A 62-year-old man presented with stable angina. Coronary angiography revealed 90% stenosis at distal left circumflex coronary artery (LCx) and the proximal part was tortuous (Figures 1A and 1B, Video 1). The left coronary artery was engaged with a 7-F extra back-up guiding catheter (Cordis, Warren, New Jersey). The LCx was crossed with a 0.014-inch guidewire (Runthrough NS, Terumo, Tokyo, Japan) and pre-dilated with a 2.5 × 15-mm short track (ST) sliding balloon (Nippro, Osaka, Japan) (Figure 1C). We were unable to deliver a 3.5 × 29-mm sirolimus-eluting stent (Shanghai MicroPort Medical Group, Shanghai, China) due to proximal tortuosity and calcification (Figure 1D). The 2.5 × 15-mm ST balloon was subsequently inflated at the distal part of the LCx, and we were then able to deliver the stent with the same wire (Figure 1E, Video 2). The balloon was deflated and easily removed without interfering with the well-placed stent (Figures 1F and 1G, Videos 3 and 4). The final angiogram revealed excellent results at the LCx (Figure 1H, Video 5).
A 74-year-old woman without a prior history of coronary artery disease underwent surgical replacement of ascending aorta for type A acute aortic dissection. Six days after the surgery, she developed new onset chest pain with ST-segment elevation in inferior leads. Urgent coronary angiography revealed diffusely ectatic coronary tree and abrupt occlusion of the left circumflex artery (Figure 1A). Thrombolysis in myocardial infarction grade 2 coronary flow was obtained after 2.0-mm balloon dilatation (Figure 1B). Although angiographically indistinguishable, high-definition intravascular ultrasound (IVUS) (Altaview, Terumo, Tokyo, Japan) clearly demonstrated large thrombus in the proximal site (Figures 1C and 1D) and homogeneous, extremely hypoechoic objects in the distal site of culprit lesion (Figures 1E and 1F, Video 1). We performed repeated thrombectomy using a 7-F aspiration catheter and successfully extracted some yellow fragments (Figure 2A) from the distal lesion, which had a histopathologically homogeneous artificial structure (Figure 2B). The morphological characteristics of the aspirated materials coincided with BioGlue (CryoLife, Kennesaw, Georgia), a surgical adhesive. Based on these findings, we speculate that coronary embolism with BioGlue was occurred during or after vascular surgery, resulting in reduced coronary blood flow and subsequent proximal thrombus formation.
A 71-year-old woman, who had received a redo mitral valve replacement due to recurrent regurgitation after a mitral valve repair 1 month earlier, made her first visit to our hospital after discharge. She was generally in good condition, but a huge and pulsatile lump was noted at the anterior thorax near the surgical incision (Figure 1A, Video 1). Contrast-enhanced computed tomography revealed a hyperattenuating mass, which originated from the left internal mammary artery (IMA) (Figures 1B and 1C). She was diagnosed with a left IMA pseudoaneurysm and was hospitalized on the day of the admission. Because there was a risk of rupture, percutaneous coil embolization of the left IMA was immediately performed (Figure 1D). The aneurysm was successfully embolized, and she was discharged 5 days after the treatment without complications (Figure 1E).
A 58-year-old presented with recurrent angina following the recent implantation of 2 drug-eluting stents (Xience Sierra 3.5 × 28 mm, Xience Xpedition 2.5 × 48 mm, Abbott Vascular, Santa Clara, California) from the proximal left main artery (LM) into the mid left anterior descending artery (LAD) 3 months prior (Figure 1). During the present diagnostic catheterization with a 5-F TIG catheter (Terumo, Tokyo, Japan), a hazy linear opacity was seen within the LM stent (Figure 2, Videos 1 and 2). Optical coherence tomography (OCT) and intravascular ultrasound confirmed a thin flap that started just inside the proximal edge of the LM stent and ended before the LAD and left circumflex artery bifurcation. The imaging catheters entered the false lumen at the proximal stent edge, before re-entering the true lumen at the distal LM (Figures 3, 4 and 5, Videos 3 and 4). A thin layer of neointima covered the struts on the side of the true lumen, but there were uncovered struts on the side of the false lumen where the neointima had been “peeled off.” The most logical cause of this flap was an iatrogenic injury of the neointima by the diagnostic catheter. Although fractional flow reserves in both the LAD and left circumflex artery were negative, we elected to cover the flap with a drug-eluting stent (Synergy 4.0 × 8 mm, Boston Scientific, Marlborough, Massachusetts) due to concerns of late complications (Figure 6). Final angiography and OCT were satisfactory, with no residual dissection flap (Figures 7 and 8, Videos 5 and 6).
