Perforation of the sinus of Valsalva by guiding catheter during the percutaneous coronary intervention via the right transradial approach: A very unusual complication

Iatrogenic dissection of the sinus of Valsalva or of the ascending aorta is a rare but potentially fatal event, during the percuteneous coronary intervention (PCI). We reported a case of perforation of the sinus of Valsalva by guiding catheter during PCI via the right transradial approach (TRA) successfully managed and sealed without any sequelae. The choice of guiding catheter into the right TRA should be done carefully and its manipulation should be performed with caution in the coronary artery and in the sinus of Valsalva. © 2011 Wiley Periodicals, Inc.     

Aortocoronary dissection resolved by coronary stenting guided by intracoronary ultrasound.

Percutaneous coronary intervention (PCI) was performed for chronic total occlusion of the proximal right coronary artery in a 70-year-old male with unstable angina. The forceful manipulation of the guide catheter led to an aortocoronary dissection involving the right Valsalva sinus and the ascending aorta. Intracoronary ultrasound (ICUS) showed the important characteristics of the dissection, enabling successful coronary stenting under ICUS guidance.     

Judkins Left指引导管在起源异常的右冠状动脉经桡动脉行经皮冠状动脉介入治疗中的应用

目的评价Judkins Left系列指引导管在起源于左冠状窦的右冠状动脉经桡动脉行经皮冠状动脉介入治疗（PCI）中应用的安全性和有效性。方法 11例患者起源于左冠状窦的右冠状动脉存在狭窄或闭塞病变,均采用右侧桡动脉穿刺,选择JL 3.5或JL 4.0指引导管行右冠状动脉PCI,根据病变情况必要时应用双导丝技术或5进6子母导管技术增加指引导管同轴性和支撑力。慢性闭塞病变常规应用微导管增加指引导丝支撑力,以便于更换导丝。观察手术成功率、并发症和近期随访结果。结果 11例患者中,3例为右冠状动脉慢性闭塞病变,8例为严重狭窄病变,同时合并左冠状动脉病变。所有患者均使用Judkins Left系列指引导管经桡动脉成功完成右冠状动脉PCI,7例应用JL 3.5指引导管,4例应用JL 4.0指引导管。2例在Judkins Left系列指引导管基础上应用5进6子母导管,其中包括1例右冠状动脉慢性闭塞病变;4例应用双导丝技术增加支撑力。3例慢性闭塞病变在微导管支持下均成功行PCI,其中1例先应用双导丝技术、后5进6子母导管增强支撑力。所有患者均成功置入药物洗脱支架,共置入支架19枚,每例右冠状动脉置入支架1~3（1.7±0.7）枚,置入支架长度为18~99（44.1±23.8）mm。术中所有患者均未出现冠状动脉穿孔、栓塞或夹层等并发症,手术成功率100%。住院期间无心脏压塞及支架血栓等并发症。术后临床随访6~12个月,无死亡及心肌梗死等不良心血管事件发生。结论对于右冠状动脉起源于左冠状窦病变,经右侧桡动脉途径,可以选择Judkins Left系列指引导管行PCI,支撑力不够时,可辅以其他增加支撑力的技术,如微导管技术、双导丝技术、子母导管技术等完成手术操作。     

Percutaneous transluminal coronary angioplasty of anomalous left circumflex coronary artery

We present our experience of percutaneous transluminal coronary angioplasty in two patients with an anomalous left circumflex coronary artery with severe stenosis. In the first case, the anomalous vessel originated from the first portion of the right coronary artery, and in the second case it originated from the right sinus of Valsalva. Cannulating the anomalous vessel with the guiding catheter can be difficult. The right Judkins-type catheter, with a posteriorly directed tip, is the most appropriate catheter for cannulating the anomalous circumflex artery when the vessel originates from the first portion of the right coronary artery, and the left Amplatz-type 1 is most appropriate when the vessel originates from the right sinus of Valsalva.     

