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.     

Modified “T” stenting: A technique for kissing stents in bifurcational coronary lesion

The kissing stenting using a new technique in two patients is reported. A stent was positioned at the ostium of the side branch. Another stent was advanced into the main vessel until the center of the stent was positioned near the origin of the side branch. The stent at the ostium of the side branch was deployed and the balloon and the guidewire were removed from the side branch. Thereafter, the stent in the main vessel was deployed. The follow-up angiogram of those patients showed no restenosis in both the vessels. Cathet. Cardiovasc. Diagn. 43:323–326, 1998. © 1998 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.     

Probe "balloon on a wire" ultra-low-profile coronary catheter: results of PTCA in 107 patients

A new low-profile "balloon-on-a-wire" angioplasty catheter, the Probe (USCI), was used in 107 patients over a 4-month period. Twenty-nine patients had stable angina, 59 had unstable angina, and 19 had had myocardial infarction (MI) 3 to 15 days prior to the procedure; 71 patients had single-vessel and 36 had multi-vessel disease. In this series, 57 lesions were defined as complex. Successful dilatation was defined as a residual stenosis of less than 30%. Of 132 non-total obstructions, 127 (97%) were successfully dilated. Two distal lesions could not be reached, two lesions could not be crossed by the balloon, and a distal lesion dilatation resulted in acute closure in one case. Of 19 total obstructions, 16 (84%) were successfully dilated (mean residual stenosis 23%). The wire tip was unable to cross the lesion in the three unsuccessful procedures. Seven complications occurred in the series, all involving non-total obstructions: closure of a distal vessel and a side branch caused no clinical symptoms or EKG changes; three local dissections were tacked back with repeat dilatation; and two longitudinal dissections caused no apparent reduction in luminal diameter. The Probe's low-profile and exceptional trackability enabled it to cross very tight lesions with minimal trauma to the vessel wall. The high degree of conformability of the PET balloon minimizes vessel straightening or sheer forces and appears to reduce the potential for dissection. The device may therefore extend the indications and ease of PTCA while reducing complications of the procedure.     

Double loop guiding catheter: A primary catheter for angioplasty of the right coronary artery

Double loop guiding catheters have been used for percutaneous transluminal coronary angioplasty (PTCA) of the right coronary artery (RCA) in 42 consecutive cases. A catheter with a 90- degree primary curve was used when the proximal RCA had horizontal or inferior orientation. When the proximal segment of the RCA was oriented superiorly (shepherd's crook), the catheter with a 75-degree primary curve was used. Catheters were fabricated with short (1.5 cm) or long (2.3 cm) (USCI, C.R. Bard, Inc., Billerica, MA) distal tips. Short-tip catheters were satisfactory in the majority of cases. When the RCA had a complex course and more backup was necessary or when the ascending aorta was wide, long-tip catheters were found to be the best choice. Angioplasty of 49 lesions was attempted in 42 consecutive patients. In 39 patients successful dilatation was achieved (93%). In three patients the procedure was unsuccessful. In one patient, the lesion could not be crossed with the guidewire despite an excellent backup. In another patient, two of three stenoses were dilated successfully; the distal lesion was crossed with a guidewire but could not be crossed with the balloon catheter in spite of a good backup. The lack of a satisfactory engagement and inadequate backup were responsible for the failure in only one patient. There were no complications related to these guiding catheters. We conclude that double loop guiding catheters are safe and can be the primary choice in all right coronary angioplasties. These catheters provide an excellent backup with consequent high success rate.     

Trifurcation triple balloon angioplasty in a dual left anterior descending coronary artery: The “Ménage à trois” revisited

We describe a case of simultaneous triple balloon angioplasty of a trifurcation stenosis in a dual left anterior descending coronary artery variant using over-the-wire and monorail balloon catheters and a single guide catheter. © 1996 Wiley-Liss, Inc.     

Initial experience with a new balloon-on-a-wire catheter: The bijouTM

This paper presents our initial experience with a new low-profile balloon “on-a-wire” catheter, the Bijou. The concept of this balloon is to provide an additional side lumen with the advantages of (1) the ability to measure pressure gradient, (2) the possibility of drug infusion, and (3) the ability to advance a steerable guidewire through this side lumen. The balloon has been tested in 15 patients; 14 underwent an elective procedure for stable angina pectoris (with 2 cases of restenosis) and one an emergency angioplasty in a case of acute myocardial infarction. The stenosis was located on the left anterior descending artery in 11 procedures, on the right in 3, on a marginal branch in 2, on the circumflex and a saphenous vein graft in 1. All stenoses could be dilated successfully (residual stenosis <25%). The transstenotic pressure gradient felt from 49±13 mmHg to 7±4 mm Hg after angioplasty. Except for an uncomplicated dissection in 3 patients, no other complication was noted. With this new catheter, the double-lumen configuration adds the advantages of an “over-the-wire” to an “on-a-wire” system. © 1993 Wiley-Liss, Inc.     

PTCA of “shepherd's crook” right coronary arteries with a new shape of guiding catheter

Percutaneous transluminal coronary angioplasty (PTCA) of lesions in a right coronary artery with a “shepherd's crook” configuration may pose procedural difficulties due to inadequate guiding catheter back-up support. We evaluated the utility of a new shape of guiding catheter, previously evaluated for PTCA of lesions in the left coronary artery, in five cases with this particular right coronary artery anatomy. Factors responsible for success in these cases relate to the catheter's shape and construction.     

