Treatment for LMCA ostial stenosis using a bifurcation technique with a retrograde approach

A 69‐year‐old man who underwent coronary artery bypass surgery in February 2008. The surgery included grafting of the left internal thoracic artery (LITA) to the diagonal branch (D1) and a saphenous vein graft (SVG) to the left circumflex artery (LCX) due to ostial stenosis of the left main coronary artery (LMCA). The patient presented with recurring effort chest pain 18 months later. Coronary CT revealed that the LITA‐D1 graft was patent, the SVG‐LCX graft was occluded, and there was severe ostial stenosis of the LMCA. Coronary angiography was performed in August 2009, but a 5‐Fr diagnostic catheter could not be engaged due to the severe ostial stenosis. Percutaneous coronary intervention (PCI) was performed 5 days later with an attempt to cross the lesion with a guidewire using a retrograde approach through the LITA‐D1 graft. However, the guidewire could not be crossed using a conventional technique due to the extreme angulation of the LITA‐D1 anastomosis. Therefore, we attempted to use a reversed guidewire technique. After crossing the LMCA ostial lesion the retrograde wire was snared through antegradely for insertion of the guiding catheter via the right brachial artery. We were able to engage the guiding catheter in the left coronary artery and implant the stent successfully using the antegrade approach. © 2009 Wiley‐Liss, Inc.     

Percutaneous coronary intervention using a virtual 3‐Fr guiding catheter

Background : We have recently reported a novel percutaneous coronary intervention (PCI) system using a hydrophilic‐coated sheathless guiding catheter (Virtual 3‐Fr, Medikit, Tokyo, Japan), which provides us with less invasive angioplasty and a puncture site injury equivalent to a conventional 3‐Fr introducer sheath. Here, we report the initial results of PCI using this novel system. Methods : A total of 36 coronary artery lesions of 27 patients were treated by using a virtual 3‐Fr PCI system. Procedural outcomes of virtual 3‐Fr PCI were retrospectively evaluated. Results : The mean age was 73.0 ± 8.7 years (range, 46–84 years), and 15 were men (56%). Access sites included the radial artery in 18 patients (67%), the brachial artery in eight patients (30%), and the femoral artery in 1 patients (4%). Among 36 lesions, seven were chronic total occlusions, and a virtual 3‐Fr PCI was successful in 33 lesions (92%). Among the successfully treated 33 lesions, coronary stents were deployed in 32 (97%), and intravascular ultrasound examination was performed in 19 (58%). Hemostasis was achieved immediately after PCIs in all cases. No access‐site related complications including radial artery occlusion were observed. Conclusions : The performance of a virtual 3‐Fr PCI system appears to be comparable to one using a regular 5‐Fr guiding catheter while the puncture‐site damage remains equivalent to that of a 3‐Fr introducer sheath. Virtual 3‐Fr PCI may have a potential to serve as a minimally invasive strategy for the treatment of coronary artery diseases. © 2010 Wiley‐Liss, Inc.     

Buddy‐wire technique during rotational Atherectomy: Simple and effective solution to achieve strong back‐up support

A 52‐year‐old male underwent percutaneous coronary intervention (PCI) using rotational atherectomy (RA: 1.5‐mm burr) for a severely calcified lesion in the proximal to mid obtuse marginal (OM) branch. Even with 7 Fr extra back‐up guiding catheter via femoral access, the burr could not cross the lesion due to insufficient back‐up support. In order to achieve stronger back‐up support, we kept the burr at the position in the OM branch and placed a supportive wire in left anterior descending artery through the side of drive‐shaft sheath of the Rotablator, which sufficiently stabilized the guiding catheter during the ablation and the burr crossed the lesion. This case demonstrates that a simple technique of placing additional supportive wire in the other vessel during RA could be an effective and safe solution to facilitate improved back‐up support without necessity to change the PCI system used already.     

