Diagnostic significance of angioscopy in patients with coronary heart disease

Coronary angioscopy (CA) using ultrathin fiberscopes was performed in 30 patients with coronary heart disease during cardiac catheterization and in 11 patients during bypass surgery. For percutaneous CA the angioscope was introduced from the femoral artery through a 9F guiding catheter. During short-time occlusion of the coronary ostium by the tip of the guiding catheter the viewing field was flushed with Ringer's solution. Intraoperative CA was performed both by the retrograde and antegrade way during flushing with cardioplegic solution. Percutaneous CA was successful in 57% of patients. 13 patients showed eccentrically and irregularly shaped stenoses and 3 of these patients had an additional plaque rupture. In 2/5 patients CA after PTCA revealed intimal dissections not visualized by angiography. Intraoperative CA was successful in 9/11 patients. In 3 patients nonocclusive thrombi were found at the site of the coronary lesion. Additionally we studied the efficacy of angioscopic guidance during intravascular radiofrequency application. In 11/11 thrombotically occluded peripheral vessels this new method allowed a nearly complete recanalization. There was only one perforation of the vessel. We conclude, that CA is a powerful diagnostic tool providing prognostically relevant information in the diagnosis of coronary heart disease.     

Experimental and clinical percutaneous angioscopy experience with dynamic angioplasty

The authors have used ultrathin angioscopes with high optical resolution to assess the effects of dynamic angioplasty in vitro and in vivo. Experimentally, angioscopy was used to study the effects of the 5F "Kensey" catheter in "normal" porcine coronary arteries (NPCA) and postmortem human coronary arteries (PMHCA). In NPCA, the catheter keeps a coaxial position. Intimal flaps (IFs) were seen in 21/23 NPCAs. They occurred with all cam rotation speeds and were usually single and small (less than 25% of lumen). Perforations in patent arteries were rare (1/23). However, when the catheter was forced against the wall by passing through a narrowing of 5F diameter (made by a band ligature), perforations were more common at higher cam speeds. The epicardium remained intact in two thirds of perforations. Angioscopy visualized perforations in only 10% of cases (1/10), the common sign being that of large and multiple intimal flaps, which were often obstructive (5/10). In PMHCAs, angioscopy was more sensitive than angiography in detecting atheromatous lesions. The authors were able to give a better assessment of the effect of dynamic angioplasty on treated lesions, including the demonstration of intimal flaps that were not visible on angiography. In vivo, they have performed percutaneous angioscopy before and after dynamic angioplasty using 8 French Kensey catheters. Angioscopy revealed features that were not shown angiographically.     

Feasibility of the PCI through 6F diagnostic catheters.

BACKGROUND: The choice of guiding catheter for optimal back-up support is critical in order to achieve a successful PCI. Diagnostic 6 French (F) catheters have an internal lumen diameter as large as 5F guiding catheters. The aim of this study was to demonstrate for the first time the feasibility of performing PCI with Cordis 6F diagnostic catheters in selected coronary lesions. METHODS: 32 coronary stents were implanted using 6F diagnostic catheters in 27 eligible patients at the Montreal Heart Institute. The inclusion criteria were TIMI angiographic score < B2 in native coronary arteries or in coronary artery bypass grafts. Bifurcations and left main disease were not included. RESULTS: Eighty-five percent of the patients underwent PCI for acute coronary syndromes (ACS). PCI was performed in 5 lesions (19%) of the left coronary circulation; in 21 lesions (78%) of the right coronary artery and in one lesion (4%) of the 1st obtuse marginal branch of the circumflex artery, through a left mammary artery bypass. Only stents suitable for 5F guiding catheters were used. The largest stent was 4.0 mm in diameter and 32 mm in length. Direct stenting was performed in 75% of patients. The angiographic success for PCI of target lesions was 100%, without clinical or angiographic complications. CONCLUSIONS: In selected cases, diagnostic 6F catheters can be used for PCI with 5F compatible balloons and stents. PCI via a diagnostic catheter may provide even better back-up support and allows for significant resources and time savings, especially in patients with ACS.     

