Percutaneous left main coronary artery stent for acute myocardial ischemia after repaired ALCAPA

Percutaneous coronary artery stent angioplasty is rare in the pediatric population but can be a life‐saving by rapidly reestablishing flow to an obstructed coronary artery. It is a technically challenging and high‐risk procedure in infants and further limited by the need for future surgical intervention. We report of an infant with anomalous left coronary artery from the pulmonary artery who underwent acutely successful surgical reimplantation of the left coronary artery onto the ascending aorta. One month later, she developed acute myocardial ischemia and emergent catheterization diagnosed near‐total occlusion of the left coronary artery. We implanted a 2.5 mm coronary stent in the left main coronary artery with reestablishment of flow. The patient's left ventricular systolic function recovered within 4 weeks and repeat angiography 3 months later showed complete normalization of the entire left coronary artery system. The patient weighed 3 kg and was < 6 weeks of age at the time of stent implantation which to our knowledge is the smallest and youngest reported patient to undergo coronary stent angioplasty. This case supports the feasibility of this procedure in infants as a temporizing solution to hemodynamic instability from myocardial ischemia due to coronary artery stenosis. The left ventricular systolic function remained normal at 7 months after stent placement and the patient was clinically well from a cardiac perspective. © 2014 Wiley Periodicals, Inc.     

An avoidable complication of percutaneous coronary intervention-entrapment of stent and disconnected balloon catheter

During percutaneous coronary intervention, entrapment of catheter materials is a rare but life-threatening complication that sometimes requires emergency surgical treatment. Coronary artery stents have been developed to prevent acute coronary closure and reduce restenosis after coronary angioplasty. The most frequently reported complications of coronary stents are related to stent thrombosis and anticoagulation problems. This case study describes a 60-year-old female who had stable angina pectoris and underwent stent insertion into the left circumflex artery. Unfortunately, the coronary stent with balloon catheter was entrapped while crossing the angulated segment between the left circumflex and left main coronary artery. The stent catheter was surgically removed, and the patient underwent coronary artery bypass grafting successfully. Physicians should keep in mind that extremely angulated segments may reduce the successful rate of coronary stenting and contribute to the stent entrapment complication.     

Longitudinal Stent Compression is Not Always a Bad Event: A Case Report

Ostial left anterior descending artery stent implantation was performed, while trying to cross another stent through the left main coronary artery into the left circumflex artery the stent was detached from the delivery balloon, subsequently jamming the stent of the ostial left anterior descending artery stent. Removing the detached stent was possible, but longitudinal compression of the ostial left anterior descending artery stent occurred. We finally took advantage of the longitudinal compression to advance the equipment into the left circumflex artery with good final result.     

Inadvertent stenting of left main coronary artery complicated by later in-stent restenosis.

Stenting of both the protected and unprotected left main coronary artery has been described. This case presents a patient who had inadvertent left main stent deployment. A 47-year-old female presented with a non-Q-wave infarction and subsequent angina leading to angiography and angioplasty of her proximal ramus intermedius artery. Recurrent angina and ECG changes necessitated repeat coronary angiography and angioplasty on the same day with Wiktor stent deployment to treat a resultant dissection. Poststent deployment pictures revealed that the stent had been partially deployed in the left main coronary artery. Additional balloon dilatations were performed at the ostia of the left anterior descending and circumflex arteries through the stent. Three months later the patient presented with progressive angina and was discovered to have severe distal left main stenosis. In a case such as this, stent removal may be preferable to leaving an unnecessary stent within the left main coronary artery. Cathet. Cardiovasc. Intervent. 48:194-197, 1999.     

冠状动脉内支架置入术在冠心病治疗中的价值

目的 评价冠状动脉内支架置入术在冠心病治疗中的临床应用价值。方法 对157例206支冠状动脉病变内置入203只支架，其中置入左前降支103只，右冠状动脉57只，左回旋支42只，左主干1只。结果 157例全部置入成功。置入后经冠状动脉造影证实狭窄消失，效果良好。其中5例急性心肌梗死患者由于急诊置入支架后，病情迅速缓解。择期冠状动脉支架置入术全部置入成功，无一例发生严重并发症。结论 冠状动脉内支架置入术是治疗冠心病的一种安全可靠、效果良好的介入性治疗方法、有良好的应用价值。     