Repeat percutaneous coronary revascularization: Indications and outcomes in a “Real World” cohort

Objectives : To investigate rates of and reasons for second and subsequent stent procedures in an unselected, “real‐world” population. Background : Repeat stenting is the primary difference reported in clinical trials of alternative revascularization strategies. The incidence, indication, and outcome for repeat stenting in contemporary practice outside the more selective populations of trials and registries has not been described. Method : All patients undergoing a first percutaneous coronary intervention (PCI) procedure with stenting from January 2001 to August 2009 (10,509) from a large UK tertiary referral and district general hospital were identified. Mortality and the incidence, timing, and indication for repeat revascularization in this population were investigated from patient records. Results : Of 10,509 patients undergoing a first PCI and stent implant 23.5% underwent repeat angiography of which 11.2% required repeat PCI and 2% coronary artery bypass grafting (median follow‐up of 3.8 years). A total of 1.3% went on to a third PCI. The commonest indication for repeat stenting was disease progression remote from the original stent (46%) and planned staged PCI (23%); 21% had a stent‐related indication. Functional assessment before repeat stenting was used in one‐third of stable patients. Mortality was 2.5% per annum. Conclusions : In contemporary practice, patients undergoing a first stenting procedure have a low subsequent mortality, and the substantial majority (86.4%) requires no further revascularization over a median 3.8 year follow‐up. For those who do require repeat stenting, this is most commonly at a site remote from the first stent. © 2012 Wiley Periodicals, Inc.     

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.     

Transradial coronary intervention using a novel 5‐Fr sheathless guiding catheter

We have recently developed a 5‐Fr sheathless guiding catheter system (Virtual 3‐Fr, Medikit, Japan), composed of a hydrophilic catheter and a central dilator. This combination of catheter and dilator enables us to introduce the catheter into the artery without the need of an introducer sheath. Because the outer diameter of this 5‐Fr sheathless guiding catheter system is approximately 2‐Fr sizes smaller than a conventional guiding catheter system, this system provides us with less invasive angioplasty and a puncture site injury equivalent to a conventional 3‐Fr introducer sheath. To demonstrate the potential of this 5‐Fr sheathless guiding system, we report two cases of chronic total occlusion successfully treated by the transradial approach. This novel 5‐Fr sheathless system may become a viable alternative to conventional guiding catheters, and provide a favorable impact upon vascular access complications and patient morbidity. © 2009 Wiley‐Liss, Inc.     

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.     

“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.     

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.     

“Kissing” stents for bifurcational coronary lesion

The coronary stents implantation into each vessel of a bifurcational lesion (“kissing” stents) in two patients is reported. The first patient had two short “kissing” stents implanted in an ostial lesion of the left anterior descending and the intermediate branch. The second patient had successful “kissing” stents implantation in the bifurcational lesion of the left main coronary artery.© 1993 Wlley-Liss, Inc     

“Double wire” angio‐seal closure technique after balloon aortic valvuloplasty

Objectives : To report the feasibility of a collagen‐mediated closure device using a modified Angio‐Seal closure technique for access site management following percutaneous balloon aortic valvuloplasty (BAV). Background : With the advent of percutaneous aortic valve replacement therapies, there has been a resurgence of interest in BAV procedures. Vascular complications, including bleeding, are a common source of morbidity post procedure as a result of the requirement for large bore femoral artery access. The use of vascular closure devices may reduce bleeding complications. Methods : We describe a new technique for vascular closure in this setting. At the conclusion of the valvuloplasty procedure, two 0.035″ wires are inserted through the femoral artery sheath. A conventional collagen‐mediated closure device (8F Angio‐Seal) is deployed over the first wire and along side the second wire. If immediate hemostasis is not achieved, a second device is loaded onto the second wire and deployed to achieve hemostasis. Results : Percutaneous BAV was performed in 21 patients. Hemostasis was successfully achieved in all patients with either a single 8F Angio‐Seal closure device (18 patients) or after placement of a second device (three patients). Conclusions : The modified “Double Wire” Angio‐Seal technique is a feasible method for hemostasis following percutaneous BAV. © 2009 Wiley‐Liss, Inc.     

PCI using a 4‐Fr “child” guide catheter in a “mother” guide catheter: Kyushu KIWAMI® ST registry

Objectives: With the development of PCI techniques, the indications for stents have been expanding as well. On the other hand, we often encounter the situations where deploying a stent/stents by the conventional method is technically challenging. We report a novel stent delivery system using a newly developed 4Fr. straight catheter with Mother‐and‐Child method. Methods and results: We collected the data on coronary angioplasty in which we experienced the difficulty to deliver coronary stents and used 4Fr. KIWAMI ST01. The case number amounts to 32 cases over a six‐month period from October 2009 through March 2010;76:919‐–923. The angioplasty was performed for lesions in the RCA in 9 patients (28%), lesions in the LAD in 15 patients (47%), lesions in the LCX in 5 patients (16%), lesions in the saphenous vein grafts in 2 patients (6%), and lesions in the internal thoracic artery (LITA) grafts in 1 patient (3%). And the reasons for the difficult stent delivery by the conventional methods were as follows: severe calcification in 12 patients (37%), intense tortuosity in 7 patients (22%), poor backup support for guide catheter in 8 patients (25%), and trapping of the stent proximal to the target lesion in 5 patients (16%). The dislodgment of stent did not happened in all cases. Conclusions: KIWAMI® ST01 stent delivery system is feasible, safer, and effective in cases where stent delivery is difficult by the conventional method. © 2010 Wiley‐Liss, Inc.     

Origin of the left main coronary artery from the “non-coronary” sinus of valsalva

A case is described in which the left main coronary artery arises from the posterior sinus of Valsalva in an otherwise normal heart. This coronary anomaly did not result in any functional obstruction or myocardial ischemia but represents only the third such anomaly described in the English language literature.