不同途径经皮冠状动脉介入诊治心脏并发症的分析

目的 探讨不同途径经皮冠状动脉介入诊断（CAG）和治疗（PCI）的非心脏并发症和心脏相关并发症发生原因及防治措施。方法 收集2003年9月-2006年5月山西省人民医院行CAG和PCI的病人443例，其中经股动脉CAG 126例。其中PCI 78例。经桡动脉CAG 317例，其中PCI 131例。回顾性分析比较两种途径CAG和PCI并发症发生率及处理分析。结果 发生各种并发症18例。其中心脏并发症8例（经股动脉7例，经桡动脉1例）。心脏并发症10例（经股动脉4例，经桡动脉6例）。结论 经桡动脉非心脏并发症显著减少，而两途径心脏相关并发症无差别。     

10 plus-years follow-up after patch angioplasty of the left main coronary artery

In ostial or proximal left main coronary artery (LMCA) obstruction, re-establishment of normal antegrade flow via the main trunk may be preferable to distal bypass grafting. The objective of this study was to assess the effectiveness of patch plasty of the left main (LM) trunk of the coronary artery for more than 10 years. Direct widening of the LMCA was recommended to patients with ostial, proximal, or midpoint stenosis of the main trunk. Group I of 16 patients had isolated LM obstruction with no distal disease, and Group II of 15 patients had, in addition, right coronary obstruction. The mean age was 60.9 years (age group, 47 to 83 years). Nineteen patients underwent this operation through an anterior transverse aortotomy. No endarterectomies were performed. In Group II, in addition, a single saphenous vein bypass graft was placed in the right coronary artery. There were no operative deaths. Follow-up period extends from 10 to 18 years (mean 11.2). Eight patients had angiography from 3 to 9 years after surgery and all show adequate LM trunk caliber. Noncardiac deaths occured in five patients (26.3%) at 2 months, and 1, 4, 6, and 7 years after surgery. Two women with isolated ostial stenosis diagnosed as a spasm have not shown progression of coronary disease 7 to 9 years after the operation. Widening of the LMCA should be considered in selective cases, only when ostial, proximal, or midportion stenosis of the main vessel exist, even if a right coronary bypass graft is required.     

568例急诊冠状动脉造影的临床体会

目的评价对急性冠状动脉综合征患者施行急诊冠状动脉造影的安全性与有效性。方法自1996年1月至1999年12月,我们共施行急诊冠状动脉造影568例,其中疑诊急性心肌梗死416例,疑诊不稳定性心绞痛152例。结果416例拟诊急性心肌梗死病例中,有328例施行了梗死相关血管的直接经皮冠状动脉腔内成形术(PrimaryPTCA,P-PTCA)治疗;有32例造影发现冠状动脉梗死相关血管直径狭窄<75%,前向血流TIMIⅢ级,未行P-PTCA治疗;有12例左主干和(或)三支血管病变患者施行急诊冠状动脉旁路移植术（CABG）;16例左主干和(或)三支血管病变患者在主动脉内球囊反搏(IABP)辅助下,行择期CABG治疗;有8例因梗死相关血管不能确定或是不适宜P-PTCA或CABG病例接受了冠状动脉内溶栓治疗,有4例梗死相关血管细小,未行特别处理;有13例急诊冠状动脉造影示结果正常或体表心电图判定的梗死相关血管正常。152例拟诊不稳定性心绞痛患者中行急诊PTCA治疗108例,CABG33例,动脉造影正常8例,因弥漫性冠状动脉病变不适宜PTCA/CABG治疗,选用IABP短期辅助治疗加药物治疗维持2例。2例急性心梗和1例梗死后心绞痛患者死于术中或术后即刻。结论对于急性冠状动脉综合征患者施行急诊冠状动脉造影是必要的和安全可行的。     

Acceleration of the left main coronary artery stenosis following PTCA: a report of a case

