Significant left main coronary stenosis occurs in 5–7% of patients undergoing coronary angiography.^1,2 Patients with “unprotected” left main coronary artery (ULMCA) disease treated medically have an estimated 3-year mortality rate of 50%.^3,4 Since clinical trials have consistently demonstrated a survival benefit of coronary artery bypass graft (CABG) surgery over medical therapy,^5,7 the current standard of care for treatment of ULMCA stenosis is CABG surgery.
Percutaneous coronary intervention (PCI) of ULMCA is associated with a high rate of early restenosis (especially when the procedure involves the distal left main bifurcation). Since acute thrombotic occlusion and mortality were reported in earlier clinical studies, the American College of Cardiology and American Heart Association have discouraged elective PCI for ULMCA.⁸

Advances in interventional cardiology are reflected in the increased complexity of percutaneous coronary interventions (PCI). This leads to an increasing use of fluoroscopic guidance in these procedures with a concomitant increase in concern regarding radiation exposure of patients and staff.¹ An increased level of radiation exposure has been reported to be associated with operator experience, radial (compared with brachial) vascular approach, previous coronary artery bypass grafting (CABG), and complex vessel and lesion characteristics including chronic total occlusions, bifurcation lesions, and severely calcified lesions.^2–10

Endovascular treatment has become the predominant method of revascularization for arterial obstructive disease for both coronary and peripheral vascular disease. As such, radiation exposure and fluoroscopy times during percutaneous coronary and peripheral interventions (PCI) have increased, thus raising concerns over radiation skin injuries and associated injuries.^1–7 Given improvements in technologies with PCI and peripheral interventions, the complexity of the cases has likewise increased. Increased fluoroscopic times and radiation exposure times have been associated in previous studies with all types of percutaneous coronary interventional and peripheral devices.

Cardiogenic shock is the leading cause of death in patients with acute myocardial infarction (AMI) who reach the hospital alive.^1,2 The reported incidence of cardiogenic shock in patients with AMI is 7–10%.^1,3 The mortality rate in these patients is very high, approaching 80%,^1,3 and is not significantly reduced by the use of fibrinolytic therapy.4 For the cohort of patients suitable for inclusion in the large fibrinolytic trials, a mortality rate of around 60% has been seen in shock patients treated with the most effective thrombolytic agents.^4,5

A strategy of early revascularization with intensive hemodynamic support saves lives in patients with cardiogenic shock in comparison to conventional medical management.⁶ The SHould we emergently revascularise Occluded Coronaries for cardiogenic shocK (SHOCK) trial demonstrated that in patients with AMI complicated by cardiogenic shock, early mechanical revascularizatio

Technological advancements have revolutionized the field of interventional cardiology by introducing newer devices and better pharmacological agents.

While contemporary percutaneous coronary intervention (PCI) is predominantly a stent-based strategy, other modalities are occasionally used in lieu of or in addition to stents. Rotational atherectomy uses a high-speed rotating bit to pulverize plaque into microparticles and is often used for debulking calcific lesions.^1,2 With the widespread use of drug-eluting stents, it is increasingly being used to facilitate stent delivery in calcified vessels.

Percutaneous diagnostic and therapeutic cardiovascular procedures rely on intravascular use of iodinated radiocontrast agents for visualization in the cardiac catheterization laboratory. The use of radiocontrast agents has been associated with the development of nephropathy following such procedures and most importantly, subsequent increased mortality and morbidity.^1–6 Radiocontrast-induced nephropathy (RCIN) is the third most common cause of in-hospital renal failure and accounts for a significant increase in both length of stay and cost.⁷

The importance of prompt and straightforward determination of patients at highest risk of RCIN is paramount, since supportive care and adjuvant agents may reduce the impact of these agents on kidney function. Despite reports of risk factors associated with the development of RCIN, no predictive score has been externally validated or universally adopted as a clinical risk stratification mechanism.

HIV Disease

Human immunodeficiency virus (HIV) infection results from one of two similar retroviruses (HIV-1 and HIV-2) that destroy CD4+ lymphocytes and impair cell-mediated immunity, affecting multiple organ systems, increasing the risk of certain infections and cancers. Its manifestation ranges from asymptomatic carriage to the acquired immune deficiency syndrome (AIDS), which is defined by serious opportunistic infections or cancers. Since its global epidemic in the late 1970s, and the recognition of AIDS in 1981, more than 40 million people have been infected (one-third have died, two-thirds are living with infection) with HIV disease. Approximately 90% of patients live in the developing world, 70% in Africa, and most of the new infections occur in Asia and sub-Saharan Africa. The Centers for Disease Control and Prevention (CDC) estimates that there are 650,000–900,000 people living with this disease in the United States.

Case Presentation. A 58-year-old male presented with substernal chest pain that started while mowing his lawn. The chest pain radiated to the left shoulder and was not relieved with sublingual nitroglycerin. He had controlled hypertension and type II diabetes mellitus. He had undergone percutaneous intervention with bare-metal stenting of the ostial circumflex (CFX) and ostial left anterior descending (LAD) arteries. The patient developed in-stent restenosis of his CFX and LAD stents. He underwent coronary artery bypass surgery (CABG), involving placement of a left internal mammary artery (LIMA) graft to the left anterior descending (LAD) artery, and a Y radial artery graft to the second obtuse marginal artery. He also underwent dual-chamber pacemaker implantation for symptomatic sinus bradycardia.

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