Potential risk of provisional stenting in left main coronary artery bifurcation in multivessel‐related acute coronary syndrome

We present a case of an elderly man suffering from an acute coronary syndrome (ACS) with preshock vital signs and remarkable ST–T wave depression in leads V4–V6, and ST elevation in lead aVR. Coronary angiography showed total occlusion of the right coronary artery (RCA) and impending occlusion in the distal left main coronary artery (LMCA) with a tandem lesion in the proximal left anterior descending artery (LAD). After insertion of an intra‐aortic balloon pump both the LAD and left circumflex artery (LCX) were dilated alternatively; and cross‐over stenting in the LMCA bifurcation was subsequently performed. However, total occlusion of the LCX occurred and it caused acute hemodynamic collapse and ventricular fibrillation storm. Immediate installation of percutaneous cardio‐pulmonary support system allowed stent deployment to be performed in the RCA and subsequent reopening of the LCX that led to a return to sinus rhythm. The patient recovered almost normal left ventricular wall motion and previous activity without any neurological deficit within 2 weeks. Provisional stenting in ACS in the LMCA bifurcation with multivessel disease has a potential risk of acute hemodynamic collapse; a planned two‐stent deployment strategy may assure a higher rate of safety in such cases. © 2011 Wiley‐Liss, Inc.     

Balloon assessment of patent foramen ovale morphology and the modification of tunnels using a balloon detunnelisation technique

Background: Percutaneous coronary intervention (PCI) using a guiding catheter with small diameters may have a favorable impact on vascular access complications and patient morbidity. Here, we report the initial results of PCI using a 4‐Fr coronary accessor. Methods: A total of 31 patients underwent 4‐Fr PCI. Exclusion criteria for 4‐Fr PCI were (1) lesions associated with large side branches requiring wire protection or kissing balloon technique and (2) planned use of angioplasty devices which were not compatible with 4‐Fr catheter. Results: A total of 36 lesions, including 4 chronic total occlusions (CTO), were treated. Access sites included radial artery in 19 patients (61%), brachial artery in 8 (26%), and femoral artery in 4 (13%). Four‐Fr PCI was successful in 34 of 36 lesions (94%) in 29 of 31 patients (94%). One of the two unsuccessful patients was a case of CTO, and the other a case of tortuous right coronary artery. In both, crossover to a 6‐Fr PCI was necessary. Among successfully treated 34 lesions of the 29 patients, coronary stents were deployed in 30 lesions (88%). There were no stent dislodgements or inadequate contrast opacification. No access‐site related complications including radial artery occlusion were observed. Conclusions: PCI with a 4‐Fr coronary accessor is a viable alternative to the use of larger guide catheters. The advent of 4‐Fr stent delivery system may afford a less invasive approach for the treatment of patients with coronary artery disease. © 2008 Wiley‐Liss, Inc.     

Intra‐aortic balloon pump insertion through the right subclavian artery in a patient of anterior wall myocardial infarction with ventricular septal rupture and severe peripheral artery obstruction disease

Intra‐aortic balloon pump (IABP) is used in cardiogenic shock of different etiologies. Routinely, it is inserted through the transfemoral access, but in the patients with severe peripheral artery obstruction disease (PAOD), use of alternative approach is needed. In this case report, IABP insertion through the right subclavian artery with the help of cardiothoracic surgeon in a patient of anterior wall myocardial infarction (AWMI) with severe PAOD has been described. A 60‐years‐old male patient, with the history of chronic smoking, presented with progressing chest pain for last 3 days. On the basis of clinical examination and radiological findings, he was diagnosed with AWMI along with the ventricular septal rupture and PAOD. The patient was advised to undergo coronary artery bypass graft with VSR repair, but to stabilize the patient, it was necessary to put him on IABP. Because of the severe PAOD, femoral access was not suitable to insert the IABP, and hence, the right subclavian route was accessed. Then, the patient was operated and no other complications were encountered. Subclavian arterial IABP insertion under local anesthesia is easier and safer to perform and allows increased patient mobility. Other routes, such as, ascending aorta and axillary artery have also been discussed in other literatures, but subclavian arterial IABP insertion was found to be the best in the patients with severe PAOD. Trans‐subclavian route is an effective approach in extended IABP utilization even in patients with severe PAOD. © 2014 Wiley Periodicals, Inc.     