Acceleration of the left main coronary artery (LMCA) stenosis induced by guiding catheter which was used for percutaneous transluminal coronary angioplasty (PTCA) was demonstrated in a 68 years old man with post-infarction angina. He underwent PTCA to a subtotal lesion in the left anterior descending coronary artery (LAD). The LMCA with mild stenosis of 18% reduction of luminal diameter was unchanged during the course of PTCA. The guiding catheter was pushed repeatedly with considerable force for introducing balloon catheter due to the rigid lesion in LAD. Progression of the LMCA stenosis to a 64% was demonstrated at 6 months later angiographic restudy. It was considered that repetitive sliding of guiding catheter through the LMCA caused subangiographic intimal trauma and facilitate subsequent progression of stenosis. We examined the guiding catheter to the LMCA diameter ratio, the angle of the tip portion of the guiding catheter with LMCA, and severity of the target lesion in this case compared with other 27 controls in whom PTCA was performed to the lesion in left coronary artery. No difference of these 3 factors between this case and other 27 controls was obtained. Thus it might be difficult to predict progression of LMCA stenosis by these angiographic factors. Although the incidence of catheter-induced progression of LMCA stenosis was as low as 1 of 160 cases (0.6%) in our experience, it is important to attend to catheter-induced progression of LMCA stenosis and to make an early detection.     

Use of femoral artery guiding catheters via the left brachial artery for transluminal coronary angioplasty

Percutaneous transluminal coronary angioplasty using the right brachial artery has been described using either a cutdown and arteriotomy or a percutaneous entry. Each method requires the use of a brachial artery guiding catheter (Stertzer guiding catheter; (USCI). This communication reports the use of percutaneous entry of the left brachial artery and coronary angioplasty performed with femoral guiding catheters. In this manner coronary angioplasty has been successfully performed in 42 of 47 patients (90%) without major complications.     

Ptca of gastroepiploic bypass

A technique for percutaneous transluminal coronary angioplasty (PTCA) of gastroepiploic bypass is described using standard PTCA devices. Severe spasm of gastroepiploic bypass occurred. Modification of guide catheter position is suggested to avoid inducing gastroepiploic bypass spasm.     

Extreme coronary guide catheter support: report of two cases of a novel telescopic guide catheter system.

Extra support of the guiding catheter is required in selected cases of percutaneous coronary intervention (PCI). We describe two successful cases of PCI of very calcified and tortuous right coronary arteries in which a novel telescopic guide system was devised. The system utilizes a long sheath that "armors" the guide catheter. The operator can adjust the support of the guiding system from soft up to extremely stiff.     

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 interventions using a new 5 French guiding catheter: results of a prospective study.

The aim of this prospective study was to analyze the technical feasibility, the success rate, and the special complications of percutaneous coronary interventions (PCIs) using a newly released 5 Fr guiding catheter with an inner diameter of 0.058". The study was performed in 150 consecutive patients subjected to coronary angioplasty. In 89% of the patients, the intervention was started with a 5 Fr catheter (JR4 or JL4); in 16 patients a 6 or 7 Fr catheter was used because of unstable clinical conditions according to the decision of the interventional cardiologist. In 12 out of 134 patients, the guiding catheter had to be changed during the intervention from 5 Fr to a 6 or 7 Fr catheter due to poor backup support. In 112 out of 118 patients, the intervention was successfully performed using a 5 Fr catheter (95%); in 12 out of 16 patients, after changing the guiding catheter, the overall success rate was 93%. In patients with type A and B lesions who were initially treated using a 5 Fr catheter, the procedural success rate was 100% (81 out of 81), whereas in patients with type C lesions the procedural success rate was 83% (43 out of 53; P = 0.000053, Fisher's exact test). Furthermore, in patients with a diameter stenosis < 90%, the procedural success rate was 100% (57 out of 57), whereas in patients with a diameter stenosis of 90%-100%, the procedural success rate was 87% (67 out of 77; P = 0.0050). Stent implantation was performed successfully in 24 patients (18%) using the 5 Fr guiding catheter. This study confirms that PCI was technically feasible using a 5 Fr guiding catheter in the majority of consecutive patients with a success rate of 95%. There were significant differences in the success rate depending on the lesion type and the diameter stenosis. Complications were very rare and were not related to the guiding catheter. Limitations of the 5 Fr guiding catheters arose mainly from a poor backup support in long lesions and severe stenosis. Cathet Cardiovasc Intervent 2001;53:308-312. Copyright Wiley-Liss, Inc.     

