Percutaneous intervention for renal artery stenosis was born in controversy and remains a debatable treatment strategy for the 2–4 million Americans affected. However, this important intervention remains the best option for many. This article presents a summary of early examinations and may serve to place the current deliberations into context.

Atrial Septal Defects
Atrial septal defects account for about one-third of all congenital heart abnormalities detected in adults.¹ A large defect in adult patients results in symptoms and complications such as arrhythmias, cardiac failure and pulmonary hypertension.^1,2 The first transcatheter device closure of an atrial septal defect was described in 1976.³ Today, percutaneous closure of this defect is widely practiced using different types of devices and has replaced surgical closure of a simple secundum atrial septal defect in most centers.^4–13

Since the discovery of X-rays in 1895, there has been continuous development, first of imaging techniques, but over the last several decades, of therapeutics, to address the number-one killer of individuals in the industrialized world….heart disease. Since Andreas Gruentzig’s initial description of coronary angioplasty,¹ a whole host of additional percutaneous therapeutics have been developed. Along with percutaneous therapeutics, there has also been tremendous growth in percutaneous diagnostic techniques and equipment. As a testament to Gruentzig’s pioneering work, there are in excess of 20,000 citations in PubMed regarding the search term “PTCA”.²

When German-born Andreas Roland Grüntzig arrived in 1969 in Zurich, Switzerland, and joined the Angiology Division of the University Hospital, founded some years before, he stated: “I have dedicated my life to the vascular diseases”.¹ First, he proved his dedication by showing that the relaxation time of the Achilles tendon reflex is significantly prolonged in intermittent claudication during calf muscle pain (Figure 1).² He also contributed to the evaluation of the recently-introduced continuous wave Doppler ultrasound for the measurement of systolic ankle pressure and for the diagnosis of deep venous thrombosis.³

Percutaneous coronary intervention is the accepted optimum strategy in the treatment of both myocardial infarction and stable angina resistant to medical therapy.¹ Traditionally most procedures have been performed via the femoral access route however adverse events due to vascular complications are not uncommon. In addition the use of evidence based therapies such as clopidogrel,² fondiparinux,³ low-molecular weight heparins4 and glycoprotein (GP) IIb/IIIa antagonists⁵ increase the risk of such complications. Recent studies have shown the transradial route to be a feasible alternative with lower rates of vascular complications but requiring greater technical skill.

Mechanical complications comprise the second leading cause of in-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI), especially in the elderly.¹ Among them, ventricular septal rupture (VSR) complicates approximately 0.2% of STEMI cases and is associated with very high mortality.² It usually occurs within 1 week, primarily within the first 24 hours of symptom-onset.

Anaphylaxis is a severe, life-threatening, generalized hypersensitivity reaction that is mostly mediated by IgE antibodies, often starting with erythema, urticaria and/or angioedema, and occasionally involving cardiovascular and respiratory systems. However, non-IgE-mediated reactions, clinically indistinguishable, may occur.¹
Acute coronary syndromes have been described as potential, yet rare, complications of any type of anaphylactic reaction, and have been reported as a consequence of insect sting,^2,3 shellfish ingestion,⁴ drugs^5–8 or contrast media administration.^9–12 However, the mechanisms involved are not yet completely understood.^13,14

Case Report. An 86-year-old female with a medical history of hypertension and hypercholesterolemia who was on medication complained of dyspnea, chest pain and shortness of breath that was relieved at rest. She had a positive stress test and her electrocardiogram indicated sinus bradycardia, left anterior fascicular block and left ventricular hypertrophy. Her CK-MB and troponin I values were normal.

A computed tomography angiogram (CTA) revealed an anomalous left main (LM) artery originating from the right sinus of Valsalva coursing posteriorly with focal stenoses at the origin of the LM and right coronary (RCA) arteries (Figure 1A). Cardiac catheterization corroborated the CTA, revealing a 70% stenosed ostial RCA, 70% ostial, and 80% distal LM and coronary artery stenoses (Figure 1B). The patient had normal left ventricular function and no mitral or aortic stenosis.