Transbrachial intra-aortic balloon pumping for a patient with fulminant myocarditis

A 57-year-old man with acute myocarditis was transferred to our hospital from a local clinic. The patient experienced unexpected sudden cardiac arrest 16 h after admission. Mechanical cardiopulmonary support was started using percutaneous cardiopulmonary support, intra-aortic balloon pumping (IABP), continuous hemodialysis filtration, and temporary cardiac pacing with percutaneous cannulation of the femoral vessels. Hematoma developed at the IABP insertion site on the 5th day after admission. The IABP was removed, and another IABP system was inserted via the left brachial artery. The patient’s condition improved, and the IABP was removed on the 9th day after admission. The remainder of the patient’s in-hospital treatment was uneventful, and he showed near-normal left ventricular systolic function 1 year after discharge.     

Dual wire technique for aortic coarctation stent placement

A young adult presented for percutaneous treatment of a narrow aortic coarctation. A very large left subclavian artery originated immediately proximal to the coarctation. In order not to exclude or jail the left subclavian artery with a stent, a double wire technique was used. From a femoral approach, two guide wires were positioned, one in the aortic arch and another in the subclavian artery. A stent crimped over a 16‐mm balloon and a 4‐Fr catheter was advanced over the two wires within a 14‐Fr long introducer sheath. The stent was successfully deployed and molded within the bifurcation by a kissing balloon technique, relieving the obstruction and leaving a guaranteed passage to the subclavian artery. The double wire technique is an elegant way to deliver a stent safely across a narrowing with guaranteed access to important side branches. © 2011 Wiley‐Liss, Inc.     

Use of intraaortic balloon counter pulsation in a patient with tortuous aorta

The intraaortic balloon pulsation (IABP) catheter is commonly used to treat left ventricular failure. The abnormality of the descending thoracic and abdominal aorta is considered as a relative contraindication for its insertion. We present here a patient with acute myocardial infarction with a post-infarct ventricular septal defect who presented with left ventricular failure. During coronary angiography, tortuous abdominal aorta was noted and IABP catheter was inserted under fluoroscopic guidance to support the cardiovascular system. This case is reported to encourage discussion on the use of IABP catheters in patients with tortuous aorta and avoidance of events described.     

Left‐to‐right shunt reduction with intra‐aortic balloon pump in postmyocardial infarction ventricular septal defect

This case aims to describe the hemodynamic effects of intra‐aortic balloon pump (IABP) in patients with ventricular septal defect (VSD) complicating myocardial infarction (MI). A 79‐year‐old man with no previous cardiovascular history presented to the emergency department with subacute inferior myocardial infarction associated with mild signs of systemic hypoperfusion. A transthoracic echocardiography revealed a large akinesia of the left ventricular inferior wall with preserved global left ventricular ejection fraction, as well as a large VSD in the midinferior portion of the interventricular septum. Coronary angiography showed an occlusion of the mid portion of a dominant circumflex coronary artery. The invasive hemodynamic evaluation showed a sizable left‐to‐right shunt (Q_p/Q_s = 3.1). Activation of the IABP led to an immediate reduction of the shunt (Q_p/Q_s = 2.4 = 22% reduction), an increase in systemic cardiac output (from 2.1 L/min to 2.4 L/min = +12%) and a decrease in the systemic vascular resistances (from 2240 to 1920 dyne‐sec/cm⁵ = 15% reduction). In patients with post‐MI VSD, placement of IABP leads to an immediate reduction in left‐to‐right shunt and as a consequence to an increase in systemic cardiac output, which may allow hemodynamic stabilization of the patient prior to surgical VSD closure. © 2012 Wiley Periodicals, Inc.     

Contralateral Iliac Occlusion can be Successfully Achieved Using an Amplatz Vascular Plug During Aorto-uni-iliac Endovascular Aneurysm Repair

IntroductionAorto-uni-iliac endovascular aneurysm repair is usually accompanied by contralateral iliac occlusion, but access limitations may make plug deployment impossible.ReportA 73-year-old male underwent aorto-uni-iliac endovascular aneurysm repair via left femoral access for a 5.8 cm abdominal aortic aneurysm; the right common iliac artery was occluded by a 16 mm Amplatz Vascular Plug II via a 7Fr Flexor Ansel Sheath, followed by femorofemoral crossover. The aneurysm was successfully excluded with no endoleaks at follow-up.DiscussionAccess limitations are a consideration for both device deployment and contralateral occlusion whilst undertaking aorto-uni-iliac endovascular aneurysm repair. This paper describes a simple and effective method for achieving iliac occlusion when access vessels are stenosed.     