Failure of Fluoroscopy and Success of Intravascular Ultrasound to Locate an Intracoronary Embolized Palmaz-Schatz Stent

We describe a patient in whom one half (disarticulated) Palmaz-Schatz stent was lost during a failed stenting procedure of an ostial left anterior coronary artery (LAD) stenosis. The embolized stent could not be located by fluoroscopy and was found in the left main coronary artery by intravascular ultrasound. The stent could not be removed using a retrieval device and was successfully deployed in the left main coronary artery by high-pressure balloon dilatation. Subsequently, LAD stenosis was successfully treated with deployment of two additional half Palmaz-Schatz stents.     

冠状动脉左主干病变介入治疗

冠状动脉左主干病变的介入治疗具有挑战性。现从冠状动脉左主干的解剖特点、冠状动脉左主干病变的病因形成、左主干病变的诊断、左主干病变的治疗、左主干病变支架术的适应证和禁忌证、器械选择、治疗策略等进行了详细的阐述。对于存在冠脉旁路移植术禁忌证、拒绝外科治疗或经严格选择的左心功能正常的无保护左主干病变的病人,冠脉支架置入术是一种较理想的治疗方法。     

Ultra Long Stent in an Aberrant Right Coronary Artery

The prevalence of anomalous origin of right coronary artery from the left sinus is about 0.92%. A percutaneous coronary intervention (PCI) in such a vessel is challenging especially when maneuvering long stents. We report a case of 75-year old female patient with recent acute coronary syndrome. The angiogram showed significant lesions in the left anterior descending coronary artery and the left circumflex coronary artery with an aberrant RCA originating from the left sinus close to the origin of LMCA with multiple tight lesions. The aberrant RCA was stented with a 50 mm long stent. To the best of our knowledge, the placement of such a long stent in an aberrant coronary artery has hitherto never been reported in the literature.     

Treatment of rotablation‐induced ostial left circumflex perforation by papyrus covered stent and its fenestration to recover the left anterior descending artery during CHIP procedure

Coronary artery perforation is a rare complication of percutaneous coronary intervention (PCI). Covered stents have been successfully used in these situations. We report a case of ostial left circumflex (LCx) artery perforation during rotablation PCI of left main coronary artery (LMCA) and LCx artery. After failed attempts to balloon tamponade the perforation, a PK Papyrus covered stent was deployed from proximal LCx into LMCA. This resulted in acute exclusion of the left anterior descending (LAD) artery from coronary circulation. Using a dual lumen catheter, a stiff wire was advanced through the side port toward the occluded LAD to fenestrate the membrane of the covered stent. A series of balloons were used to dilate the fenestration in the covered stent to restore a normal flow into the LAD.     

Rescue left main coronary artery stenting for acute myocardial ischemia after coronary angiography in a 7-year-old girl with homozygous familial hypercholesterolemia.

Homozygous familial hypercholesterolemia (HFH), resulting from mutation of the low-density lipoprotein (LDL) receptor gene with subsequent defective catabolism of the LDL cholesterol, leads to premature atherosclerosis and coronary artery disease. We report a successful urgent stent implantation in a 7-year-old patient with HFH and a severe left main coronary artery stenosis, who presented critical acute myocardial ischemia immediately after left coronary angiography. Percutaneous transluminal coronary angiography with stent implantation allowed for rapid coronary flow reestablishment without sequelae. Aggressive lipid-lowering therapy with high doses statins and LDL-apheresis was maintained, together with lifelong antiaggregant acetylsalicylic treatment with good short-term patency of the stent at 1-year follow-up. In conclusion, coronary artery stent implantation may be considered as a valid rescue therapeutic alternative for pediatric patients with HFH and severe ostial coronary stenosis in case of emergency.     

