiction, #Thrillers, #working
Time passed, and the question became less important, until the night they attended a gala
suppercumcharity auction at one of the most expensive restaurants in Milan. They were both
there for differ- ent reasons: Igor in order to firm up the details of a contract with an
Italian firm, and Ewa in order to attend the Fashion Week, where she intended to make a
few purchases for her Moscow shop.
And what had happened in the middle of Siberia was repeated in one of the most
sophisticated cities in the world. This time, a friend of theirs, rather the worse for
wear, sat down at their table uninvited and started joking and making inappropriate
remarks. Ewa saw Igors hand grip the handle of his knife more tightly. As tactfully and
politely as possible, she asked the friend to go away. By then, she had already drunk
several glasses of Asti Spumante, as the Italians refer to what used to be called
champagne because the use of the word champagne was banned under the so-called Protected
Designation of Origin. Champagne simply means a white wine made using a particular bacte-
ria which, when rigorously controlled, begins to generate gases inside the bottle as the
wine ages over a period of at least fifteen months. The name refers to the region where
its produced. Spumante is exactly the same thing, but European law doesnt allow it to be
known by the French name, since the vineyards are in Italy and not in the Cham- pagne
region of France.
They started talking about champagne and about the laws govern- ing names, while she tried
to drive from her head the question she had tried to suppress and which was now returning
in full force. While they were talking, she kept drinking, until there came a moment when
she could hold back no longer.
What does it matter if someone gets a little drunk and comes over to talk to us?
When he answered, Igors voice had changed.
Because we so rarely travel together. Besides, you know what I think about the world we
live in: that were being suffocated by lies, encouraged to put our faith in science rather
than in spiritual values and to feed our souls with the things society tells us are
important, when, in reality, were slowly dying because we know whats going on around us,
that were being forced to do things we never planned to do, and yet even so, are incapable
of giving it all up and devoting our days and nights to true happiness, to family, nature,
love. And why is that? Because we feel obliged to finish what we started, so that we can
achieve the financial stability we need in order to enjoy the rest of our lives devoting
ourselves to each other because were responsible people. I know you sometimes think I work too much, but its not true. Im building our
future and soon well be free to dream and to live out our dreams.
Financial stability was hardly something they lacked. They had no debts and they could
have got up from that table there and then with just their credit cards and simply left
behind them the world Igor ap- parently hated and start all over again, and never have to
worry about money. She had often spoken to him about this, and Igor always said the same
thing: It wont be much longer. Besides, this wasnt the moment to discuss their future as a
God thought of everything, he went on. We are together be- cause he decided we should be.
You may not fully appreciate your im- portance in my life, but without you, I would never
have got where I am today. He placed us side by side and lent me his power to defend you
whenever necessary. He taught me that everything is part of a plan, and I must respect
that plan down to the last detail. If hadnt done so, I would either be dead in Kabul or
living in poverty in Moscow.
And it was then that the Spumante or champagne revealed what it was capable of, regardless
of what it was called.
What happened to that beggar in Siberia? she asked.
Igor didnt at first know what she was talking about. Ewa reminded him of what had happened
in the restaurant there.
Id like to know what you did. I saved him. She gave a sigh of relief. I saved him from a
filthy, hopeless life in those freezing winters, with his body being slowly destroyed by booze. I let his soul depart toward the light
because the moment he came into that restaurant to destroy our happiness, I knew that his
spirit was inhabited by the Evil One.
Ewa felt her heart begin to pound. She didnt need him to say out- right: I killed him. It
was clear that he had.
Without you I dont exist. Anything and anyone who tries to sepa- rate us or to destroy the
little time we have together at this particular moment of our lives gets the treatment
they deserve.
Meaning perhaps that they deserved to be killed? Could such a thing have happened before
without her noticing? She drank and drank some more, and Igor began to relax again. Since
he never opened his heart to anyone else, he loved their conversations.
We speak the same language, he went on. We see the world in the same way. We complete each
other with a perfection that is granted only to those who put love above all else. As I
said, without you I dont exist.