一种穿刺置管新方法在ECMO联合IABP介入治疗复杂高危冠心病中的应用

目的 评估应用同侧股动脉置入主动脉内球囊反搏（IABP）和大直径经皮冠状动脉介入（PCI）治疗指引导管,联合对侧股动脉与股静脉用于置入体外膜肺氧合（ECMO）的穿刺策略,观察该置管方式对于复杂高危冠心病患者（CHIP）完成PCI手术的安全性和可行性。 方法 共纳入7例患者,左侧股动脉与股静脉置入ECMO鞘管（动脉置管直径15F,静脉置管直径17F）,右侧股浅动脉置入IABP（均为7F动脉鞘管）,右侧股总动脉置入PCI股动脉鞘管（均为7F动脉鞘管）,ECMO动脉及静脉穿刺处采用预置ProGlide血管缝合器止血,PCI和IABP股动脉穿刺处应用Angioseal血管封堵器止血。术后针对股动脉、股静脉穿刺部位进行临床症状与体征评估,并全部进行血管超声检查,观察该穿刺置管的成功率以及完成PCI手术的可行性,观察住院期间穿刺部位相关的并发症发生率。 结果 7例患者中,男性6例,女性1例,年龄（57±12）岁,合并高血压5例（71%）、糖尿病3例（43%）、慢性肾病1例（14%）、高脂血症4例（57%）、卒中1例（14%）、外周血管疾病4例（57%）。双侧股动脉,左侧股静脉穿刺成功率100%,PCI手术完成率100%。仅一例患者术后超声检查发现股浅动脉穿刺部位发生皮下小血肿,所有患者住院期间均未观察到严重血管并发症。 结论 在CHIP患者中,当需要ECMO联合IABP维持血流动力学稳定,并需要穿刺股动脉置入大直径指引导管完成复杂PCI手术的情况下,可采用同侧股浅动脉置入IABP,股总动脉置入大直径（7F）PCI动脉鞘管,对侧股动脉、股静脉置入ECMO的手术穿刺策略,该方法安全可行。     

Transfemoral endografting of thoracic aortic aneurysm under local anesthesia: a simple, safe and fast track procedure.

BACKGROUND: Endovascular aneurysm grafting of the descending thoracic aorta is a minimally invasive catheter technique, which is performed under general anesthesia. We describe a technique allowing to perform transfemoral endovascular repair of thoracic aortic repair under local anesthesia. PATIENTS AND METHODS: In 9 consecutive patients local anesthesia was performed in order to gain an opened femoral artery access for the delivery system, and a percutaneous access to the left brachial artery. A pigtail catheter was then placed through the left brachial artery for the location of the origin of the left subclavian artery and/or the aneurysm and self-expanding endoprosthesis was released under fluoroscopic guidance. For the deployment of the endograft a short period of controlled hypotension with nitroglycerin bolus application was produced. RESULTS: All the aneurysms could be successfully sealed with the intended endovascular technique. There was no vascular access complication or pulmonary or ischemic (cardiac, cerebral or peripheral) complication. In the follow-up period of 6 +/- 3 months one patient needed a redo endovascular procedure because of the development of a severe and symptomatic distal endoleak 6 weeks postoperative. This procedure was again performed under local anesthesia. CONCLUSIONS: From a technical point of view, transfemoral endovascular repair of thoracic aneurysm can be performed under local anesthesia. This is a very simple and fast track procedure which combines a minimally invasive catheter technique and a less invasive anesthetic management.     