冠状动脉内支架置入术在冠心病治疗中的应用

目的 :评价冠状动脉内支架置入术在冠心病治疗中的临床应用价值。方法 :对 186例 2 0 4支冠状动脉病变内置入 2 2 9只支架 ,其中置入左前降支 12 3只 ,右冠状动脉 73只 ,左回旋支 31只 ,左主干 2只。结果 :186例全部置入成功。置入后经冠状动脉造影证实狭窄消失 ,即刻效果良好。其中 12例急性心肌梗死患者急诊置入支架后 10例病情迅速缓解 ,2例术后死亡 ,死因分别为再次心肌梗死和颅内出血。择期冠状动脉支架置入术无一例死亡。其他并发症为股动脉假性动脉瘤 2例 ,术后低血压反应 9例。结论 :冠状动脉内支架置入术是治疗冠心病的一种安全可靠、效果良好的介入性治疗方法 ,值得临床广泛应用。     

Unprotected left main stent placement in a patient with Takayasu's arteritis: an unusual solution for an unusual disease

We describe the case of a young woman with Takayasu's arteritis that initially manifested as heart failure due to left main coronary artery stenosis. The patient's occluded subclavian artery and the active inflammatory process of Takayasu's arteritis precluded coronary artery bypass grafting with the use of arterial grafts. Therefore, a drug-eluting stent was placed in the unprotected left main artery. This procedure resulted in the resolution of symptoms, with a patent stent and no new coronary lesions observed on 3-month angiography, and normal left ventricular function on 9-month echocardiography. We conclude that the use of drug-eluting stents may be an important treatment option for Takayasu's arteritis patients with life-threatening coronary artery disease for whom coronary artery bypass grafting is not an option.     

药物洗脱支架年代无保护左主干病变血运重建策略的选择

冠状动脉旁路移植术一直被认为是治疗无保护左主干病变的金标准.近年来,由于经皮冠状动脉介入治疗技术及器械的迅速发展,特别是药物洗脱支架的广泛应用,使冠状动脉介入治疗术后由再狭窄导致的再次靶病变血运重建率明显降低,经皮冠状动脉介入治疗无保护左主干病变研究以及和冠状动脉旁路移植术疗效对比研究越来越多,并且显示药物洗脱支架对无保护左主干病变有良好的疗效,其安全性与冠状动脉旁路移植术相似,甚至在某些方面具有优势.现就近年来冠状动脉旁路移植术和冠状动脉介入治疗无保护左主干病变的研究进展做一综述,探讨在药物洗脱支架年代无保护左主干病变治疗策略的选择.     

Very Late Development of Coronary Artery Aneurysm with Total Occlusion following Sirolimus-Eluting Stent Implantation

A 41-year-old African American woman presented with chest pain and was found to have non-ST segment elevation myocardial infarction with a peak cardiac troponin I of 28.5. Elective cardiac catheterization revealed a 70% ostial left anterior descending (LAD) artery stenosis. The patient underwent percutaneous coronary intervention and a sirolimus-eluting stent (Cypher, Miami, FL, 3.5 × 8 mm) was successfully deployed. Three years after stent implantation, the patient presented with recurrent angina. Repeat coronary angiography revealed a large aneurysm involving the proximal portion of the stent with a total occlusion at the mid to distal portion of the stent with collaterals to LAD from left circumflex artery. The patient underwent coronary artery bypass surgery with left internal mammary artery graft to LAD and ligation of LAD at its origin proximal to the aneurysm.     

Should the left main be covered entirely with drug-eluting stents in percutaneous intervention

Restenosis after percutaneous intervention in the left main coronary artery may present as sudden cardiac death. Although drug-eluting stents have demonstrated promising results, there remains the question about appropriate length of the left main artery to be covered with the stent. We describe a patient who received two drug-eluting stents with the balloon crushing technique in the distal left main coronary artery. Three months later, this patient presented with a new lesion in the segment of the left main artery not covered with stent, but instead at the site where the balloon was inflated in the initial procedure.     

Successful long-term therapy following saphenous vein-covered stent deployment for atherosclerotic coronary aneurysm.

We describe a case of atherosclerotic aneurysm involving the left main coronary artery in a patient with prior coronary artery bypass surgery. A saphenous vein-covered stent was used to seal the aneurysm in conjunction with conventional stenting of an associated native vessel coronary stenosis. Focal late restenosis involving the stent graft was successfully treated with repeat angioplasty and brachytherapy. Autologous vein-covered stent deployment should be considered in the treatment of symptomatic or progressively enlarging coronary aneurysms.     