Look at the Superclass around us. They think theyre so impor- tant, so socially aware,
because theyre willing to pay a fortune for some useless item at a charity auction or to
attend a supper organized to raise funds to help the homeless in Rwanda or to save the
pandas in China. Pandas and the homeless are all one to them. They feel spe- cial,
superior to the average person, because theyre doing something useful. Have they ever
fought in a war? No. They create wars, but they dont fight in them. If the war turns out
well, they get all the credit. If not, others get the blame. Theyre in love with
My love, Id like to ask you something else . . .
At that point, a presenter climbed onto the stage and thanked ev- eryone for being there
that night. The money raised would go toward buying medicine for refugee camps in Africa.
What he doesnt say, Igor went on, as if he hadnt heard her, is that only ten percent of
the total amount raised will reach its destina- tion. The rest will be used to pay for
this event, for the cost of this supper, for the publicity and the organizers, in short,
for the people who had the brilliant idea in the first place, and all at an exorbitant
price. They use poverty as a way to get even richer.
So why are we here?
Because we need to be. Its part of my work. I have no intention of saving Rwanda or
sending medicine to refugees, but at least I know that I dont. The other guests here
tonight are using their money to wash their consciences and their souls clean of guilt.
When the geno- cide was going on in Rwanda, I financed a small army of friends, who
prevented more than two thousand deaths. Did you know that?
No, you never told me. I didnt need to. You know that I care about other people.
The auction began with a small Louis Vuitton travel bag. It sold for ten times its retail
price. Igor watched the auction impassively, while she drank another glass of Spumante and
wondered whether she should or shouldnt ask that question.
An artist danced to a soundtrack provided by Marilyn Monroe and simultaneously painted a
picture. The bids for the finished work of art were sky-highthe price of a small apartment
in Moscow.
Another glass of wine. Another item sold. For an equally absurd price.
She drank so much that night that she had to be carried back to the hotel. Before he put
her into bed and before she fell asleep, she finally got up the courage to ask:
And what if I were to leave you? Drink less next time. Answer me. That could never happen.
Our marriage is perfect. Common sense returned, but she knew she had an excuse now and so pretended to be drunker than she was. Yes, but what if I did? Id make you come back,
and Im good at getting what I want, even if that means destroying whole worlds. And what if I met another man? He looked at
her without rancor, almost benevolently. Even if you slept with every man on Earth, my
love would still survive.
And since then, what had
seemed a blessing began to turn into a nightmare. She was married to a monster, an
assassin. What was that story about financing an army of mercenaries to intervene in a
tribal war? How many other men had he killed to keep them from troubling their marital
peace? She could blame the war, the traumas he had suffered, the hard times he had been
through, but many other men had endured the same experiences, without emerging from them convinced that they were
the instrument of Divine Justice, carrying out some Grand Plan.
Im not jealous, Igor used to say whenever he or she set off on a business trip, because
you know how much I love you, and I know how much you love me. Nothing will ever happen to
destabilize our marriage.
She was more convinced than ever that this was not love. It was something sick and morbid,
which she would either have to accept and live the rest of her life a prisoner to fear, or
else free herself as soon as possible, at the first opportunity.
Several opportunities arose, but the most insistent, the most per- sistent was the very
last man with whom she would have imagined building a real relationship: the couturier who
was dazzling the fash- ion world, growing ever more famous, and receiving a vast amount of
money from his own country so that the world would understand that the nomadic tribes had
solid moral values that were completely at odds with the reign of terror imposed by a
religious minority. He was a man who, increasingly, had the world at his feet.
Whenever they met at fashion shows, he would drop whatever other commitments he had,
cancel lunches and suppers, just so that they could spend some time together in peace,
locked in a hotel room, often without even making love. They would watch television, eat,
drink (although he never touched a drop of alcohol), go for walks in parks, visit
bookshops, talk to strangers, speak very little of the past, never of the future, and a
great deal about the present.
She resisted for as long as she could, and, although she was never in love with him, when
he proposed that she leave everything and move to London, she accepted at once. It was the
only possible way out of her private hell.
Another message appears on her
phone. It cant be; they havent been in touch for two years.
Were nearly there. Remember, we havent got much time.
The limousine has to maneuver its way toward the entrance of the Hotel Martinez. On both
sides, behind the metal barriers erected by the police, people of all ages spend the whole
day hoping to get a close-up look at some celebrity. They take photos with their digital
cameras, tell their friends whom theyve seen, and send messages over the Internet to the
virtual communities they belong to. They would feel the long wait was justified for that
one moment of glory: catching a glimpse of an actress, an actor, or even a TV presenter!
