ABSTRACT: Iatrogenic aortocoronary dissection is a rare but devastating complication of percutaneous coronary interventions and cardiac surgery,¹ with a mortality rate up to 35%. Of the type-A dissections in the International Registry of Aortic Dissections (IRAD),² 27% were caused by coronary interventions. The mechanism involves an initial dissection in the coronary artery, which then propagates in a retrograde fashion past the sinuses of Valsalva, often several centimeters beyond the aortic valve. With the advent of complex interventions such as left main stent implantation, revascularization of chronic total occlusions and mechanical thrombectomy, this complication may become more prevalent.^3,4 Here we present a unique case of percutaneous coronary intervention (PCI) of the left circumflex (LCx) artery complicated by a left main coronary dissection that propagated approximately 8 cm into the ascending aorta and caused abrupt left main coronary

ABSTRACT: An anomalous right coronary artery (RCA) arising from the left anterior descending artery (LAD) is very rare, and has previously been considered a variant of single coronary artery. This is the first report of an anomalous RCA arising from the LAD with a coexisting proximal RCA. The anomaly was discovered incidentally during cardiac catheterization for severe mitral regurgitation. The incidence, anatomy and clinical associations of anomalous coronary arteries are reviewed here.

ABSTRACT: Although myocardial bridges are mostly confined to the left anterior descending coronary artery, several cases of right coronary artery myocardial bridging have been reported in the literature. In the current case report, we present a 65-year-old female with a well-functioning mechanichal mitral valve prosthesis, severe pulmonary hypertension and right ventricle wall motion abnormality in whom diagnostic angiography revealed myocardial bridging confined to the right ventricular branch of the right coronary artery.

ABSTRACT: We report a case of axial plaque redistribution after coronary stent deployment assessed by intravascular ultrasound (IVUS) as well as coronary angiography. A 72-year-old male with a history of hypertension, hyperlipidemia and a nuclear stress test demonstrating anterior and lateral ischemia was admitted for cardiac catheterization. Coronary angiography and IVUS examination revealed eccentric stenoses in the left anterior descending artery (LAD) and the left circumflex artery (LCx), just before the bifurcation of the first obtuse marginal branch. After successful LAD stent placement, the LCx was also stented, jailing the obtuse marginal branch. Immediately after dilatation, however, the coronary angiogram showed a new significant stenosis at the distal adjacent segment. IVUS examination after administration of nitroglycerin revealed a secondary critical lesion that was not observed before the interventional procedure. A significant plaque increase at the new lesion sit

ABSTRACT: Percutaneous transluminal angioplasty with stenting is now an established modality for treatment of atherosclerotic renal artery stenosis. However, the rate of restenosis can be as high as 20%. While intravascular brachytherapy has proven efficacy in coronary artery in-stent stenosis, its role in the treatment of renal artery in-stent stenosis is not well understood. We report a case of recurrent in-stent renal artery stenosis treated successfully by brachytherapy with excellent follow up results at 22 months.

ABSTRACT: Percutaneous revascularization of coronary chronic total occlusion remains a challenge for the interventional cardiologist. Operator experience and specific tips and tricks for more difficult cases are needed to obtain procedural success in the majority of situations. We describe a case of successful reopening of a chronically occluded right coronary artery using a retrograde wire as a landmark of the true lumen and a novel penetration device (Tornus, Ashai) to facilitate balloon and stent deployment.

ABSTRACT: Percutaneous coronary intervention for the treatment of aorto-ostial in-stent restenosis poses unique technical challenges not offered by other lesion subtypes. These difficulties are further enhanced when encountered with a case of deformed stent struts preventing coaxial guiding catheter engagement and introduction of guidewire through the true stent lumen. In this report, we describe a method of stenting through stent struts “side-strut stenting” for treating aorto-ostial in-stent restenosis associated with deformed stent struts resulting in good long-term outcome

ABSTRACT: Background. In-stent neointimal hyperplasia typically has a homogenous echoreflective appearance during intravascular ultrasound (IVUS) imaging. However, the neointimal hyperplasia of some brachytherapy failure lesions contains a very echolucent, dark zone that has been termed “black hole”. We sought to investigate the frequency and determinants of “black holes” (BH) after sirolimus-eluting stent (SES) implantation. Methods. A prospective, consecutive series of 33 intrastent SES restenosis (> 50% neointimal hyperplasia with a minimal lumen area < 4.0 mm²) was studied with IVUS. Patients were divided into 2 groups: 8 patients with BH versus 25 patients without BH. Results. Fifty percent of the BH cases occurred in saphenous vein graft lesions. BH tissue was noticed in 8% of all patients with in-stent restenosis. Three patients in each group had previous vascular brachytherapy failure (p = 0.1). Compared to non-BH cases, a greater proportion of B

