Fracture of coronary guidewire during rotational atherectomy with coronary perforation and tamponade.

We present the case of a calcified right coronary artery lesion with a 90-degree exit angle. Attempts at rotational atherectomy led to wire transection and vessel wall perforation necessitating emergent pericardiocentesis and bypass surgery. We review the literature on complications of rotational atherectomy and the management of coronary perforations and retained guidewire fragments.

Embolization of IMA side branch for post-CABG ischemia.

The existence of a chest wall "steal" of blood away from the myocardium through patent internal mammary artery branches has been hypothesized as a cause of recurrent angina pectoris after coronary artery bypass grafting. Although some authors believe that such a steal is physiologically impossible because coronary flow occurs in diastole and chest wall flow in systole, we recently documented ischemia in the left anterior descending coronary artery distribution before embolization of a large left internal mammary artery first intercostal branch that had been left intact at the time of operation. After embolization of the branch, clinical and objective evidence of ischemia resolved.

Coronary thrombi increase PTCA risk. Angioscopy as a clinical tool.

BACKGROUND: The presence of angiographically identified intracoronary thrombus has been variably associated with complications after coronary angioplasty. Angiography has been shown to be less sensitive than angioscopy for detecting subtle details of intracoronary morphology, such as intracoronary thrombi. The clinical importance of thrombi detectable by angioscopy but not by angiography is not known. METHODS AND RESULTS: Percutaneous coronary angioscopy was performed in 122 patients undergoing conventional coronary balloon angioplasty (PTCA) at six medical centers. Unstable angina was present in 95 patients (78%) and stable angina in 27 (22%). Therapy was not guided by angioscopic findings, and no patient received thrombolytic therapy as an adjunct to angioplasty. Coronary thrombi were identified in 74 target lesions (61%) by angioscopy versus only 24 (20%) by angiography. A major in-hospital complication (death, myocardial infarction, or emergency bypass surgery) occurred in 10 of 74 patients (14%) with angioscopic intracoronary thrombus, compared with only 1 of 48 patients (2%) without thrombi (P = .03). In-hospital recurrent ischemia (recurrent angina, repeat PTCA, or abrupt occlusion) occurred in 19 of 74 patients (26%) with angioscopic intracoronary thrombi versus only 5 of 48 (10%) without thrombi (P = .03). Relative risk analysis demonstrated that angioscopic thrombus was strongly associated with adverse outcomes (either a major complication or a recurrent ischemic event) after PTCA (relative risk, 3.11; 95% CI, 1.28 to 7.60; P = .01) and that angiographic thrombi were not associated with these complications (relative risk, 0.85; 95% CI, 0.36 to 2.00; P = .91). CONCLUSIONS: The presence of intracoronary thrombus associated with coronary stenoses is significantly underestimated by angiography. Angioscopic intracoronary thrombi, the majority of which were not detected by angiography, are associated with an increased incidence of adverse outcomes after coronary angioplasty.

Rotational atherectomy in restenotic lesions at the distal saphenous vein graft anastomosis.

Restenotic lesions at distal saphenous vein graft (SVG) anastomoses have been notoriously difficult to treat with standard angioplasty techniques. We explored the potential of rotational atherectomy in three patients with nonthrombotic, focal restenoses at the SVG touch down. The Rotablator safely and successfully recanalized the lesions, allowing further treatment with dilation or stenting or both. Rotational atherectomy may warrant investigation as a treatment for nonthrombotic restenotic SVG lesions.

Bleeding complications with the chimeric antibody to platelet glycoprotein IIb/IIIa integrin in patients undergoing percutaneous coronary intervention. EPIC Investigators.

