Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) has procedural and ultimate long-term success rates that are significantly less than those currently reported for nonocclusive lesions. A CTO is generally defined as an occlusion, with thrombolysis in myocardial infarction (TIMI) grade 0 or 1 antegrade flow, that is more than 3 months old. On angiography, CTO lesions occur in approximately one-third of patients with significant coronary lesions, but PCI for CTO only accounts for approximately 10% of patients undergoing PCI.¹ Successful recanalization of CTO with PCI reduces the need to resort to bypass surgery; furthermore, observational studies have shown lower cumulative rates of cardiac death or myocardial infarction and an improvement in symptomatic status after successful PCI for CTO.^2–5

Coronary artery vasospasm may be observed in 3–4% of diagnostic coronary angiography procedures.¹ It is more likely to occur in younger females who are heavy smokers and who present with rest pain.² In addition to occurring spontaneously, coronary spasm may be induced by the angiographic catheter tip. The right coronary artery is more commonly involved, whereas spasm of the left main coronary artery is rare. Differentiation of spasm from fixed obstructive coronary lesions is crucial, as treatment strategies are different. This can be difficult, particularly in more distal spasm. We describe a case of a patient presenting with rest angina and a strongly positive exercise stress test whose coronary angiography demonstrated an apparent severe left main coronary lesion. This led to expeditious surgical revasculariztion.

Anomalous coronary arteries occur in less than 2% of the general population.¹ Anomalous origin of the left circumflex artery (LCx) from the right coronary artery or the right sinus of valsalva is the most common coronary anomaly reported in angiographic series and necropsy studies.² The LCx origin from the pulmonary artery is a very rare anomaly. As an isolated lesion, anomalous origin of the LCx from the pulmonary artery as a cause of classic angina in adults is extremely uncommon.

Since the initial description in late 1960s by Porstmann and associates^1,2 of a patent ductus arteriosus (PDA) occluding device, a number of other devices have been studied, as reviewed elsewhere.^3,4 Transcatheter closure of PDA using various devices and coils^5–14 is now an established practice in most cardiac centers. These techniques have proven to be safe and cost-effective.^14–16

Injury to a left internal mammary artery (LIMA) bypass graft is a known complication of repeat cardiothoracic surgical intervention. This report details the percutaneous intervention to an entrapped LIMA graft to the left anterior descending artery (LAD).

Elevated cholesterol is a well-established major cardiac risk factor for the development of coronary artery disease (CAD). Multiple randomized controlled trials have clearly demonstrated that lowering low-density lipoprotein (LDL) levels with statin therapy significantly reduces overall mortality and major adverse cardiac events.^1–4 This significant benefit also extends to patients undergoing percutaneous coronary intervention (PCI).^4–7

Approximately 7 million angiograms and interventional procedures are performed worldwide each year, and the incidence of these procedures continues to rise, particularly in developing countries. The vast majority of these procedures are performed utilizing access via the femoral artery.^1,2 Traditionally, manual compression has been utilized to achieve closure of the arteriotomy despite the close observation, prolonged immobilization and bedrest that are required for this method. In the past decade, a variety of closure devices has been developed to facilitate access site management and to increase patient comfort. Although a number of new devices has been introduced in the last several years, there remain concerns about the safety, efficacy and ease-of-use with these closure devices.^3–8

Dear Editor,

We read with interest the article in the November 2004 issue concerning nickel allergy in a case where an atrial septal defect was being closed.¹ To test whether a patient reporting nickel allergy was sensitive to a device, they applied the device to the skin, eliciting a contact allergic response. Nickel allergy has also been implicated in adverse responses to other steel implants. We have had a number of cases where percutaneous coronary intervention was required in patients reporting nickel allergy, raising concern about possible reaction to the stents. Nickel allergy has been postulated as having a role in in-stent restenosis, a response to the nickel present in virtually all stents, though this is disputed.^2,3

Atrial septal defects (ASD) are increasingly being subjected to closure by percutaneous techniques.^1–3 Exact sizing of the ASD is a prerequisite for optimal selection of the occlusion device. Sizing of ASDs can be done by echocardiography (transthoracic, transesophageal or intracardiac) and by sizing balloons in the catheterization laboratory. Stretched ASD balloon diameter measured by the balloon is considered the gold standard among them. Here we report a hitherto unreported complication of rupture of the atrial septum by the sizing balloon.

Renal artery stenosis is the second most common cause of secondary hypertension. Its prevalence is increasing with advancing age and has been shown to be 28% in high-risk males referred for cardiac catheterization, or 15% in an autopsy series of patients who died of a stroke.^1,2 Ninety percent of cases are due to atherosclerotic disease, with involvement of mainly the proximal renal artery in older male patients and fibromuscular dysplasia in 10% of the patients with the middle portion of the renal artery being involved, seen usually in young females.³ The combination of atherosclerotic renal artery stenosis and fibromuscular dysplasia in the same renal artery is very rare, with one case reported in the literature to the best of our knowledge.4 We report an unusual case of an elderly lady with concomitant atherosclerotic and fibromuscular dysplasia renal artery stenosis.