Plaque rupture or fissure leading to the exposure of highly thrombogenic material to platelets and coagulation factors and subsequent thrombosis of the coronary artery is thought to be the principal mechanism associated with acute coronary syndromes including acute myocardial infarction (MI) and unstable angina/non-ST-elevation MI.^1-3 Percutaneous coronary intervention (PCI) on thrombus-containing lesions represents a clinical challenge to the interventional cardiologist, since thrombus has been identified as a predictor of adverse outcome.^4,5 In attempts to reestablish coronary perfusion, PCI of thrombus-laden native coronary arteries and bypass saphenous venous grafts (SVGs) can lead to distal embolization.⁶ Distal embolization of thrombus, fibrin content and other atherosclerotic plaque particulate matter can lead to a varying degree of consequences ranging from asymptomatic cardiac enzyme leak to flow-limiting microvascular obstruction, which m

The transradial approach is a useful technique in patients undergoing percutaneous coronary intervention. As compared to femoral access, it is associated with reduced access site bleeding, lower patient morbidity, less post-procedure staff utilization and has been adopted at an increasing number of centers worldwide.^1–5 Although unusual, the presence of severe subclavian occlusive disease is an occasional cause for inability to access the coronaries from the radial artery. We describe two cases in which transradial coronary stenting of severe subclavian artery stenoses allowed successful coronary stenting as part of the procedure.

Case Report 1. A 65-year-old white, diabetic female with no prior history of coronary artery disease was admitted for recurrent chest pain, an abnormal stress test and elective cardiac catheterization with possible intervention.

Case Report. This is the case of a 50-year-old woman who presented to hospital with an anterior myocardial infarction. She was treated with thrombolysis, with front loaded r-tPA, within 2 hours of onset of symptoms. She had previously been fit and well with no known risk factors for cardiovascular disease. She had no history of illicit drug use. She had been taking zolmitriptan (2.5 mg o.d.) for migraine for 6 months. Two days prior to her myocardial infarction, she increased the dose of zolmitriptan to 2.5 mg b.d. She had recurrence of chest pain with further ST elevation anteriorly (Figure 1) over the following 2 days and subsequently underwent urgent coronary angiography which showed normal coronary arteries. Left ventriculography showed antero-apical akinesia with an estimated ejection fraction of 45% (Figure 2). Over the ensuing few days, she developed further chest pain associated with ST-elevation in the same territory.

The presence of coronary artery aneurysm (CAA) is revealed in 1–4% of coronary angiography1 but the association with aortic abdominal aneurysm (AAA) is only anecdotal.2–3 Atherosclerosis (50% of cases)1 and more rarely, Marfan disease,4 Kawasaki disease5 and rheumatoid arthritis6 are considered the main causes of coronary aneurysms, while atherosclerosis (80% of cases) and inflammation (3–10% of cases)7 constitute practically the only etiologies of aortic abdominal aneurysms.
No association of CAA with inflammatory AAA has been reported thus far. We present a case of CAA and inflammatory AAA in which staged surgical treatment of both diseases was performed instead of endovascular management.

The percutaneous implantation of left ventricular leads in patients with congestive heart failure can be difficult in approximately 5% of implants. A variety of curved introducer sheaths, guidewires and steerable electrophysiology catheters has helped to facilitate these procedures. This case report illustrates the utility of a novel steerable introducer sheath to help engage and define the coronary sinus ostium.

The treatment of coronary or saphenous vein graft (SVG) aneurysms has traditionally been surgical.^1,2 With the advent of percutaneous coronary techniques, less invasive approaches are possible in the management of this rare but serious condition.³ Acute coronary syndrome, myocardial infarction, graft rupture and fistula formation have all been reported as a result of SVG aneurysms.^4–6 Stenting of coronary and saphenous vein graft aneurysms have been reported with vein-covered stents.^7,8 The use of polytetrafluoroethylene (PTFE)-covered stents has been reported in the treatment of coronary arterial aneurysms;⁹ reported use of this device in SVG aneurysms has been rare, if at all, in the literature. Our review showed no direct reported cases of PTFE-covered stents in SVG aneurysms.

It has been reported that the percutaneous coronary intervention (PCI) for bifurcation lesions results in a much higher restenosis rate than that for non-bifurcation lesions.^1,2 Moreover, stent implantation to bifurcation lesions often causes side branch occlusion or narrowing, mainly due to the plaque shift from the parent vessel and/or the ostium being compromised by the stent struts themselves.³ Yet another problem is that stenting at a bifurcation lesion might impair accessibility to newly developed stenosis of a side branch, especially when a slotted tube stent is implanted at a previous PCI, a situation generally called “stent jail.” However, owing to the refinement of stent design — not only coil stents but also many slotted tube stents — excellent side branch accessibility is now possible. Consequently, problem PCI cases with regard to stent jail have become rare these days.

The arterial access required during most invasive vascular procedures provides a common source of complications and morbidity. This problem has been aggravated by recent trends in earlier ambulation. Both suture mediated and collagen hemostasis devices are advantageous from the standpoint of earlier ambulation and patient comfort. They are associated with iatrogenic complications of their own with vascular occlusion and endovascular infection being the most dreaded.
The incidence of major complications of closure devices is 1.2–1.4%, depending on the degree of concomitant anticoagulation and the device studied.¹ Major complications include need for surgical repair or transfusion. Minor complications like local infection, hematomas and small pseudoaneurysms range from 7–14%, depending on the study population and the device used.²

Dear Readers,

Free wall rupture (FWR) is one of the major causes of mortality of acute myocardial infarction (AMI).1–3 Acute free wall rupture leads to cardiac tamponade, rapid hemodynamic deterioration and almost instantaneous death. Previous studies demonstrated some clinical predictors of FWR, such as anterior or lateral location, female gender, ST-elevation, protracted or recurrent chest pain, history of hypertension and advanced age.1,3–10
Because emergent coronary angiography and durable reperfusion strategy with coronary angioplasty was demonstrated to reduce rates of death or nonfatal reinfarction,11–15 the indication of angiography for patients with AMI is becoming more frequent than ever. But it is not clear whether FWR can be predicted with coronary angiography.