Although its only thanks to them that the celebrity industry keeps going, they are kept at
a safe distance; strategically positioned body- guards ask anyone going into the hotel for
proof that they are stay- ing there or meeting someone. Then you either have to get out
the magnetic card that serves as your room key or else be turned away in full view of the
public. If youre having a business meeting or have been invited for a drink at the bar,
they give your name to the security people and, with everyone watching, wait to see if
what you say is true or false. The bodyguard uses his radio to call reception, and you
wait there for what seems like an eternity, and then, finally, after that very public
humiliation, youre allowed in. Those who arrive in limousines, of course, are treated
quite differently.
The two doors of the Maybach are opened, one by the chauffeur and the other by the hotel
porter. The cameras turn on Ewa and start to shoot; even though no one knows who she is,
if shes staying at the Martinez and has arrived in a fancy car, she must be important.
Perhaps shes the mistress of the man shes with, and if she is and hes having an
extramarital affair, theres always a chance they can send the photos to some scandal rag.
Or perhaps the beautiful blonde is a famous foreign celebrity as yet unknown in France.
Later, theyll find her name in the so-called people magazines and be glad that they were
once only four or five yards from her.
Hamid looks at the small crowd pressed up against the metal barri- ers. He has never
understood this phenomenon, having been brought up in a place where such things simply
dont happen. Once he asked a friend why there was so much interest in celebrities.
Dont assume theyre all fans, said his friend. Since time imme- morial, men have believed
that being close to something unattainable and mysterious can bring blessings. Thats why
people make pilgrim- ages to visit gurus and sacred places.
But Cannes?!
It can be anywhere they might catch a distant glimpse of some elusive celebrity. For the
adoring crowd, a wave from a celebrity is like being scattered with ambrosia dust or manna
from heaven.
Its the same everywhere. Take, for example, those massive pop concerts that seem more like
religious meetings, or the way people are willing to wait outside some sell-out
performance at a theater just to see the Superclass entering and leaving. Take the crowds
who go to foot- ball stadiums to watch a bunch of men chasing after a ball. Celebrities
are idols, icons if you like, after all, they do resemble the paintings you see in
churches and can become cult images in the bedrooms of ado- lescents or housewives, and
even in the offices of industrial magnates, who, despite their own enormous wealth, envy
their celebrity.
Theres just one difference: in this case, the public is the supreme judge, and while they
may applaud today, tomorrow theyll be equally happy to read some scandalous revelation
about their idol in a gossip magazine. Then they can say: Poor thing. Im so glad Im not
like him. They may adore their idol today, but tomorrow theyll stone and crucify him
without a twinge of conscience.


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Some words in the English language can be very hard to say. For example, it took a long time for my children to say 'animal' instead of 'aminal' – and sometimes they still get it wrong. Our family always has a giggle every time characters in Finding Nemo try to say 'anemone.' I had to practice how to say 'antidisestablishmentarianism' when I was younger so I could impress my university friends with what I've been told is one of the longest words in the English dictionary.
But it seems like one of the hardest words in the English language to say is 'sorry.'
It is easy to read the word 'sorry', but if you think saying it is easy, try going to someone you have wronged in the past and telling them you're sorry for what you did. We can find it difficult to do that for a range of reasons. Maybe we don't think we have anything to apologise for because whatever happened was their fault. Maybe we are so ashamed of what has happened that we would prefer not to face it. Or maybe we just don't want to take responsibility for what we have done. No matter what our reasons might be, saying 'sorry' to someone we have wronged can be very hard to do.
When James encourages us to confess our sins to each other in 5:16, he is reminding us that confession is more than turning up to church and saying 'sorry' to God. One reason why it's important to have time in worship where we confess our sin to God and God speaks his word of forgiveness to us is that there is a strong tendency in our humanistic culture to think that we're good people who don't need to be forgiven. However, when I look at my life, I know that I fail to love God with all my heart, mind soul and strength, and that I fail to love others in the same way that God loves me through Jesus. Hearing God's words of forgiveness helps me to remember that my identity is found in his forgiveness, not in my failures. Hearing a word of forgiveness helps us grow into the people God is making us as his children whom he loves and with whom he is well pleased.