Successful fenestration using a chronic total occlusion-dedicated guidewire in a patient with catheter-induced dissection of the right coronary artery

Guiding catheter-induced coronary artery dissection is a rare, but hazardous complication of percutaneous coronary intervention (PCI) and is associated with the potential risk of impairment of coronary blood flow. Therefore, occurrence of this complication mandates a prompt revascularization procedure. A 68-year-old female patient with acute myocardial infarction caused by total occlusion of the proximal right coronary artery (RCA) underwent PCI. After revascularization by thrombus aspiration, catheter-induced dissection of the ostium of the right coronary artery (RCA) occurred when the guiding catheter and guidewire were accidentally removed. An attempt to engage the guiding catheter and guidewire into the true lumen failed because of total occlusion of the right coronary ostium. A chronic total occlusion (CTO)-dedicated guidewire was then used to create a fenestration of the intimal flap, and after it penetrated into the distal true lumen, a low-profile balloon catheter was dilated, and coronary flow from the false to the true lumen was established. After balloon dilatation, stents were deployed at both the dissection site and in the distal lesion. The final angiogram revealed restoration of coronary blood flow. We propose that application of a CTO-dedicated guidewire to create a fenestration of the intimal flap in the region of the coronary dissection is a feasible and effective alternative to conventional procedures.     

Dissection of the aortic sinus of valsalva complicating coronary catheterization: Cause,mechanism, evolution,and management

We have rarely observed the appearance of a dissection of the aortic sinus of Valsalva during catheterizations of the related coronary artery. The aim of this study is to describe the cause, mechanism, and evolution of this complication, which have implications for the management of the patient. According to our experience (one case out of 12,546 diagnostic and three cases out of 4,970 angioplasty procedures performed during the last 6 years), the dissection of the sinus of Valsalva always results from the retrograde extension of a dissection of the right coronary artery. It usually remains localized, but it may quickly involve the entire aorta. Contrast injections and balloon inflations promote its propagation, so these procedures should be avoided if possible. Instead of angiography, transesophageal echocardiogram is a safe and accurate method for studying its extension and as a follow-up method. The sinus of Valsalva dissections that remain localized during catheterization tend to spontaneously resolve in the first month. Cathet. Cardiovasc. Diagn. 43:273–279, 1998. © 1998 Wiley-Liss, Inc.     

Successful percutaneous coronary intervention of anomalous origin right coronary arteries with 3-D RCA guide catheters: a report of three cases

Right coronary arteries with anomalous origin (ARCA) may be associated with myocardial ischemia and sudden death. Selective catheterization and percutaneous coronary intervention (PCI) of ARCA can be technically challenging due to their slit-like orifice and aortic intramural course with abrupt angulation. The 3DRCA guide catheter is a unique catheter with a helical configuration that provides optimal guide support during PCI. We describe three cases of successful PCI to right coronary arteries with anomalous origin (two from the left sinus of Valsalva, one with ectopic origin from the right sinus of Valsalva) using 3DRCA guide catheters after a variety of other catheters were tried unsuccessfully.     

Pseudoaneurysm of the non‐coronary sinus of Valsalva: A rare complication of percutaneous coronary intervention

Pseudoaneurysm of the non‐coronary sinus of Valsalva is an exceptionally rare but potentially fatal complication of percutaneous coronary interventions (PCI). Here, we report a case of a 53‐year‐old man with pseudoaneurysm of the non‐coronary sinus of Valsalva following PCI who presented with recurrent chest pain and was treated successfully by closure of the orifice of the pseudoaneurysm and coronary artery bypass grafting.     

Percutaneous transluminal coronary angioplasty with stenting of anomalous right coronary artery originating from left sinus of Valsalva using the Voda guiding catheter: a report of two cases.

Coronary arteries of anomalous origin are uncommon and some forms seem to be predisposed to atherosclerosis. We report two cases of successful stent implantation in an anomalous right coronary artery originating from the left sinus of Valsalva using the Voda guiding catheter.     

An improved guide catheter for percutaneous transluminal coronary angioplasty

An improved guiding catheter (IGC) for PTCA is presented. The IGC's distal tip is formed into a slit. This provides two advantages: 1) Via the proximal portion of the slit, positioned in the sinus of Valsalva, coronary perfusion is assured. With the IGC the flow is twice as great in vitro as with a guiding catheter with two sideholes. Since blood pressure is measured at the point of entry into the coronary artery, coronary flow can be reliably monitored through the pressure curve. 2) Positioned in the left main stem, the guide wire and the balloon catheter can be lead out of the slit in any chosen direction, with the position of the IGC remaining stable and both major branches being well perfused. The IGC was used in the treatment of 90 patients with good results and without complications.     