A 77-year-old otherwise healthy woman was admitted to the emergency department with cardiogenic shock after acute onset of chest pain, global ST-segment depression, and ST-segment elevation in lead aVR (Figure 1). Nonselective left coronary angiography showed a stenotic left main coronary artery (LM), which upon proper engagement and contrast injection was seen as a tubular stenosis, though the caliber changed dynamically during contrast injection (Figures 2A and 2B, Video 1). Type 3 spontaneous coronary artery dissection was therefore suspected. Left ventriculography and pressure gradient measurement between the left ventricle and the aorta did not show any abnormalities (Figure 3). LM dissection was confirmed with intravascular ultrasound imaging (Figure 4A, Video 2). There were no signs of atherosclerosis in the right coronary artery, left anterior descending coronary artery, or left circumflex coronary artery (LCx). Bifurcation stenting to the left anterior descending coronary artery and LCx was performed as the dissection propagated to the LCx (Figure 4B). The patient’s symptoms and the electrocardiographic changes completely resolved. Creatine kinase peaked on the following day at 2,500 U/l. Follow-up echocardiography before discharge revealed a dilated ascending aorta with a double-layer wall structure (dissection) (Figure 5, Video 3). Computed tomography confirmed the presence of a type A aortic dissection (Figures 6A and 6B). The patient was consequently referred for aortic surgery. Two months after surgery, the patient has fully recovered and is in good general condition.
Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) provide more detailed information on calcified lesions than angiography (1). Therefore, they are utilized as supportive imaging devices during percutaneous coronary intervention (PCI) with rotational atherectomy (RA). In this case, the differences in IVUS and OCT images of calcified lesions taken during PCI with RA are clearly shown. The coronary angiography and computed tomography images of a 79-year-old man with exertional angina showed severe stenosis with severe calcification in the mid left anterior descending artery (Figures 1A and B). Because high-pressure dilatation with a noncompliant balloon failed to dilate the lesion, we decided to perform an RA. After debulking the calcified lesion with a Rotablator 1.75-mm burr (Boston Scientific, Marlborough, Massachusetts), the OCT images showed that the lesion had residual circumferential calcium (Figure 1C). The IVUS images also showed circumferential calcium with reverberation, but the thickness of the calcium was not visible (Figure 1D). Therefore, we drilled the lesion again with a Rotablator 2.15-mm burr. Then, the calcium was much thinner, and a crack was clearly visible in the OCT images (Figure 1E). However, in the IVUS images, the crack was barely confirmed, and the calcified lesion still showed circumferential calcium, even in the areas of very thin calcium shown in the OCT images (Figure 1F).
In this viewpoint paper, the authors are tackling criticism to the limits of invasive imaging modalities for identification and treatment of vulnerable plaques. They believe in the clinical usefulness of invasive imaging modalities for identification of vulnerable plaques, and are suggesting an explanation for the suboptimal results of past studies, that failed to demonstrate a correlation between interventional treatment of vulnerable plaques, and reduction of hard clinical endpoints. Vulnerability studies have been based, so far, on the detection and measurement of plaques lipid content, because of its ease. However, the search for lipid “lakes” as a single common causal feature of acute coronary syndromes does not seem sufficient to identify patients at risk of adverse events. New imaging studies provided the rationale for improving clinical outcomes, adopting a more comprehensive assessment of target plaque morphology. There is little rationale in pursuing a functional assessment of coronary lesions to predict myocardial infarction. Recent studies are further confirming this hypothesis, suggesting that the clinical benefit of the fractional flow reserve-guided strategy is simply due to a significant reduction in the rate of repeated revascularizations, with no significant differences in the incidence of hard endpoints. There is a need to develop new randomized studies, requiring a feasible number of patients, to test the superiority of an approach based on vulnerable plaque sealing and treatment.
Objectives The aim of this study was to assess the impact of access-site crossover in patients with acute coronary syndrome undergoing invasive management via radial or femoral access.
Objectives The aim of this study was to compare the rate of proximal radial artery occlusion (RAO) with Doppler ultrasound between distal and conventional radial access 24 h and 30 days after a transradial coronary procedure.
Objectives The objective of this study was to assess contemporary use of operator directed sedation (ODS) and anesthesiologist care (AC) in the pediatric/congenital cardiac catheterization laboratory (PCCL), specifically evaluating whether the use of operator-directed sedation was associated with increased risk of major adverse events.
Objectives The aim of this study was to determine the risk period for increased stent thrombosis (ST) after percutaneous coronary intervention (PCI) in patients with acute coronary syndromes (ACS) and whether this increased risk is related to high platelet reactivity (HPR).
Objectives The aim of this study was to compare ticagrelor monotherapy with dual-antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stents.
Objectives The aim of this study was to evaluate 2 abbreviated dual-antiplatelet therapy (DAPT) regimens in patients at high bleeding risk (HBR) undergoing percutaneous coronary intervention (PCI).
Objectives This study sought to evaluate clinical implications of the residual fractional flow reserve (FFR) gradient after angiographically successful percutaneous coronary intervention (PCI).
Objectives The aim of this study was to evaluate the 1-year safety and efficacy of a dual-layered stent (DLS) for carotid artery stenting (CAS) in a multicenter registry.
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