Percutaneous transluminal coronary angioplasty of the “very proximal” coronary artery stenosis

We report on 11 patients with “very proximal” lesions out of a total of 300 consecutive patients who underwent percutaneous transluminal coronary angioplasty (PTCA). Eight patients had native left anterior descending (LAD) lesions and three had LAD saphenous vein grafts lesions. Lesions were considered to be “very proximal” when one half or more of the balloon was inflated in the left main coronary artery for the native LAD lesions or the aorta for the LAD coronary artery saphenous vein bypass graft (CABG) lesions. There was a mean reduction in stenosis from 88.3% (range 75–99) to 13.8% (range 0–60) and a mean reduction in transtenotic gradient from 47.2 mmHg (range 20–80) to 8.3 mmHg (range 0–20). The initial success rate was 90.9% (10 out of 11 patients) with a partial success in the other patient. No complications occurred in any of the patients. Two patients had restenosis (18.2%) at 3 months and 6 months, respectively, post-PTCA. It is concluded that “very proximal” lesions can be successfully dilated with a high initial success rate and low complication rate. Nevertheless, these lesions may present problems with guiding catheter stability and, because of the potential risk of circumflex (CX) occlusion, this vessel may have to be protected with a second guidewire.     

Myocardial ischemia in patients with fixed occlusive coronary artery disease secondary to vasospasm in the “normal” vessel

Seven patients with significant fixed occlusive coronary artery disease had coronary artery spasm in a “normal” vessel. All patients had one or more episodes of rest angina and six had exertional angina as well. Four sustained previous myocardial infarction. During spontaneous angina, five patients had ST-segment elevation in the inferior electrocardiographic leads. One patient had ST-segment elevation in anterior leads. During angiography, spasm was demonstrated in the right coronary artery in three patients and in the left anterior descending coronary artery in one patient. This study emphasizes the interaction of fixed and vasospastic disease and has strong implications concerning the management of patients with ischemic heart disease.     

Coronary embolization of the membrane fixing a “multilink” stent to its delivery balloon

We report on a case of coronary embolization of an elastic membrane fixing the ACS RX Multilink stent over its balloon, after a successful stent delivery. The membrane was dislodged from the balloon in the ostium of the right coronary artery as the delivery balloon was being pulled back into the guiding catheter. All attempts to retrieve the membrane, to cover it with another stent, or to push it into a terminal segment of the artery to limit the jeopardized myocardial mass were unsuccessful. No CABG was performed because the left coronary system was normal and the procedure occurred 2 months after an incomplete inferior myocardial infarction. There was no increase in cardiac enzymes nor electrocardiographic signs of a new myocardial infarction at discharge or at 1-mo follow-up. It seems preferable to avoid further use of stents tied to their balloons with an intermediary, and possibly detachable, element. Cathet. Cardiovasc. Diagn. 43:68–70, 1998. © 1998 Wiley-Liss, Inc.     

“Back-squeezing” of the clot: An unusual complication of primary coronary angioplasty

Distal coronary embolism of thrombotic material is quite common in the setting of primary coronary angioplasty for evolving acute myocardial infarction. Embolization to another coronary artery is, however, much more uncommon. We report on a case in which a large thrombus migrated from the proximal left anterior descending artery (LAD) to the proximal left circumflex artery (CX) during inflation of the dilatation balloon. The putative mechanism was retrograde expulsion of the thrombus by the deploying balloon. Cathet. Cardiovasc. Diagn. 42:64–67, 1997. © 1997 Wiley-Liss, Inc.     

Ergonovine provocative testing: Description of a “double catheter technique”

Since coronory arteries should be immediately accessible during ergonovine provocative testing (EPT), a double catheter technique is described. Using the catheter sheath technique from the right and left femoral arteries, right and left Judkins' catheters are introduced into each femoral artery. Selective coronary cineangiography during EPT is thus rapidly performed without the delay of exchanging catheters. Should coronary arterial spasm occur during the test, nitroglycerin can be administered into the coronary artery without delay.     