New endovascular technique for thrombus in the non‐stenting zone—the Grab a Clot and Hold ON “(GACHON) technique”: Case report

It is difficult to treat a thrombotic embolism in the common femoral artery or popliteal artery (POP A), i.e., the non‐stenting zone. We report a new technique for the treatment of thrombotic embolism in the non‐stenting zone using a self‐expandable nitinol stent. Case 1 had an external iliac artery (EIA) occlusion that occurred over several months. A self‐expandable nitinol stent was placed in the right EIA lesion via a retrograde approach using a distal 9‐Fr balloon protection guide catheter in the right femoral artery. A thrombotic embolism occurred at the balloon protection site. It was too big to be removed using an aspiration catheter; therefore, we attempted removal with a self‐expandable stent. Using a crossover approach, we delivered a nitinol self‐expandable stent to the distal site of the thrombus, opened the tip of the stent, and pulled it up to the proximal site. Finally, we “grabbed a clot,” moved it to the stenting zone, and “held on” the vessel wall without occurrence of a distal embolism. We named this the “GACHON technique.” Case 2 underwent endovascular therapy for an acute thrombotic embolism in POP A after thoracic endovascular aortic repair for dissection. This thrombus was too big to aspirate, and we successfully treated it using the “GACHON technique.” The “GACHON technique” may be considered as a choice of treatment for a thrombotic embolism in the non‐stenting zone. © 2016 Wiley Periodicals, Inc.     

Incidence and predictors of large‐artery complication (aortic aneurysm,aortic dissection,and/or large‐artery stenosis) in patients with giant cell arteritis: A population‐based study over 50 years

Objective

To determine the incidence and predictors of large‐artery complication (aortic aneurysm, aortic dissection, and/or large‐artery stenosis) in patients with giant cell arteritis (GCA).

Methods

The cohort of all residents of Olmsted County, Minnesota, in whom GCA was diagnosed between January 1, 1950, and December 31, 1999, was followed up. The incidence of aortic aneurysm, aortic dissection, and large‐artery stenosis was determined. Possible predictors and correlates of large‐artery complication were assessed.

Results

Forty‐six incident cases of large‐artery complication (representing 27% of the 168 patients in the cohort) were identified. These included 30 incident cases (18%) of aortic aneurysm and/or aortic dissection. Of these cases, 18 (11%) involved the thoracic aorta, with aortic dissection developing in 9 (5%). There were 21 incident cases (13%) of large‐artery stenosis. Fifteen patients (9%) had incident cervical artery stenosis, and 6 (4%) had incident subclavian/axillary/brachial artery stenosis. One patient (0.6%) had incident iliac/femoral artery stenosis attributable to GCA. Hyperlipidemia and coronary artery disease were associated with aortic aneurysm and/or dissection (P < 0.05 for both). Cranial symptoms (headache, scalp tenderness, abnormal temporal arteries) were negatively associated with large‐artery stenosis (hazard ratio [HR] 0.10 [95% confidence interval (95% CI) 0.03–0.35, P < 0.0005]), as was a higher erythrocyte sedimentation rate (HR 0.80 [95% CI 0.67–0.95, P < 0.05] per 10 mm/hour).

Conclusion

Large‐artery complication is common in GCA. Increased awareness of large‐artery complication in GCA, particularly early‐occurring aortic dissection, may decrease associated mortality.

     

Fatal ischemic stroke related to nonpermissive peripheral artery access for percutaneous aortic valve replacement.

This report describes an 85 year-old man who underwent percutaneous aortic valve replacement (PAVR). With a logistic euroSCORE of 37%, the patient had been refused surgical aortic valve replacement because of an unacceptably high peri-operative risk. During the PAVR procedure, severe resistance was encountered when advancing the 21 Fr delivery catheter through the left iliac artery despite pre-dilatation with a 7 mm balloon. Following this, PAVR was promptly achieved without difficulty, with excellent valve positioning, no peri-valvular leak and good hemodynamics. However, transesophageal echocardiography revealed a mobile echogenic mass within the outflow tract of the left ventricle. The mass was retrieved with a cardiac bioptome manipulated via the left femoral artery through a 9 Fr sheath. A right cerebral ischemic stroke manifested shortly after the post-procedure and the patient died on the fourth post-operative day. Post-mortem findings revealed a left subclavian artery occlusion by iliac vascular tissue. This report highlights the imperative for device-specific vascular access screening criteria and the need to minimize device size in order to safely accomplish PAVR.     