BACKGROUND: The potential for novel antiplatelet and antithrombin agents to contribute to periprocedural bleeding complications of percutaneous coronary revascularization is poorly defined. In the Evaluation of c7E3 Fab in Preventing Ischemic Complications of High-Risk Angioplasty (EPIC) trial, the periprocedural use of aspirin, heparin, and a chimeric antibody to the platelet glycoprotein IIb/IIIa integrin c7E3 Fab in 2099 patients significantly reduced postprocedural ischemic complications and 6-month clinical restenosis but was associated with increased procedural bleeding complications. We review these complications and describe clinical and procedural variables associated with increased bleeding complications in the EPIC trial. METHODS AND RESULTS: Patients with high-risk clinical or lesion morphological characteristics were randomized to receive placebo bolus plus placebo infusion, c7E3 Fab bolus plus placebo infusion, or c7E3 Fab bolus plus c7E3 Fab infusion. Patients received periprocedural aspirin and intravenous heparin continued for a minimum of 12 hours after the procedure. Outcomes reflecting bleeding complications were measured: transfusions, decreased hemoglobin, and an index including both parameters. Major bleeding complications unrelated to bypass surgery occurred in 3.3%, 8.6%, and 10.6%, and blood product transfusions were used in 7.5%, 14.0%, and 16.8% of patients treated with placebo, bolus c7E3 Fab, and bolus plus infusion c7E3 Fab, respectively (both P < .001). Most major bleeding complications occurred at the femoral access site, regardless of treatment. Intracranial hemorrhage (0.3%) and death (0.09%) attributable to major bleeding complications were rare. Multivariable regression analyses identified several variables significantly and independently related to major bleeding complications or greater blood loss, including greater age, female sex, lower weight, c7E3 Fab therapy, and duration and complexity of the index procedure. Major bleeding complications and blood loss in patients receiving bolus plus infusion were not significantly greater than in those receiving bolus alone (P = .38 and P = .14, respectively). CONCLUSIONS: Bleeding complications unrelated to bypass surgery were two to three times more frequent in patients receiving c7E3 Fab than in those receiving placebo, but most were transient and well tolerated. Risk-factor analysis and modification of concomitant antithrombotic and antiplatelet treatment strategies may aid in reducing bleeding complications and enhancing clinical benefit in patients receiving c7E3 Fab during percutaneous coronary revascularization.

Endovascular techniques in adult aortic coarctation: the use of stents for native and recurrent coarctation repair.

PURPOSE: To report initial experiences with stent implantation in the treatment of native and recurrent aortic coarctation in adults. METHODS: Two adult patients were diagnosed with aortic coarctation: in one, the native aorta was involved, and in the other, the stenosis involved a prior coarctation repair. Both patients were offered and selected angioplasty with possible stent implantation as an alternative to surgery. RESULTS: In the patient with recurrent narrowing, thrombolysis and balloon dilation preceded the successful deployment of three Palmaz stents along the grafted segment. In the case of native disease, one Palmaz stent was implanted primarily at the site of a critical, focal stenosis. No complications were encountered, and recovery was uneventful. Follow-up at 12 and 6 months, respectively, showed sustained clinical improvement with resolution of symptoms and excellent hemodynamic values. CONCLUSIONS: The positive outcome in these early cases supports further evaluation of the efficacy of adjunctive or primary stenting for treatment of native or recurrent aortic coarctation in adults.

Endoluminal grafting for percutaneous aneurysm exclusion in an aortocoronary saphenous vein graft: the first clinical experience.

PURPOSE: Aneurysms develop only rarely in aortocoronary saphenous vein grafts (SVGs), and the usual treatment is surgical replacement of the diseased segment. However, in patients at appreciable risk for redo surgery, alternative therapies are desirable. We report the first compassionate use of a percutaneously delivered endoluminal graft (ELG) for internal exclusion of an SVG aneurysm. METHODS: A 47-year-old male with two coronary bypass procedures and SVG angioplasty presented with an 8-mm diameter aneurysm lying between 80% and 70% stenotic lesions in an SVG to the obtuse marginal branch. The risks of a third bypass operation were considerable, so the decision was made to attempt internal exclusion of the SVG aneurysm. RESULTS: An ELG composed of 2.0-mm diameter unexpanded PTFE graft material with Palmaz stents for fixation was delivered with a low-profile system, but a second ELG was necessary for complete exclusion of the aneurysmal sac. Both ELGs were dilated after initial deployment. The patient was discharged after 9 days without sequelae, and he remains asymptomatic with arteriographically documented ELG patency 5 months after treatment. CONCLUSIONS: In this patient with limited therapeutic options, percutaneous aneurysm exclusion in an SVG was effective in restoring a viable blood conduit. It remains to be seen if ELGs have a potential in aortocoronary SVGs.