Significance of catheter ablation as emergency intervention in patients with sustained monomorphic ventricular tachycardia]

Treatment of incessant ventricular tachycardia (VT) refractory to antiarrhythmic drugs and DC cardioversion is difficult and still debated. We performed catheter ablation (CA) of sustained monomorphic ventricular tachycardias (VT) with high-energy DC shock (360-400 Joule) in 11 patients (pts) with incessant VT (duration greater than 24 h), refractory to antiarrhythmic drugs and DC cardioversion. Ten pts suffered from coronary disease and one pt from dilated cardiomyopathy. DC energy was delivered either at the site of the earliest endocardial activation (EEA) (six pts) or at the area of slow conduction (ASC) (five pts). In nine pts incessant VT could be terminated by DC ablation; two pts had to undergo emergency endocardial resection. During the mean follow-up of 31 +/- 26 (1-66) months nonfatal VT recurrences occurred in five pts with CA at the EEA and in one pt with CA at the ASC. We conclude that CA of incessant VT is an effective approach to terminate VT. However, there is a high incidence of nonfatal recurrence after CA, particularly when DC energy is delivered at the earliest site of endocardial activation.     

Percutaneous transluminal coronary angioplasty--effect of the moveable guide wire on the complication rate

Beginning with the first percutaneous transluminal coronary angioplasty (PTCA) performed at Baystate Medical Center, 152 consecutive procedures were analyzed. Sixty were done using USCI-G (nonsteerable) series catheters. In two patients both a G and S (steerable) catheter were used. In 90 procedures the S system was used exclusively. Among the attempted angioplasties with the G series catheter, the percutaneous transluminal coronary angioplasty was successful in 47 (78%). Eight coronary occlusions were induced and all these patients underwent coronary bypass surgery. There were no deaths, but three patients (5%) had acute myocardial infarctions (MI). The two patients in whom both G and S catheters were used had occlusions. One went to surgery and died postoperatively of uncontrollable ventricular arrhythmias. The other patient had a myocardial infarction and recovered. Of the 90 attempts with the exclusive use of the steerable system, 75 were successful (83%). Three coronary occlusions were induced in the 90 attempts and two of the patients had coronary artery bypass surgery. None of the three sustained a myocardial infarction. In summary, the proportion of patients requiring emergency surgery was significantly reduced from 13.3% (8 of 60) to 2.2% (2 of 90) (p=0.02), the incidence of myocardial infarction was reduced from 5 to 0%, and there was a slight increase in the siccess rate of the procedure after the introduction of the steerable system. It is concluded that the steerable system increases the safety of PTCA.     

Directional coronary atherectomy in a distal right coronary lesion using a shorter standard guide catheter

An ulcerated and eccentric distal right coronary artery plaque was found in a 56-year-old male with post-infarction angina. The 100 cm length of present DVI (Devices for Vascular Intervention, Inc., Redwood City, CA) atherectomy guiding catheters limits the ability to reach many complex distal stenoses with the 125 cm Simpson Atherocath. After shortening the proximal portion of a standard DVI Judkins right guiding catheter without changing the distal contour, successful directional coronary atherectomy was performed. © 1993 Wiley-Liss, Inc.     

A prospective study on percutaneous coronary angioscopy with different guiding techniques in patients with coronary heart disease.

The technical success of percutaneous coronary angioscopy using different guiding techniques was evaluated in 17 patients before (n = 17) and after (n = 8) coronary angioplasty. Steering the angioscope along or over a guidewire was successful in both groups; failures were predominantly due to insufficient alignment of the angioscope using along-the-wire guiding. Although over-the-wire angioscopy promises superior guiding and alignment capabilities, several technical problems remain unsolved.     