A first‐in‐man study of the reitan catheter pump for circulatory support in patients undergoing high‐risk percutaneous coronary intervention

Objectives : To investigate the safety of a novel percutaneous circulatory support device during high‐risk percutaneous coronary intervention (PCI). Background : The Reitan catheter pump (RCP) consists of a catheter‐mounted pump‐head with a foldable propeller and surrounding cage. Positioned in the descending aorta the pump creates a pressure gradient, reducing afterload and enhancing organ perfusion. Methods : Ten consecutive patients requiring circulatory support underwent PCI; mean age 71 ± 9; LVEF 34% ± 11%; jeopardy score 8 ± 2.3. The RCP was inserted via the femoral artery. Hemostasis was achieved using Perclose? sutures. PCI was performed via the radial artery. Outcomes included in‐hospital death, MI, stroke, and vascular injury. Hemoglobin (Hb), free plasma Hb (fHb), platelets, and creatinine (cre) were measured pre PCI and post RCP removal. Results : The pump was inserted and operated successfully in 9/10 cases (median 79 min). Propeller rotation at 10,444 ± 1,424 rpm maintained an aortic gradient of 9.8 ± 2 mm Hg. Although fHb increased, there was no significant hemolysis (4.7 ± 2.4 mg/dl pre vs. 11.9 ± 10.5 post, P = 0.04, reference 20 mg/dl). Platelets were unchanged (pre 257 ± 74 × 10⁹ vs. 245 ± 63, P = NS). Renal function improved (cre pre 110 ± 27 μmol/l vs. 99 ± 28, P = 0.004). The RCP was not used in one patient following femoral introducer sheath related aortic dissection. All PCI procedures were successful with no deaths or strokes, one MI, and no vascular complications following pump removal. Conclusions : The RCP can be used safely in high‐risk PCI patients. This device may be an alternative to other percutaneous systems when substantial cardiac support is needed. © 2009 Wiley‐Liss, Inc.     

Brachial artery catheterization via cutdown and a direct needle puncture

Brachial artery catheterization via cutdown and a direct needle puncture was evaluated in 369 patients undergoing arteriography at the authors' medical center from January, 1970, to March, 1988. The indications for retrograde brachial arteriography were absence of palpable femoral pulses, failure of a femoral approach, previous aortic bypass surgery, and/or aneurysms of the abdominal aorta. The technique and results are described. Two patients lost their radial pulse; 1 of them had thrombectomy and, one year later, developed an aneurysm at the site of the needle puncture. The authors conclude that catheterization of the brachial artery through direct needle puncture is a safe procedure with good results.     

Transseptal and retrograde left ventricular catheterization in patients with the stent-mounted porcine xenograft valve prosthesis in the aortic position

Cardiac catheterization techniques for measuring the systolic pressure gradient across the stent-mounted porcine xenograft in the aortic position and accomplishing left ventriculography are described. The transseptal technique is a rapid and predictable means of entering the left ventricle but requires a highly skilled operator. Retrograde left ventricular catheterization via the femoral artery is a technique familiar to all invasive cardiologists. Usually a pitfall catheter is used. In patients with the stent-mounted procine xenograft in the aortic position, we have found the A2 Multipurpose catheter to be the fastest and most predictable means of entering the left ventricle from the groin. Potential complications of retrograde left ventricular catheterization in patients with aortic valve prostheses are discussed.     

A safe,rapid method of transfemoral retrograde left ventricular catheterization in valvular aortic stenosis

We report our experience with the use of a standard left Amplatz coronary catheter and a guidewire to cross the aortic valve in 34 patients being evaluated for valvular aortic stenosis. A number 2 Amplatz left coronary catheter inserted via the femoral artery was positioned above the noncoronary aortic valve cusp with the tip aligned toward the aortic valve. This catheter allowed a soft-tipped, Teflon-coated guidewire to be guided through the aortic valve orifice. The catheter was then advanced over the guidewire into the left ventricle. This technique was successful within six minutes in 32 of 34 patients (94%). The stenotic aortic valve was crossed in less than two minutes in 15 patients (42%) and in less than four minutes in 31 (91%). The aortic valve was not crossed in two patients. Twenty-one patients (62%) had an aortic valve area area of less than 0.75 cm². There were no complications. We conclude that this technique provides a method for safe, rapid transaortic left ventricular catheterization in patients with aortic stenosis of all degrees of severity.