Long-term angiographic and clinical outcome after implantation of balloon-expandable stents in aortocoronary saphenous vein grafts.

Balloon angioplasty of aortocoronary saphenous vein graft lesions is associated with high restenosis and clinical event rates. The goal of this multicenter study was to assess long-term angiographic and clinical outcome of patients electively treated with single Palmaz-Schatz stents in aortocoronary saphenous vein grafts. In 198 patients (209 lesions), elective placement of single Palmaz-Schatz stents was attempted. Angiography was performed at baseline, immediately after stent placement, and at 6-month follow-up. Stent placement was successful in 98.5% of patients. One patient (0.5%) had stent thrombosis. Restenosis occurred in 34% (45 of 133) of the restudied lesions. Restenosis was lower in de novo lesions than in restenotic lesions (22% vs 51%, p < 0.001). Ostial lesions had a higher restenosis rate than nonostial lesions (61% vs 28%, p = 0.003). Freedom from death, myocardial infarction, coronary artery bypass surgery, and repeat angioplasty was present in 70% of patients. Eighty-two percent of patients with de novo lesions remained event-free at 1 year, whereas only 55% of patients with prior angioplasty were event-free at 1 year (p < 0.001). The use of the Palmaz-Schatz stent for the treatment of focal, de novo, aortocoronary saphenous vein graft lesions is associated with a high procedural success rate, a low angiographic restenosis rate, and low clinical event rates, including the need for repeat revascularization. The results of this study need validation by a prospective randomized trial comparing stent implantation with angioplasty.

Angioscopy: a valuable tool in the deployment and evaluation of intracoronary stents.

Intracoronary stents were designed to improve balloon dilation results; however, to accomplish this, various criteria of optimal stent deployment must be met. Standard imaging techniques are neither sensitive nor specific enough for intraprocedural use in the verification of these implantation parameters. To assess the usefulness of angioscopy in the procedural and follow-up evaluations of Palmaz-Schatz and Strecker coronary stent deployment, 17 patients underwent angioscopy, 15 during stent placement and 2 during follow-up for stent restenosis. In the latter cases, thrombus formation was suspected; however, angioscopy showed tissue subtotally occluding the lumen without thrombus, so thrombolytic therapy was avoided. Similarly, among the 15 intraprocedural assessments, angioscopy disclosed intravascular thrombus unappreciated on angiography in two cases; another patient at high risk for intravascular thrombus was found not to have clot. In four patients, angioscopy disclosed residual narrowing in need of redilation at the Palmaz-Schatz stent articulation site. Thus in 9 (53%) of 17 stent patients, angioscopic findings either guided therapeutic selection or significantly modified the anticipated procedure. Angioscopy offers important information critical to the accurate placement and evaluation of intracoronary stents.

New treatment approach for chronic total occlusions of saphenous vein grafts: thrombolysis and intravascular stents.

Balloon dilation of saphenous vein graft (SVG) occlusions has a lower success rate than angioplasty of native coronary arteries. To improve this outcome, a new therapy for chronic total SVG occlusions was developed. In three aortocoronary bypass graft patients with class III-IV angina and chronic occlusion of the SVGs to the left anterior descending artery (age of occlusions: 2-24 wk, age of graft 1-13 yr), standard recanalization was achieved with a guide wire and intracoronary urokinase infusion (0.5-1.0 million unit bolus followed by 100,000 IU/hr for 11-24 hr; mean infusion time: 19.7 hr). In each patient, a residual focal stenosis (average 82.5%) was successfully dilated and stented (single 4.0 mm Palmaz-Schatz in two patients and a 3.5 mm Strecker stent in the other). All patients had complete relief of symptoms and no sequelae. During a mean 7.7 mon follow-up, 6-mon arteriographic evaluation in two patients showed minimal intra-stent narrowing (26% and 34%). In the Strecker stent patient, the device proved too small for the vein graft, leading to an 89% stent stenosis found on follow-up arteriography at 5 mon. The stent was redilated successfully with a 5% residual narrowing. After urokinase recanalization of chronic total SVG occlusions, intravascular stents may improve the long-term results seen with conventional SVG angioplasty.

