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BACKGROUND: Among the two stent strategies, contemporary evidence favors double kissing crush technique (DKC) for complex unprotected distal left main bifurcation (UdLMB) lesions. However one of the major challenges to these lesions is side branch (SB) restenosis. AIMS: Our aim was to identify optical coherence tomographic (OCT) characteristics that may predict SB restenosis (SBR) after UdLMB angioplasty using DKC technique. METHODS: This was a single-center, retrospective study that included 60 patients with complex UdLMB disease, who underwent OCT-guided angioplasty using DKC technique. Angiographic follow-up was performed in all patients at 1 year to identify patients with SBR. Patients with SBR group were compared with patients without SBR (NSBR group) for OCT parameters during index procedure. RESULTS: Twelve (20%) patients developed SBR at 1-year follow-up. The SBR group had longer SB lesion (18.8 ± 3.2 vs. 15.3 ± 3.7 mm, p = 0.004) and neo-metallic carinal length (2.1 vs. 0.1 mm, p < 0.001) when compared to the NSBR group. Longer neo-metallic carinal length was associated with the absence of the dumbbell sign, presence of hanging stent struts across the SB ostium on OCT of final MB pullback. On multivariate regression analysis, SB distal reference diameter (DRD) and SB stent expansion were identified as independent predictors of SBR with SB-DRD of ≤2.8 mm (area under curve-0.73, sensitivity-83.3%, and specificity-62.5%) and SB stent expansion of ≤89% (area under curve-0.88, sensitivity-83.3%, and specificity- 81.2%) as the best cut off values to predict SBR. CONCLUSIONS: SB DRD and SB stent expansion are the OCT predictors of future SBR after UdLMB angioplasty using DKC technique.
Subject(s)
Angioplasty, Balloon, Coronary , Coronary Artery Disease , Drug-Eluting Stents , Heart Valve Diseases , Humans , Angioplasty, Balloon, Coronary/adverse effects , Angioplasty, Balloon, Coronary/methods , Retrospective Studies , Tomography, Optical Coherence , Treatment Outcome , Coronary Artery Disease/therapy , Coronary Artery Disease/surgery , Stents , Constriction, Pathologic , Coronary Angiography/methodsABSTRACT
BACKGROUND: Non-eruptive calcium nodules (CNs) are commonly seen in heavily calcified coronary artery disease. They are the most difficult subset for modification, and may result in stent damage, malapposition and under-expansion. There are only limited options available for non-eruptive CN modification. Intravascular lithotripsy (IVL) is being explored as a potentially safe and effective modality in these lesions. AIMS: This study aimed to investigate the safety and efficacy of the use of IVL for the modification of non-eruptive CNs. The study also explored the OCT features of calcium nodule modification by IVL. METHODS: This is a single-center, prospective, observational study in which patients with angiographic heavy calcification and non-eruptive CN on OCT and undergoing PCI were enrolled. The primary safety endpoint was freedom from perforation, no-reflow/slow flow, flow-limiting dissection after IVL therapy, and major adverse cardiac events (MACE) during hospitalization and at 30 days. MACE was defined as a composite of cardiac death, myocardial infarction (MI), and ischemia-driven target lesion revascularization (TLR). The primary efficacy endpoint was procedural success, defined as residual diameter stenosis of <30% on angiography and stent expansion of more than 80% as assessed by OCT. RESULTS: A total of 21 patients with 54 non-eruptive CNs undergoing PCI were prospectively enrolled in the study. Before IVL, OCT revealed a mean calcium score of 3.7 ± 0.5 and a mean MLA at CN of 3.9 ± 2.1 mm2. Following IVL, OCT revealed calcium fractures in 40 out of 54 (74.1%) CNs with an average of 1.05 ± 0.72 fractures per CN. Fractures were predominantly observed at the base of the CN (80%). Post IVL, the mean MLA at CN increased to 4.9 ± 2.3 mm2. After PCI, the mean MSA at the CN was 7.9 ± 2.5 mm2. Optimal stent expansion (stent expansion >80%) at the CN was achieved in 85.71% of patients. All patients remained free from MACE during hospitalization and at the 30-day follow-up. At 1-year follow-up, all-cause death had occurred in 3 (14.3%) patients. CONCLUSIONS: This single-arm study demonstrated the safety, efficacy, and utility of the IVL in a subset of patients with non-eruptive calcified nodules. In this study, minimal procedural complications, excellent lesion modifications, and favorable 30-day and 1-year outcomes were observed.
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A 49-year-old male presented with class III exertional angina, 1 year after angioplasty of the left anterior descending artery (LAD) and right coronary artery. Coronary angiogram revealed 90% in-stent restenosis (ISR) in mid-LAD with angiographic impression of stent fracture. Optical coherence tomographic evaluation of mid-LAD ISR showed a distinct 3 mm long "eclipse sign" indicating embolized, broken guiding catheter tip as a cause of ISR, which was confirmed on reviewing 1-year-old angiographic images. This was managed with "cut and fix technique" using cutting balloon and another drug-eluting stent. Optical coherence tomographic at 9 months showed well endothelialized stent with a thin layer of neo-intimal hyperplasia over the sandwiched broken guiding tip.