ABSTRACT: While debulking with rotational atherectomy (RA) prior to balloon angioplasty (BA) improves acute results by reducing elastic recoil, treatment of an ostial side branch lesion that is covered (“jailed”) by a stent represents a particular challenge. We report our experience with RA in conjunction with BA for the treatment of ostial stenosis in jailed side branches. Methods and Results. Thirty-two lesions in side branches jailed by a stent were treated with RA and BA 39 times in 30 patients. The mean age was 65.5 ± 11.5 years; 26.3% were women; 18.4% had diabetes mellitus; and 18.4% had a history of prior bypass surgery. Of the treated side branches, 53.9% were diagonals, 71.8% were jailed by a slotted-tube stent, and 86.5% were previously dilated prior to RA. The burr sizes used to treat the jailed side branch origin ranged from 1.25 to 2.25 mm, with a mean burr size of 1.62 ± 0.31 mm. An average of 1.53 ± 0.72 burrs were used per lesion. Quantitative coronary an

ABSTRACT: Background. Determination of a transvalvular pressure gradient for measurement of aortic valve area (AVA) by hemodynamic cardiac catheterization usually requires 2 catheters and 2 arterial access sites. We assessed the feasibility of using a single arterial puncture and a 0.014 inch pressure wire for evaluation of aortic stenosis. Methods. Eighteen patients (mean age, 76 years; 10 men) underwent hemodynamic catheterization for assessment of AVA. Cardiac output was determined by thermodilution (using a pulmonary artery catheter), and the transvalvular pressure gradient was obtained from simultaneous pressure recordings (using a pressure wire to measure left ventricular pressure and a 5 Fr catheter to measure ascending aortic pressure). Results. This novel technique was technically feasible in all patients. Calibration of the pressure wire with the pressure of the fluid-filled catheter was possible and accurate in the left ventricle and aorta. The method re

ABSTRACT: Background. Transcatheter closure of patent foramen ovale (PFO) in patients with a history of cryptogenic stroke is performed with increasing frequency. However, the long-term effects of these closure devices on atrial tachyarrhythmias (ATs) are not known. Methods and Results. The study population included 71 patients [31 (44%) men, aged 54 ± 14 years] with PFO, diagnosed by transesophageal echocardiography (TEE), and ? 1 cryptogenic stroke (n = 70) or orthodoxia (n = 1). Patients underwent transcatheter closure of PFO using a 28 mm (n = 53) or a 33 mm (n = 18) CardioSEAL closure device (n = 67) or an Amplatzer occluder (n = 4). Five (7%) patients presented with newly diagnosed (n = 4) or recurrent (n = 1) episodes of AT (3 atrial fibrillation and 2 typical atrial flutter) within 1 to 480 days following the procedure, with an average time to onset of 175 ± 221 days. ATs were more frequent in those who received a 33 mm device than those who received a 28 mm devic

ABSTRACT: Background. Enoxaparin is an established therapy for the treatment of patients with acute coronary syndrome (ACS), and bivalirudin is commonly used as the antithrombotic agent during percutaneous coronary intervention (PCI). This study was designed to examine the safety of switching from enoxaparin to bivalirudin in these patients. Methods. The Switching from Enoxaparin to Bivalirudin in Patients with Acute Coronary Syndromes without ST-segment Elevation Undergoing Percutaneous Coronary Intervention (SWITCH) trial was a prospective, open-label, multicenter study including 91 patients who presented with an ACS without ST-segment elevation, and who had received >/= 1 dose of enoxaparin (1 mg/kg SC) within the 12 hours prior to PCI. Patients were enrolled into 3 time categories: Group 1: 0–4; Group 2: 4–8; and Group 3: 8–12 hours from last enoxaparin dose to PCI. The primary endpoint of the study was major bleeding complications. Results. Baseline characteri

ABSTRACT: Background. Myocardial infarction with normal coronary arteries (MINCA) is a well-documented syndrome often associated with global left ventricular wall motion abnormalities (LVWMAs). Recent literature has emphasized the occurrence of Takotsubo cardiomyopathy associated with MINCA. What has not been reported is the incidence of MINCA in the general population and the relative frequency of other types of associated LVWMAs. Methods and Results. Data were retrospectively collected on 165 consecutive patients with ST-elevation myocardial infarction (STEMI) and 244 patients with non-ST-elevation myocardial infarction (NSTEMI) who underwent cardiac catheterization at a single institution in Marin County, California. Thirty-two of the 409 (7.8%) patients had MINCA. Of the patients presenting with STEMI, 10.3% had MINCA, and 6.1% of the patients presenting with NSTEMI had MINCA. Females were more likely to present with MINCA than males, both for STEMI (21.6% vs. 5.3%; p

ABSTRACT: Objectives. The goal of this study was to evaluate a new drug-eluting stent (DES) comprising a bioabsorbable polymer eluting a moderate dose of paclitaxel in a clinically relevant animal model. Background. Although DES limit restenosis, adverse vascular pathologies and toxicities continue to be of major concern. Optimization of DES components, especially completely absorbable polymers, may reduce these toxicities. Methods. Bare-metal (BM), absorbable polymer coating only (POLY), and polymer-based paclitaxel-eluting (PACL) stents were implanted in porcine coronary arteries using intravascular ultrasound (IVUS) to optimize stent apposition. The dose density of paclitaxel was 0.30–0.35 µg/mm², with in vitro elution studies demonstrating a gradual elution over 6–8 weeks. The animals were terminated at 1 week, 1 month and 3 months. Histopathologic and histomorphometric analyses were performed. Results. The arteries with PACL showed extensive