ACS RX flow support catheter as a temporary stent for dissection or occlusion during balloon angioplasty: initial experience.

The ACS RX flow support catheter, which functions as a temporary stent, was placed successfully during four procedures in three patients who had suboptimal results following angioplasty. This investigational device allowed prolonged perfusion and supported the vessel wall when coronary blood flow was compromised, avoiding emergent coronary artery bypass graft surgery during two procedures. In the remaining procedures the device was used as a bridge to surgery. These early applications of the flow support catheter following failed balloon angioplasty suggest a rapid, effective alternative to the autoperfusion balloon when it fails or is contraindicated because of the lesion location.

Palmaz-Schatz stent implantation in stenosed saphenous vein grafts: clinical and angiographic follow-up.

Balloon-expandable stents may reduce the restenosis rate following coronary angioplasty. To evaluate this potential in saphenous vein grafts, 26 patients with 30 discrete stenoses underwent conventional balloon dilation and successful Palmaz-Schatz stent implantation as part of a multicenter trial. All patients had resolution of their angina following the procedure. In a mean 5-month follow-up period, 14 patients (54%, 16 lesions) had repeat arteriography; two patients (14%) developed recurrent ischemia ascribed to their venous grafts from in-stent restenosis (2 of 16 lesions, 13%). Two asymptomatic patients (8%) died: one from cardiac arrest (stent patent) and one from stroke (no autopsy). The clinical recurrence rate (cardiac death, myocardial infarction, bypass surgery, repeat angioplasty, or symptom recurrence) was 15%. These preliminary results show trends toward an improved primary success rate with combined vein graft angioplasty/stenting and a lower restenosis rate in stented saphenous vein grafts, but continuing follow-up will be needed to verify these observations.

Intracoronary stent implantation via the brachial approach: a technique to reduce vascular bleeding complications.

To reduce the incidence of vascular complications of intracoronary stent implantation, we used the brachial approach. We attempted implantation of the Palmaz-Schatz stent via the brachial artery approach at 10 lesions in 9 patients. Stent delivery was successful at 8 lesions. Balloon angioplasty was successfully performed in the 2 failed cases, 1 of whom required surgical repair of the brachial artery. Intravenous anticoagulation was uninterrupted from the time of stent placement until therapeutic prothrombin times from oral warfarin therapy were obtained. Neither acute nor long-term major bleeding occurred in the 9 patients. There were no embolic events, myocardial infarctions, or deaths. One subacute thrombosis occurred, and the patient underwent bypass surgery. To evaluate the risks and benefits of the brachial approach, we compared these 9 patients with 41 who had stent placement by the femoral approach during the same period. Lesion characteristics were similar in these 2 groups. There were no significant differences in the success rate or angiographic outcome between the 2 groups. Seven (17%) patients in the femoral group had vascular access complications requiring surgery, compared with 1 (11%) in the brachial group. No patient in the brachial group required transfusion, compared with all 7 of the patients who had femoral vascular complications. The potential reduction in bleeding complications makes the brachial approach to stent implantation attractive in selected patients.

Holmium laser angioplasty after failed coronary balloon dilation: use of a new solid-state, infrared laser system.

A new solid-state laser system was used in a case of saphenous vein graft occlusion untreatable by standard very low-profile balloon angioplasty. The 2100 nm infrared pulsed thulium/holmium: YAG laser successfully recanalized an obtuse marginal bypass graft without complications. The holmium laser has several advantages over excimer systems and may prove an effective adjunct or alternative to coronary balloon angioplasty.