Subject(s)
Coronary Restenosis , Drug-Eluting Stents , Male , Humans , Middle Aged , Infant , Drug-Eluting Stents/adverse effects , Treatment Outcome , Stents/adverse effects , Coronary Angiography/adverse effects , Catheters/adverse effects , Coronary Restenosis/etiology , Tomography, Optical Coherence/methodsABSTRACT
Background: Heart Failure with reduced Ejection Fraction (HFrEF) is a common disorder affecting a large population. Iron deficiency (ID) with and without anaemia is an important variable which is often underreported and under treated in clinical practice, which contributes to patient symptoms. The present study was undertaken to study the prevalence and Spectrum of Iron Deficiency in patients of HFrEF. Methods: This is a single-centre observational study. All patients with a clinical diagnosis of HFrEF presenting to the hospital were studied. Ejection Fraction (EF) was assessed on Echo and ID was diagnosed on basis of serum ferritin <100 micro g/dl or serum ferritin 100-300 micro g/dl with low Transferrin Saturation (TSAT) (< 20%). Results: We have studied a total of 204 patients with a predominantly male population (73%) and a mean age of 62.88 years. Most of our patients were in mid-level functional class (mean 2.48 ± 0.50) and had low EF (mean 29.56 ± 6.52). Out of 204 patients, 88.7% patients had ID with 83% patients having absolute ID. Of the total patients with HF, 70% had anaemia. Amongst those with anaemia 93% had ID, and even without anaemia, 68% had absolute or functional ID, underlying the importance of evaluating iron status in all patients of HF irrespective of their haemoglobin levels. Conclusion: This study highlights the burden of iron deficiency in heart failure patients in the Indian population and opens the way for large scale studies for better characterization of iron deficiency as well as therapeutic trials in the management of heart failure patients.
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BACKGROUND: Critical congenital heart diseases (CCHDs), 10% to 25% of all CHD, are duct-dependent defects that are life threatening without intervention in the neonatal period or infancy. One third of neonates with CCHDs are discharged home undetected and have a poorer outcome. Pulse oximetry screening before discharge is increasingly being used to diagnose CCHDs in developed countries. METHODS: This prospective observational study conducted at a tertiary care hospital from September 2016 to March 2019 screened all asymptomatic intramural neonates after 24 hours of life using a Masimo pulse oximeter with signal extraction technology using the standard American Academy of Pediatrics algorithm. A positive screen was followed by a confirmatory echocardiography (gold standard) and a negative screen by clinical examination at 6, 10 and 14 weeks and identification of readmissions during the study period. RESULTS: A total of 1855 neonates (82.99% of the eligible 2235 neonates) underwent screening at a mean (SD) age at screening of 32.4 (6.8) hours and took a mean (SD) time of 3.5 (1.2) minutes. The sensitivity, specificity, positive and negative predictive value of pulse oximetry screening for detection of CCHDs in asymptomatic neonates was 75% (95% CI: 28.91% to 96.59%), 99.29% (95% CI: 98.79% to 99.60%), 18.75% (95% CI: 5.80% to 43.80%) and 99.94% (95% CI: 99.66 to 99.99%), respectively. CONCLUSION: Pulse oximetry screening of asymptomatic neonates between 24 and 48 hours of life improved the detection of CCHDs with high specificity and negative predictive value, moderate sensitivity and a reasonably low false positivity rate.
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BACKGROUND: Soldiers native to lowlands, while sojourning at high altitude (HA), are referred to tertiary care centers with electrocardiographic (ECG) abnormalities. Exposure to HA may precipitate myocardial ischemia in subjects with underlying coronary artery disease (CAD). Conversely, it may produce physiological ECG changes mimicking those of CAD, causing a diagnostic dilemma. This study sought to correlate the presence of CAD on coronary angiography (CAG) with a putative diagnosis of CAD based on clinical findings and ECG. METHODS: A prospective study was conducted on patient's from HA areas, referred for evaluation for CAD to a single center at near-sea-level. Thirty-five minimally symptomatic/asymptomatic soldiers with ECG changes suggestive of CAD, underwent CAG. Correlation was sought between ECG and CAG evidence of CAD. RESULTS: The association of CAD on CAG with clinical and ECG diagnosis of CAD was not significant, 4 of the 35 soldiers (11.4%) showing CAG evidence of CAD (chi square 3.849, p = 0.697). The association between symptoms and coronary artery lesions was, also, not significant, only four of twenty-three (17.4%) minimally symptomatic subjects having CAD on CAG. CONCLUSION: Insignificant numbers of previously healthy persons, who present with minimal symptoms and ECG changes suggestive of CAD while sojourning at HA, have coronary artery involvement on CAG. Those with incidental ECG changes, without symptomatology, do not have CAD on CAG.
