Arterial revascularization by means of percutaneous transluminal angioplasty (PTA) is a mainstay in the management of patients with peripheral artery disease and critical limb ischemia (CLI). However, when employing standard approaches, percutaneous transluminal angioplasty (PTA) of below-the-knee arteries may fail in up to 20% of cases. In the present article, we report on a novel interventional strategy, the pedal-plantar loop technique, which we successfully employed in a patient with critical lower limb ischemia. This technique may sensibly increase success rates of PTA in very challenging total occlusions of below-the-knee arteries (e.g., those lacking a proximal occlusion stump). Technical points pertinent to this case are clearly illustrated, including the need to accurately choose guidewires and balloons of appropriate length, and the extensive use of the subintimal angioplasty technique. J INVASIVE CARDIOL 20007;19:E34–E36

We describe a case of successful percutaneous closure of a moderate-sized paravalvular leak using the Amplatzer septal occluder device in a patient with excessive surgical risk. We were able to successfully close the paravalvular leak without interfering with normal prosthetic valve leaflet function. In patients with severe periprosthetic mitral regurgitation refractory to aggressive medical therapy who are not candidates for surgical intervention, use of the Amplatzer septal occluder device offers an attractive percutaneous treatment option. J INVASIVE CARDIOL 2007;19:E46–E

Recently, reports of stent fracture with focal restenosis have suggested that it is another mechanism of in-stent restenosis after implantation of sirolimus-eluting stents. However, the mechanism by which strut disruption occurs remains unknown. Current reports of in-stent restenosis suggest that fracture of drug-eluting stents is different from bare-metal stents, and can progress to restenosis and reocclusion. We report on a patient with a fractured stent in a patent coronary artery that progressed to diffuse neointimal hyperplasia presenting with acute myocardial infarction 2 years after stent placement. J INVASIVE CARDIOL 2007;19:E43–E45

Although left ventricular pseudoaneurysm (LVPA) is a rare complication of mitral valve replacement, it is associated with an increased risk of rupture and consequent high mortality. It is important to establish the diagnosis of LVPA early so that definitive surgical therapy can be administered. Cardiac magnetic resonance imaging provides an accurate preoperative evaluation that may be useful in the routine evaluation of suspected LVPA cases. J INVASIVE CARDIOL 2007;19:88–89

Diagnosing plaque vulnerability may have therapeutic and prognostic implications. We used a heat sensor-tipped thermography guidewire to identify temperature variations in atherosclerotic coronary arteries in patients undergoing stent placement. This study is the first human experience with the ThermoCoil Guidewire (TG). TG consists of a 0.014 inch wire which rotates as it is retracted so as to interrogate the arterial lumen in a helical path. The wire has a temperature sensor in the distal tip with a sensitivity of 0.03°C. In 13 patients presenting with either acute or chronic coronary syndromes as indications for percutaneous coronary intervention, the following parameters were assessed: thermography, intravascular ultrasound (IVUS), angiography and serum markers for inflammation (C-reactive protein) and ischemia (troponin). Directional atherectomy was performed in 2 patients and tissue was analyzed histopathologically. Two patients had unstable angina, 2 had myocardial infarction,

ABSTRACT: Background. Coronary saphenous vein bypass graft (SVG) stenting has been associated with up to a 30% rate of no-reflow or myocardial infarction (MI) when performed without distal protection. Methods. We evaluated the technique using prophylactic “pharmacologic” arteriolar vasodilatation with intracoronary nicardipine followed by immediate direct stenting for the treatment of degenerated coronary SVGs without mechanical distal protection. Data were collected from 83 consecutive elective SVG interventions in 68 patients. Quantitative coronary angiographic measurements were performed by the Borgess angiographic core lab. Electrocardiograms (ECGs), CPKs, and CPK-MBs were obtained preprocedure and at 12–18 hours after the intervention. Follow-up data at 30 days were obtained in 67/68 (98%) patients. Results. The average graft age was 11.9 ± 6.6 years with thrombus in 26/83 vessels (31%). The primary adverse endpoint of total CPK > 3x the upper limit of normal (ULN), or CPK-MB >3 t

Background. The use of bivalirudin in percutaneous coronary interventions has been shown to be clinically safe and effective, and may be associated with shorter hospital stays and lower costs than heparin + glycoprotein (GP) IIb/IIIa inhibition. This study compared the utilization, clinical outcomes and costs associated with the planned use of bivalirudin versus heparin + GP IIb/IIIa inhibition in drug-eluting stent (DES) patients without acute myocardial infarction (MI). Methods. We retrospectively studied 1,842 patients who underwent DES placement between May 2003 and December 2004. Planned treatment with heparin + GP IIb/IIIa inhibition was administered to 1,305 and planned bivalirudin alone was administered to 537 patients. Clinical follow ups (mean = 782 ± 204 days) were obtained via telephone or mailed surveys in 1,813 patients (98.4%). Propensity analysis was utilized to adjust for between-groups baseline differences. Results. The unadjusted data revealed si

Background. Although the use of polymer-based drug-eluting stents appears to markedly reduce the risk of in-stent restenosis, there are concerns about their safety including polymer layer integrity. Objectives. The objective of this study was to investigate the morphology of the polymer layer of 3 commercially available polymer-coated stents, including the effects of balloon catheter expansion, by scanning electron microscopy (SEM). Methods. We assessed discontinuities and other irregularities in the polymer layer of BiodivYsio, Taxus and Cypher stents by SEM after balloon expansion in saline solution at 37°C. Results. Distinctive polymer layer morphologies were found among the 3 stent types, including responses to balloon expansion and withdrawal. The BiodivYsio stent showed no waving or other irregularities on the outer surface, but excess polymer was present on stent edges and polymer was peeled off from the inner surface. The Taxus stent showed no irregu

Background. Left main trifurcation coronary artery disease stenting is a challenging and complex percutaneous procedure that has been infrequently reported. We present our own experience with left main trifurcation stenting using the Taxus® paclitaxel-eluting stent (Boston Scientific). Methods. Twenty consecutive left main trifurcation stenting procedures were performed in 2005 at our institution. The primary endpoint of the study was the combined endpoints of death, acute stent thrombosis and target lesion revascularization (TLR). Conditional logistic regression analysis was performed to determine the predictors of the primary endpoint using a number of variable combinations. Results. The mean patient age was 71.7 ± 8.9 years. The procedure was urgent in 10%, and the left main artery was unprotected in 95% of cases. Follow up was achieved in 17/20 (85%) patients, either from medical records or by phone calls. The follow-up median duration was 272 days (range 30–5

Access for coronary angiography and intervention is increasingly achieved via the radial artery due to the significant risks of femoral access. However, anatomical and size variation mean the radial artery is not always suitable. The ulnar artery is occasionally used as an alternative in such cases, and while ulnar artery puncture may be relatively easy, there are anatomical particulars that could lead to complications following this access route. In the absence of accepted guidelines, this paper examines the available data on ulnar access for coronary procedures. A structured literature search was undertaken to gather peer-reviewed articles and conference abstracts relating to ulnar access. Data from each source were examined in a prescribed way with reference to technical aspects, procedural success or failure, catheter size and complications. A total of 9 publications and 2 conference abstracts were identified, detailing 483 transulnar coronary procedures in 463 cases. There were no