The “furrowing effect”: Guidewire-induced “directional” lesion ablation in rotational atherectomy of angulated coronary artery lesions

We discuss a guidewire induced asymmetric abiative effect in three cases of rotational atherectomy facilitated angioplasty of angulated coronary artery lesions. © 1996 Wiley-Liss, Inc.     

Percutaneous transluminal coronary angioplasty using a combined “balloon-on-a-wire” system and exchange guidewire technique

New balloon-on-a-wire dilation systems allow crossing of severely stenosed coronary arteries owing to their ultra-low profile. However, these systems do not allow for over-the-wire exchange to a larger balloon catheter or insertion of perfusion catheters, should the vessel close abruptly during dilation. Therefore, if the need for such catheters arises, the vessel must be left unprotected during attempts to recross the lesion. We describe a new technique using a combined balloon-on-a-wire system and an exchangeable guidewire, which permits the crossing and dilation of severely stenosed coronary arteries, while at the same time offering vessel protection and balloon catheter exchange.     

Catheter-induced “accordion effect” in tortuous right external iliac artery during peripheral angiography

Mechanical distortion of tortuous coronary arteries mimicking spasm or dissection during percutaneous transluminal coronary angioplasty due to balloon guidewire systems has previously been reported. This case reports a similar phenomenon in the peripheral vascular system induced by a diagnostic catheter. Recognition of this pseudo lesion may help to avoid complications and unnecessary intervention.     

Angioplasty of recent total coronary occlusions: Cardiac death can occur in “low-risk” cases

Revascularization by angioplasty of total coronary artery occlusions is generally thought to be relatively safe in experienced hands. Although success rates are lower than with diseased but patent vessels, reasonable success can be expected. In this report, different events led to a sudden and fatal outcome in two patients with total coronary occlusions subtending recently infarcted, but still viable, areas of myocardium. The cases and procedural details are presented.     

Double-wire angioplasty of the right coronary artery bifurcational stenosis

Two cases of distal right coronary artery (RCA) bifurcational stenoses involving ostia of the posterolateral (PLA) and the posterior descending (PDA) branches in patients who underwent successful coronary angioplasty using a double-wire technique are reported. A single guiding catheter and sequential balloon inflations were utilized in one, and two guiding catheters and simultaneous balloon inflations in the other. The indications, techniques, and outcomes are described.     

Early and late morphologic changes in human coronary arteries after percutaneous transluminal coronary angioplasty

Certain clinical and morphologic observations are described in 6 men who had percutaneous transluminal coronary angioplasty (PTCA) of the left anterior descending (LAD) or right (R) coronary artery early (4 hours to 7 days) or late (80, 90, and 150 days) before coronary endarterectomy and aortocoronary bypass grafting or death. Histologically, each of the 3 early patients had the site of PTCA narrowed 76–95% in cross-sectional area by atherosclerotic plaque, and each had either coronary dissection or plaque hematoma or both at the site of PTCA. Each of the 3 late patients had a decrease in the mean trans-stenotic coronary gradient (17, 38, and 43 mmHg, respectively) and an angiographic increase in the LAD luminal diameter (55, 60, and 65%, respectively) at the time of PTCA. At necropsy, 80, 90, and 150 days later, the LAD coronary artery in the area of the PTCA in each patient was narrowed 76–95% in cross-sectional area by plaques. No cracks in plaques or other lesions which may have resulted from the PTCA procedure were identified histologically in the LAD coronary artery of any late patient.     

Use of “super‐glue” to seal a perforation during chronic total occlusion coronary intervention and the potential to “unglue” it

Coronary perforation remains a dreaded complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We present a case of successful CTO recanalization complicated by a perforation treated by n‐butyl‐cyanoacrylate (medical “super‐glue”). We also present an in vitro experiment showing that a glue plug in a plastic tube can acutely be passed by a low tip load guide wire and undergo balloon angioplasty recreating a lumen. These results suggest that n‐butyl‐cyanoacrylate glue may be an alternative for treating perforation during CTO PCI with the possibility of recanalizing the vessel through the glue plug at a later time.     