Iatrogenic dissection of the anomalous-origin right coronary artery and left sinus of Valsalva

Anomalous right coronary artery arising from the left sinus of Valsalva is a rare congenital abnormality. Percutaneous coronary intervention of the anomalous-origin right coronary artery can be challenging. Iatrogenic aorto-coronary dissection is a rare and life-threatening complication. We present a case of aortocoronary dissection that occurred during angioplasty of the anomalous-origin right coronary artery.     

Successful percutaneous coronary intervention with stent implantation in anomalous right coronary arteries arising from the left sinus of valsalva: a report of two cases.

Percutaneous coronary intervention (PCI) in an anomalous right coronary artery arising from the left sinus of valsalva can be technically challenging because of difficulty in selectively cannulating the vessel. We present two cases of successful stent implantation in an anomalous right coronary artery arising from the left sinus of valsalva. In both cases, we used an oversized 6 Fr Judkins left guiding catheter, which provided excellent angiographic visualization and guide support for stent delivery.     

Aortocoronary dissection complicated with percutaneous coronary intervention: a case report

A 74-year-old female developed aortocoronary dissection during percutaneous coronary intervention. The forceful manipulation of the guide catheter and contrast medium injection seemed to be the cause of the aortocoronary dissection involving the coronary sinus of Valsalva. The entry of the dissection was closed with subsequent obliteration of the false lumen by coronary stenting under the guidance of intracoronary ultrasonography and angiography.     

Covered stent: a novel percutaneous treatment of iatrogenic aortic dissection during coronary angioplasty

We present a case of bidirectional dissection, with antegrade extension to the right coronary artery and retrograde extension to the sinus of Valsalva and the ascending aorta. The aortocoronary dissection appeared during percutaneous angioplasty to the right coronary artery. The entry site was successfully sealed by a covered stent.     

Congenital coronary artery anomaly simulating an acute aortic dissection

In this rare case, a patient had an anomalous right coronary artery originating from the left sinus of Valsalva coursing between the great vessels. He presented with symptoms and computed tomograms suggestive of an acute aortic dissection.     

冠状动脉二支主干堵塞行介入治疗完全血运重建

目的：本研究探讨对16例冠状动脉二支主干堵塞者采用分步和分次冠状动脉介入治疗术（PCI）完全血运重建的有效性和安全性。方法：（1）对5例急性心肌梗死（AMI）,采取一次性分步直接PCI术完成血运重建;（2）对11例不稳定型心绞痛（UAP）,采取多次性分步PCI术达到完全血运重建,首先解除本次发病罪犯血管的堵塞;（3）恰当使用XB导引导管、Crossit硬导丝和Maverick球囊以及主动脉内球囊反搏（IABP）支持。结果：（1）5例AMI二支堵塞冠状动脉均成功植入支架,并首先使左前降支（LAD）再通。（2）11例UAP中21／22支冠状动脉二支主干堵塞处经球囊预扩张后,均成功植入支架,所有堵塞冠脉均获得TIMI-Ⅲ级血流。（3）16例患者术后心电图显示心肌缺血明显改善,心脏超声显示左室射血分数较术前明显改善,由（42±34）％升至（51±44）％。经过平均18个月随访,患者生活质量明显提高,未发生严重心血管事件。结论：冠状动脉二支主干堵塞者行PCI术完全血运重建安全可行;对AMI者优先开通LAD的一次性PCI术安全高效;对慢性堵塞UAP者,优先开通近期罪犯病变的多次性PCI术既可达到完全血运重建,又符合临床实际。     

Treatment of aortocoronary dissection complicating anomalous origin right coronary artery and chronic total intervention with intravascular ultrasound guided stenting

Acute dissection of the ascending aorta is a rare complication of percutaneous coronary intervention (PCI). Its mechanism involves disruption of the coronary intima by mechanical trauma, followed by subintimal injection of contrast, which, in turn, contributes to subsequent extension of the dissection. In contrast to spontaneous aortic dissection of ascending aorta, which mandates immediate surgical intervention, the appropriate therapy and outcome of this rare entity are not well established. We report a case of iatrogenic aortocoronary dissection, complicating transradial PCI for recanalization of anomalous origin right coronary artery (RCA) from the left coronary cusp with chronic total occlusion. The intimal tear was created by a balloon rupture in the proximal RCA, with propagation of dissection into the ostium and the coronary sinus of Valsalva. Intravascular ultrasound (IVUS) guided coronary stenting was performed to seal the entry port, and to break down the dissection route. This case indicates that IVUS can be a useful tool to ensure complete coverage of the intracoronary dissection and precise placement of the stent to fully cover the ostium of the culprit vessel. This can be particularly important in difficult situations, such as anomalous origin of RCA from the left cusp, with acute downward anterior angulation. © 2011 Wiley Periodicals, Inc.     