Coronary aneurysm and stent fracture following stenting of a myocardial bridge

Myocardial bridge is the most common congenital coronary anomaly. We represent an extremely rare case of stent fracture combination with coronary aneurysm following stenting of a myocardial bridge. This 60‐years‐old male patient underwent coronary angiography in the local hospital four years ago. Coronary angiography revealed a myocardial bridge in the distal left anterior descending coronary artery (LAD). A 3.0 mm × 29 mm sirolimus eluting stent was deployed in the distal LAD. Three years later, repeat coronary angiography showed a large coronary aneurysm in the mid segment of the stent. The patient subsequently underwent coronary artery bypass grafting with left internal mammary artery (LIMA) to the distal segment of the LAD. But six months later, another coronary angiography showed a stent fracture in mid portion of the stent associated with a large coronary aneurysm, and the LIMA graft was totally occluded. A possible mechanism of stent fracture was long‐standing and cyclic mechanical stress on the stent by myocardium. These forces over a period of time may lead to metal fatigue and eventually fracture. Based on the observation of fracture and aneurysm in this study, we recommend that myocardial bridge should not be treated with intracoronary stenting. © 2015 Wiley Periodicals, Inc.     

Early experience with coronary stenting.

From April 1988 to December 1991, we implanted 75 coronary stents (29 self-expanding and 46 balloon expandable) in 62 patients. All had New York Heart Association class II to IV angina, and 11 (18%) had prior coronary artery bypass grafting (CABG). Thirty nine patients (63%) had 1 vessel disease, and 23 (37%) had multivessel disease. The mean left ventricular ejection fraction was 63 +/- 11%. The indications for coronary stenting were acute post percutaneous transluminal coronary angioplasty (PTCA) occlusion in 45 (73%) (bail out stenting) and restenosis in 17 (24%) (elective stenting). There were 52 single stent (84%), 7 double stent (11%), and 3 triple stent procedures (5%). The mean stent diameter was 3.8 +/- 0.5 mm, and the mean stent length 21 +/- 7 mm. The attempted vessels were the left main coronary artery in 2(3%), left anterior descending coronary artery in 27 (44%), left circumflex coronary artery in 8 (13%), right coronary artery in 17 (27%), and a saphenous vein graft in 8 (13%). Technical success was achieved in 74 stent implantations (98%). Technical failure occurred in 1 case with a self expanding stent because of inability to reach the lesion. In hospital complications (mean hospital stay 10 +/- 10, range 2-60 days) included temporary stent occlusion in 2 patients (3%) treated by balloon dilatation and thrombolysis with intravenous urokinase, permanent stent occlusion in 5 patients (8%), Q-wave infarction in 5 patients (8%), CABG in 4 patients (11%), and death in 3 patients (5%). At least 1 major complication (Q wave infarction, CABG, or death) occurred in 8 patients (13%).(ABSTRACT TRUNCATED AT 250 WORDS)     

无保护左主干病变的药物洗脱支架与冠脉搭桥治疗

无保护左主干病变一直是冠脉搭桥治疗的传统领地。随着经皮冠状动脉介入治疗的迅速发展,尤其是药物洗脱支架广泛应用以来,学者们正在用大量的试验证明应用药物洗脱支架治疗无保护左主干病变的安全性、可行性,比较与冠脉搭桥治疗孰优孰劣。随着技术的发展和器械的更新,药物洗脱支架介入治疗的适应证势必进一步拓宽,但是就目前而言,无保护左主干的介入治疗由于其自身不足,不能完全替代冠脉搭桥治疗。     

13-year result after implantation of intracoronary stent (treatment of progressing atherosclerosis of coronary arteries with the help of endovascular methods)

Clinical case of implantation in anterior interventricular artery (AIA ) of the first coronary stent in Russia is presented. Control angiogram obtained 7 years after stenting showed stent patency without restenosis with maximal 15.68% in-stent stenosis. Angiogram obtained after 13 years revealed good patency of previously stented segment of AIA. However a new stenosis appeared in left main coronary artery as a result of natural progression of atherosclerotic process. A drug eluting stent (Cypher) was implanted into left main coronary artery with good immediate result. This clinical observation demonstrates possibility of maintenance of effect of coronary artery stenting for long period of time as well as possibility of repetitive use of endovascular methods of treatment of ischemic heart disease despite newly developed complex lesions.