Anomalous “High Take‐Off” of the right coronary artery evaluated by coronary CT angiography

Congenital coronary anomalies are uncommon but can cause sudden cardiac death or myocardial ischemia. Conventional coronary angiography is an invasive and expensive modality, sometimes unable to delineate the exact origin and course of an anomalous artery. In this case report, we describe an “extremely rare” anomaly of the right coronary artery where a 64‐slice multidetector computed tomography provided valuable information regarding its exact site of the aortocoronary take‐off and its spatial relationship with the great vessels. Knowledge of CT appearances and an understanding of the clinical significance of these anomalies are essential for making the correct diagnosis and planning patient treatment. © 2010 Wiley Periodicals, Inc.     

The “Concorde” stent: A novel use of a stiff bent guidewire to facilitate stent deployment

A patient was referred for treatment of a partially deployed Palmaz-Schatz coronary stent placed in the left anterior descending (LAD) coronary artery. After crossing the stent with a guidewire, the stent was optimally dilated with a high-pressure balloon. Several novel methods used to achieve success are discussed, along with suggestions on how to avoid common problems. Cathet. Cardiovasc. Diagn. 40:277–280, 1997. © 1997 Wiley-Liss, Inc.     

“Woven” Right coronary artery: Case report and therapeutic implications

We report an unusual anomaly of the right coronary artery consisting of proximal branching of the artery and subsequent interweaving of the branches, referred to as a “woven” coronary artery. Implications and differential diagnosis are discussed.     

Percutaneous revascularization of the “unprotected” left main during acute myocardial infarction: “Dare to struggle! Dare to Win!”

Knowing the location of the vertebral and the internal mammary artery ostia is crucial during proximal subclavian artery percutaneous intervention to prevent inadvertent injury to either artery. We report a case of severe proximal left subclavian artery stenosis in a patient with a three‐vessel disease referred to coronary artery bypass graft surgery. Retrograde angiography via left radial access allowed visualization of the left internal mammary artery and the left vertebral artery ostia and placement of a Filterwire in the left vertebral artery. The proximal left subclavian artery was successfully stented without complications. Debris was retrieved in the Filterwire. © 2009 Wiley‐Liss, Inc.     

Lesion protection during fixed-wire balloon angioplasty: Use of the “buddy wire” technique and access catheters

Fixed-wire (FW) coronary angioplasty procedures have gained widespread acceptance in some institutions as a primary choice for all angioplasty procedures. These single-lumen, low-profile devices provide distinct advantages as compared to over-the-wire systems in certain circumstances. However, they have not allowed for lesion protection or guidewire access if the situation arises. Two techniques are available to provide lesion protection during FW coronary angioplasty. They are the buddy wire technique and the use of subselective intracoronary access catheters. Access catheters can be used as primary, pre-loaded devices or as secondary devices to be used over an extended FW balloon catheter. These techniques can widen the applications of FW balloon angioplasty.     

Percutaneous coronary intervention in TAVI: The “proboscis” catheter

We report a case of an 81‐years‐old male, recently implanted with a Core Valve (CV) prosthesis and admitted to the ER for acute coronary syndrome. Coronary angiography revealed the patency of the coronary artery by‐pass grafts but was impossible to cannulate the left main “imprisoned” by the CV prosthesis struts. Aortography showed an excessive gap between the CV struts and the coronary ostium. To cross the CV struts, we developed a “proboscis” catheter by cutting away the proximal end of the 7F JL 4 catheter and putting inside the 5F Heartrail catheter. The following angiograms showed a critical stenosis in the proximal obtuse marginal (branch), successfully treated with a bare‐metal stent implantation. © 2012 Wiley Periodicals, Inc.