Novel percutaneous intervention technique for obstructed coronary artery after valve-in-valve transcatheter aortic valve replacement

Valve-in-valve transcatheter aortic valve replacement (valve-in-valve TAVR) increases the risk of coronary obstruction. Although the coronary protection strategy is widely used, the use of the bailout technique after coronary obstruction is limited. Hence, we report a simple bailout technique for coronary obstruction after valve-in-valve TAVR. An 82-year-old woman presented with structural valve deterioration. The left anterior descending coronary artery had 90% stenosis. After TAVR, the prosthetic valve shifted close to the ascending aorta wall, consequently impairing coronary flow. The wire crossed with the Judkins right guiding catheter (JR) reference to the en-face and perpendicular views. Using the guide-extension catheter, the JR contacted the contralateral ascending aorta as a backup catheter. After a balloon was dilated between the prosthetic valve and aorta, JR engaged into the coronary artery with excellent backup. This novel “Whisker pole guiding technique” is useful, even after valve-in-valve TAVR.     

Percutaneous coronary angioplasty of a left anterior descending artery implanted on a Dacron coronary prosthesis on an aortic conduit

Certain surgical techniques may make it difficult to catheterizethe coronary ostia and perform percutaneous coronary angioplasty.We report the case of a 48 year old patient who developed unstableangina four years after a Bentall's procedure with reimplantationof the coronary arteries on a Dacron coronary prosthesis. Theanginal pain was related to very severe stenosis of the proximalsegment of the left anterior descending artery. The difficulties encountered during the dilatation procedurewere due to: (a) the ectopic position of the ostium of the prosthesison the anterior aortic wall; (b) the forces exerted on the aorticprosthesis wall and on the valvular prosthesis during positioningof the guiding catheter which were poorly tolerated and induceda vagal reaction; (c) the direction taken by the distal tipof the guiding catheter, perpendicular to the wall of the aorticprosthesis; (d) the sinuosity of the arterial trajectory: theleft coronary segment of the coronary prosthesis was directedtowards the left circumflex artery rather than towards the leftanterior descending artery. Coronary angioplasty succeeded afterrelatively complex technical procedures: special guiding catheter,unusual intra-aortic manoeuvres for positioning the guidingcatheter, dilatation catheter change on a 3-metre long guidewire in order to cross the stenotic segment; this was performedwith a super lowprofiled dilatation catheter. There were nocomplications and anginal pain disappeared.     

Diagnostic cardiac catheterisation in a hospital without on-site cardiac surgery

OBJECTIVE: To assess the feasibility, safety, and clinical impact of diagnostic cardiac catheterisation in a multipurpose laboratory in a district general hospital without cardiac surgery. METHODS: A prospective audit of the first 2000 consecutive cases between September 1992 and March 1997. Unstable patients were referred to a surgical centre for investigation, in line with subsequently published British Cardiac Society (BCS) guidelines, but all other patients requiring cardiac catheterisation were investigated locally and are included in this report. The function of the laboratory was also compatible with the BCS guidelines regarding staffing, operators, equipment, number of cases, and locally available vascular surgery. RESULTS: Of the 2000 cases, 1988 studies were completed (99%), 1985 (99%) included coronary angiography, and 1798 (90%) were performed as day cases. Left main stem disease was present in 157 (8%), three vessel disease in 683 (34%), two vessel disease in 387 (19%), single vessel disease in 424 (21%), and normal coronary arteries in 494 (25%). Of the latter, 284 (14% of the total) had another cardiac diagnosis for which they were investigated (for example, valvar heart disease). Referral for cardiac intervention following catheterisation was made in 1172 of the 2000 cases (intervention rate 59%; catheter:intervention ratio 1. 7:1). The interventions performed were coronary artery bypass grafting (CABG) in 736 of the 1172 cases (63%), other types of cardiac surgery in 122 (10%), combined CABG and other cardiac surgery in 71 (6%), and percutaneous transluminal coronary angioplasty in 243 (21%). There were two catheter related deaths (0. 1%), both of which occurred within 24 hours of the procedure, and a further nine major cardiovascular complications with residual morbidity (0.45%). These were myocardial infarction in two (0.1%), cerebrovascular events in two (0.1%), and surgical vascular complications in five (0.25%). In addition, there were eight successfully treated, life threatening arrhythmias (0.4%). CONCLUSIONS: Diagnostic cardiac catheterisation can be performed safely and successfully in a local hospital. When BCS guidelines are followed, the mortality is similar to published pooled data from regional centres (0.1% v 0.12%). The high intervention rate indicates a persistent unmet demand in the districts, which will continue to affect surgical and interventional services.     

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.