When we are sorry for the wrongs we have done, then we will also be willing to go to the people we have wronged and tell them that we are sorry. This isn't something that we have to do in order to get God's forgiveness. Sometimes we can have a very mechanical understanding of God's grace where we think that we have to say we are sorry before God will forgive us. There is a much more dynamic relationship that exists between our confession and God's forgiveness. As a church that practices infant baptism, we believe and teach that God forgiveness us even before we are able to confess our sin. Because God forgives us on account of Jesus' life, death and resurrection for us, we are free to go to each other and confess that we have wronged each other. We can trust that God's final word to us in Jesus will always be a word of grace and forgiveness. If God has vowed to forgive us and make us clean through the gift of his Holy Spirit, then why wouldn't we ask to receive that forgiveness from and extend that same forgiveness to each other?
The promise God gives us through James' words about confessing sin and forgiving each other is that we will find healing. We might think about physical healing, and there is no reason why almighty God can't heal those he chooses to. However, healing can also take other forms. When we wrong others, our hearts can be wounded as we carry the burden of guilt and shame. This can effect our emotional and sometimes even our physical wellbeing. I have known people who had been suffering mentally and even physically because of a wrong they had committed in the past, but they hadn't connected what they were experiencing with what they'd done. When we identified the connection, and the wrong was confessed and forgiven, then their wellbeing improved. This isn't the case with every illness, and Jesus warned us not to assume a direct connection between illnesses or disabilities and a particular sin (John 9:1-3). However, in some cases I have seen how confessing and forgiving sin can help to heal people's hearts and even their body.
Another way to understand the healing that James talks about is in our relationships. Sin and doing wrong damages relationships, but when we confess our wrongs to each other and forgive each other in Jesus' name, these relationships can be healed. We can be reconciled to each other in the same way that God reconciles with us in Jesus and heals our broken relationship with him. This can be really difficult to do for a whole range of reasons, but the promise of God that we hear through the words of James is that our relationships can be healed and restored when we admit when we are wrong and ask the people we have wronged to forgive us. The healing of the relationship we have through the forgiveness God gives us in Jesus can flow through into the other damaged relationships we have in our lives so they can be healed as well. This isn't easy to do. It requires a lot of humility, courage and faith. However, James tells us, and I have seen in my own life, that when we confess our wrongs to the people we have wronged and ask them to forgive us, not only can our relationship be healed, but we can find healing and wholeness in ourselves as well.
To whom might we need to confess our wrongs, either to restore our relationship with them or just to find healing and peace for ourselves? If there is something in your life that you're carrying, don't be afraid to go to someone you might have wronged, or to another sister or brother in Christ, and confess what you might have done. Find healing and freedom through the grace of God working in the words of forgiveness they speak to you. Because that's what God wants for us – to live each day as God's forgiven and healed children.


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According to The Guardian, the Center Against Terrorism and Hybrid Threats would be operating since January 1 and would be aimed at preventing interference into the October general elections as the Czech authorities considered that the level of online disinformation was currently rising.
Prague considered that Russia was behind inaccurate reports and fake news, though no proof was ever provided.
"The key goal of Russian propaganda in the Czech Republic is to sow doubts into the minds of the people that democracy is the best system to organise a country, to build negative images of the European Union and Nato, and [to] discourage people from participation in the democratic processes," Tomas Prouza, the Czech government's state secretary for European affairs, was quoted as saying by the Guardian.
The European authorities have repeatedly accused Moscow of propaganda, while Russia denies the accusations.
In November, in particular, the European Parliament voted in favor of a resolution on countering Russian media. The European parliament's resolution said that Sputnik and RT posed a danger to European unity and called for extra European Commission funding for counterpropaganda projects.


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Neil Lennon has to select Tom Rogic on Sunday, despite the attacking midfielder not playing a match for the club since December.
It's been a long road back to the first-team for the Australian international.
He missed out on January action at the club due to his Asian Cup national team selection and subsequently picked up an injury that has kept him out for a further two months.
There's absolutely no doubt that the player's injury and international absences have been a frustrating undercurrent to his Celtic career to date, but all that should be pushed to this side this Sunday for the visit of Rangers on Sunday.