Giant organized thrombus in the left sinus of valsalva causing intermittent left coronary obstruction: an unusual case of acute myocardial infarction.

A 48-year-old Japanese man was admitted to hospital for acute myocardial infarction associated with a giant organized thrombus occupying the left sinus of Valsalva. Cardiac catheterization revealed no organic stenosis in either coronary artery, but left ventriculography and aortography showed a filling defect above the left coronary cusp. Transesophageal echocardiography was immediately performed and showed a round mass filling the left sinus of Valsalva. A solid, round mass approximately 2.5 cm in diameter was removed during emergency surgery and determined to be a thrombus on the basis of microscopic findings. This is the second report of a giant organized thrombus occupying the entire left sinus of Valsalva, obstructing the ostium of the left coronary artery intermittently, and leading to acute myocardial infarction.     

Dual catheter technique for the treatment of severe coronary artery perforations

Objectives : To evaluate the outcome of patients with coronary perforations who were treated with the dual catheter approach. Background : Coronary artery perforation is a grave complication of percutaneous coronary intervention (PCI) with high mortality and morbidity. Treating a coronary artery perforation with two catheters through dual access enables a rapid delivery of covered stent or coils to the vessel, without losing control of the perforation site. Methods : We retrospectively reviewed all patients who had a severe coronary perforation during a PCI in our center, and compared outcomes of patients treated with the dual versus the traditional single guiding catheter approach. Results : Between April 2004 and October 2008, 13,466 PCI's were performed in Columbia University – New York Presbyterian Medical Center. There were 33 documented cases of coronary perforations during that period of time (0.245%), among these, 26 were angiographically severe (Ellis type 2 or 3 perforations). Eleven patients were treated acutely with a dual catheter technique whereas the other fifteen patients were treated using a single guiding catheter. In the dual catheter group one patient expired after emergent CABG (9.1%), and four patients underwent emergent paricardiocentesis (36.4%). In patients treated with single catheter, there were three deaths (20%), two surgical explorations (13.3%), eight emergent pericardiocenthesis (53.3%), and one event of severe anoxic brain damage (6.7%). Conclusion : The dual catheter technique is a relatively safe and reproducible approach to treat a PCI induced severe coronary artery perforation, and may improve outcome compared to historical series. © 2010 Wiley‐Liss, Inc.     

应用5F引导导管经桡动脉行冠状动脉介入治疗

目的 评价应用5F引导导管经桡动脉行冠状动脉(冠脉)介入治疗(PCI)的可行性、安全性及优越性，探讨其应用策略。方法 应用5F引导导管经桡动脉对120例患者的166处病变进行PCI，桡动脉穿刺成功后动脉鞘内注入维拉帕米5mg，根据造影显示冠脉起始段和病变近端的情况选择合适引导导管，按常规进行PCI操作；术后立刻拔出鞘管，加压包扎穿刺处，4h后解除加压包扎；术后仅限制患者穿刺侧上肢活动。结果 右冠脉(RC)病变43例中有67．4％应用Judkins RC导管(JR)，32．6％应用Amplatz导管。92例患者的121处左冠脉(LC)病变，66．3％应用Judkins LC导管，18．5％应用EBU导管，15．2％应用Amplatz LC导管。2例静脉旁路病变均应用JR。PCI成功率97％；5处(3％)仅行经皮冠脉成形术未成功；并发症仅有1例(0．8％)桡动脉闭塞，但不影响手部供血。结论 应用5F引导导管经桡动脉行PCI具有可行性，由于导管细软，大大降低冠脉和穿刺部位的并发症，具有很高的安全性和优越性；但操作难度较大，需掌握导管的选用策略，以增加导管的支持力和同轴性，提高成功率。