Volume 19 - Issue 9 - September, 2007

Comparative Intravascular Ultrasound Analysis of Ostial Disease in the Left Main versus the Right Coronary Artery

Sang-Wook Kim, MD, *Gary S. Mintz, MD, Patrick Ohlmann, MD, Salah-Eddine Hassani, MD,
Aleksandra Michalek, MD, Esteban Escolar, MD, Anh B.Bui, MD, Augusto D. Pichard, MD,
Lowell F. Satler, MD, Kenneth M. Kent, MD, PhD, William O. Suddath, MD, Ron Waksman, MD,
Neil J. Weissman, MD

The aorto-ostial junction has high elastic fiber content with significant elastic recoil.1-7 Ostial left main coronary artery (LMCA) stenoses have larger lumen areas with less plaque burden and more negative remodeling than non-ostial LMCA stenoses. Most ostial LMCA stenoses have been categorized as eccentric and less calcified.8 The RCA ostium shows a lack of arterial distensibility and excessive rigidity, presumably because it contains highly elastic rigid tissue.1,7 Both the LMCA and RCA ostia may have similar morphologic characteristics. However, there i...

Secrets of Success in Unprotected Left Main Intervention: Patient and Lesion Selection

Madan Sharma, MD and Yerem Yeghiazarians, MD

Despite advances in percutaneous coronary intervention techniques over the last two decades, the unprotected left main has largely remained the domain of cardiovascular surgery. The subset of patients with left main disease in the Collaborative Study in Coronary Artery Surgery (CASS) study demonstrated superior outcomes with bypass surgery as compared with medical therapy.1 While percutaneous intervention of the unprotected left main artery has been reported as early as in the late 1980s, initial results with balloon angioplasty of the left main were poor, with 1-year mortal...

Postocclusion Hyperemia Provides a Better Estimate of Coronary Reserve than Intracoronary Adenosine in Patients with Coronary Ar

Alain Nitenberg, MD, †Éric Durand, MD, *Bertrand Delatour, MD, †Wissem Sdiri, MD,
†Saliha Raha, MD, †Antoine Lafont, MD, PhD

The physiologic effects of the majority of coronary artery stenosis cannot be determined accurately by conventional angiographic approaches.1,2 Coronary flow reserve3,4 (CFR), and, more recently, fractional flow reserve5 (FFR) have been proposed for assessment of the functional consequence of coronary lesions and evaluation of coronary angioplasty efficiency.6,7 In addition, CFR is a useful tool for the diagnosis of coronary microvascular disease.8,9 Because FFR is the ratio of maximal flow in a stenotic vessel to maximal flow without s...

Late Angiographic Stent Thrombosis (LAST): The Cloud Behind the Drug-Eluting Stent Silver Lining?

Jack P. Chen, MD

The widespread popularity of drug-eluting stents (DES) had a dramatic impact on the modern interventional therapy of coronary artery disease; accordingly, the cardiac surgical volume has experienced a corresponding decrease. Like the introduction of bare-metal stents (BMS) during the balloon angioplasty era, DES represent yet another quantum advancement towards overcoming the challenges of restenosis. The promises of this potential panacea, however, have been recently attenuated by the looming specter of late angiographic stent thrombosis (LAST). The usual time frame for stent thrombosis is...

Right Pulmonary Artery-to-Left Atrial Fistula: A Differential Diagnosis of Cyanosis without Structural Heart Disease

*Nair Krishnakumar, DM, §Manohar R. Krishna, MCH, *J.A. Tharakan, DM

Direct communication between the right pulmonary artery and the left atrium is an unusual variation of a pulmonary arteriovenous fistula. In fact, there are only about 50 cases reported in the literature.1 This is one condition in which clinical examination may reveal only cyanosis. Contrast echocardiography may show only right-to-left shunt, and only angiography is truly diagnostic.1

Case study. A 19-year-old male presented to us with a history of recently detected cyanosis. His systemic saturation was 81%, with conjunctival congesti...

Of Octopus Pots and Broken Hearts

Jack P. Chen, MD

To the Editor:

The angiographic finding of noncritical coronary stenoses in the setting of acute coronary syndrome and even myocardial infarction has been well described. One potential etiology is Prinzmetal’s angina or coronary spasm.1 More recent Japanese literature, however, has described the so-called “octopus fishing pot”, or takotsubo cardiomyopathy, which refers to the distinctive left ventricular silhouette. The distinctive apical ballooning with basal hypercontractility resembles that of the pot used by Japanese fishermen for trapping octopi....

Endovascular Repair of a Carotid Pseudoaneurysm with Fluency® Plus Stent Graft Implantation

*Carlo Briguori, MD, PhD, §Lucio Selvetella, MD, §Maria Pia Baldassarre, MD

Pseudoaneurysm formation is a rare complication following carotid endarterectomy (CEA), with an incidence of less than 1% of cases.1 Treatment of this complication is challenging. The current standard of care is some form of repair rather than conservative management. Open surgical repair has long been the treatment of choice.2 Recently, endovascular techniques have offered a less invasive approach. We report a case of pseudoaneurysm following CEA treated by percutaneous Fluency® Plus (Bard Peripheral Vascular, Tempe, Arizona) stent graft implan...

Percutaneous Treatment of Severe Carotid Stenosis Due to Takayasu’s Arteritis Early after Carotid Endarterectomy

aLisa Emmans, MD, bTri M. Nguyen, MD, bNathan Laufer, MD

Takayasu’s arteritis (TA) is a chronic inflammatory large-vessel disease of unknown etiology involving the aorta, its major branches and the pulmonary arteries.1,2 Resultant mixed areas of stenosis, occlusion, thrombosis and/or dilatation may cause a variety of symptoms including hypertension, congestive heart failure, mesenteric ischemia and claudication. Involvement of the supra-aortic branches may lead to visual changes including blindness, transient ischemic attacks (TIAs) and cerebral vascular accidents (CVAs). Predominantly a disease of women in the second and third d...

Percutaneous Coronary Intervention of a Totally Occluded Anomalous Right Coronary Artery Arising from the Left Sinus of Valsalva

Christos Graidis, MD, Dimokritos Dimitriadis, MD, Nikolaos Chamouratidis, MD

Coronary arterial anomalies occur in approximately 1% of the population, without other congenital cardiac malformations.1 The incidence of anomalous origin of the right coronary artery out of the right sinus of Valsalva ranges from under 0.01–0.09%. It usually arises from the left sinus of Valsalva or the ascending aorta above it, and in most reported cases, it courses between the great vessels. Rarely, the anomalous origin is found to be from the posterior sinus or another coronary artery. If the anomalous vessel has significant atherosclerotic disease requiring percutaneo...

Contact Wire Technique: A Possible Strategy for Parallel Wire Techniques

*Takamatsu Horisaki, MD, §Jean-François Surmely, MD, *Takahiko Suzuki, MD

Successful recanalization of chronic total occlusion (CTO) improves left ventricular function1 and survival.2 There are, however, several difficulties with percutaneous coronary intervention (PCI) for CTO (CTOPCI). Failure to cross the occlusive lesion with a guidewire is the main cause of unsuccessful CTO-PCI.3,4 The parallel wire technique is common and useful for CTO-PCI.5 However, the parallel wire technique has some limitations, especially for tortuous CTO morphology. In order to manage tortuosity or acute bending, we employ the “contact wire tech...

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