The fact of the matter is this – Rogic is a unique talent in comparison to the rest of the Celtic squad, he is a match-winner and perhaps most importantly he is the epitome of a big game player.
The 26-year-old's incredible ability to take the ball on the half turn and expose opposition defences can hurt any team when he makes it his business and although we almost certaintly won'tt get 90 minutes out of him this weekend, that ability will remain a potent weapon for an hour or so.
He also carries a goal threat that is hard to defend against. Lethal from range and exceptional at making space for himself, how often have we seen packed defences undone by a bit of Rogic magic in the final third? That kind of spark and creative genius is something we've been massively lacking in recent weeks.
Lennon confirmed this week that Rogic has returned to full training on the grass pitches at Lennoxtown and it looks like he will get the nod from physios to be in contention for this weekend's fixture.
That leaves the manager with a massive selection call that could define the outcome of the fixture.
A pedestrian Celtic midfield will hand the advantage to Rangers from kick-off and we need an attack-minded player in the central area to pin them into their own half and start the game aggressively.
That's Rogic's role all day. Unleash him Neil.
Would you start Tom Rogic on Sunday? Share your thoughts in the comments below…


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9 Silk Chase, Forrestfield
- 3 bed
- 2 bath
- 2 car
Benefits of the Havana
Want the best of nature without sacrificing modern life? We have the answer!
Build your new home in The Hales Estate, Forrestfield, with the natural beauty of the Darling Ranges on one side and Perth CBD on the other, you get the best of both worlds. From landscaped parks and playgrounds to tranquil bushland, you'll love outdoor living at The Hales.
Stay connected with schools, the Forrestfield shopping centre and Forrestfield Train Station (due for completion in 2021) just a short walk away. Enjoy easy access to Perth Airport and transport links such as Roe Highway and Tonkin Highway.
Live comfortably with this spacious sleek, modern home design. The large free-form living area at the heart of the home offers direct outdoor access to the alfresco, perfect to enjoy all year round. The master-chef kitchen wraps around conveniently connecting to laundry for easy multi-tasking.
The theatre sits snuggly away at the front of the home so you can turn up the volume of your blockbuster movie and relax in style. The superior mast suite features a walk-in robe fit for a king and queen and a fully appointed ensuite. The children's rooms are generously sized with built-in robes and a shared bathroom.
This charming home comes packed with premium inclusions such as
- 31c ceiling to living, dining and kitchen
- 28c ceiling to alfresco
- Reverse cycle air-conditioning
- Stone benchtops throughout
- Vertical blinds throughout
- Vinyl plank "wood effect" flooring to living areas
- Carpet to all rooms
- Front fencing and landscaping
Contact us to start your build journey in the heart of Forrestfield, a place to belong.
Photos are generic as your home will be built to your specification.
Features of the Havana
- Home Theatre
- Modern Design
- Open Plan Living
- Intelligent Zoning
Location details
Check out the block
9 Silk Chase, Forrestfield


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decipara is a topic covered in the Taber's Medical Dictionary.
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Venes, Donald, editor. "Decipara." Taber's Medical Dictionary, 23rd ed., F.A. Davis Company, 2017. Taber's Online, www.tabers.com/tabersonline/view/Tabers-Dictionary/730628/all/decipara.
Decipara. In: Venes D, ed. Taber's Medical Dictionary. F.A. Davis Company; 2017. https://www.tabers.com/tabersonline/view/Tabers-Dictionary/730628/all/decipara. Accessed August 13, 2020.
Decipara. (2017). In Venes, D. (Ed.), Taber's Medical Dictionary (23rd edition). F.A. Davis Company. Retrieved August 13, 2020, from https://www.tabers.com/tabersonline/view/Tabers-Dictionary/730628/all/decipara
Decipara [Internet]. In: Venes D, editors. Taber's Medical Dictionary. F.A. Davis Company; 2017. [cited 2020 August 13]. Available from: https://www.tabers.com/tabersonline/view/Tabers-Dictionary/730628/all/decipara.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - decipara ID - 730628 ED - Venes,Donald, BT - Taber's Medical Dictionary UR - https://www.tabers.com/tabersonline/view/Tabers-Dictionary/730628/all/decipara PB - F.A. Davis Company ET - 23 DB - Taber's Online DP - Unbound Medicine ER -