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BACKGROUND: At our tertiary care cardiology center, we are receiving soldiers who sustained acute ST-Elevation Myocardial Infarction (STEMI) during the strenuous Battle Field Efficiency Test (BPET) and other such activities. METHODS: This was a single-center observational study to assimilate and analyze the precipitating causes, risk factors, symptoms, and the efficacy of the management protocols in soldiers sustaining STEMI during the BPET or other forms of strenuous military training. RESULTS: All 25 soldiers with documented STEMI following strenuous military training presented with chest pain as the primary symptom. 88% had symptoms either during or within 1st hour of the strenuous activity. 76% underwent thrombolysis with an angiographic success rate of 95%. Primary PCI was possible in only 3/25 (12%) of the cases, of which 2 (66%) did not require stenting after thrombus aspiration; 88% of soldiers reported "training for the event" for less than four times/week. CONCLUSION: STEMI precipitated by strenuous unaccustomed military training have exclusively single vessel affection with an excellent response to thrombolysis and thrombus aspiration. Thus, the timely institution of pharmacological or mechanical revascularization therapy has dramatic results in the preservation of ventricular function. The lack of training for the strenuous event provides strong evidence for comprehensive, graded, physical training prior to strenuous military activities to prevent acute coronary syndromes.
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OBJECTIVES: We compared dual-source CT (DSCT) and conventional angiography (CA) in evaluation of chronic total occlusion (CTO) of coronary arteries. BACKGROUND: Percutaneous coronary intervention (PCI) in CTO is technically difficult and has comparatively lower success rate than intervention in non-occluded artery. Accurate assessment of lesion morphology is an important determinant of PCI success in CTO. METHODS: Nineteen symptomatic patients (18 men, age: 58.6 ± 10.6 years) with a CTO on CA were subjected to a DSCT (Definition, Siemens, Germany). Heart rate (HR) control was not performed. Dedicated post-processing software was used for lesion analysis on both modalities. Presence of bridging collaterals, stump morphology, calcification, side branch, proximal tortuosity, occlusion length, distal vessel interpretability, and distal lesions were statistically compared. RESULTS: There were 20 CTOs. HR during DSCT ranged from 53 to 131 bpm. Bridging collaterals were seen in 3/20 (15%) lesions on CA and in none on DSCT. Stump anatomy and side branch were identified equally well. Plaque calcification was identified in 5/20 (25%) lesions on CA and in 12/20 (60%) lesions on DSCT (P = 0.025). Nature and extent of calcification were better visualized on DSCT. No proximal tortuosity was noted. Distal vessel was better interpretable on DSCT (15/20; 75%) compared to CA (9/20; 45%) (P = 0.05). No significant difference in lesion length was noted. CONCLUSION: DSCT performs as well as CA for most features of CTO. Avoidance of need to control HR, ability to better detect and characterize calcium and to interpret distal vessels make it a useful pre-intervention investigation. © 2014 Wiley Periodicals, Inc.
Subject(s)
Computed Tomography Angiography , Coronary Angiography/methods , Coronary Occlusion/diagnostic imaging , Coronary Vessels/diagnostic imaging , Adult , Aged , Chronic Disease , Collateral Circulation , Coronary Circulation , Coronary Occlusion/physiopathology , Coronary Occlusion/therapy , Coronary Vessels/physiopathology , Female , Humans , Male , Middle Aged , Percutaneous Coronary Intervention , Pilot Projects , Plaque, Atherosclerotic , Predictive Value of Tests , Radiographic Image Interpretation, Computer-Assisted , Software , Vascular Calcification/diagnostic imagingABSTRACT
BACKGROUND: Competitive sports training causes structural and conductive system changes manifesting by various electrocardiographic alterations. We undertook this study to assess the prevalence of abnormal ECG in trained Indian athletes and correlate it with the nature of sports training, that is endurance or strength training. METHODS: We evaluated a standard resting, lying 12 lead Electrocardiogram (ECG) in 66 actively training Indian athletes. Standard diagnostic criteria were used to define various morphological ECG abnormalities. RESULTS: 33/66 (50%) of the athletes were undertaking endurance training while the other 33 (50%) were involved in a strength-training regimen. Overall 54/66 (81%) sportsmen had significant ECG changes. 68% of these changes were considered as normal training related features, while the remaining 32% were considered abnormal. There were seven common training related ECG changes-Sinus Bradycardia (21%), Sinus Arrhythmia (16%), 1st degree Atrioventricular Heart Block (6%), Type 1 2nd-degree Atrioventicular Heart Block (3%), Incomplete Right bundle branch block (RBBB) (24%), Early Repolarization (42%), Left Ventricular Hypertrophy (LVH) (14%); while three abnormal ECG changes--T-wave inversion (13%), RBBB(4%), Right ventricular hypertrophy (RVH) with strain (29%) were noted. Early repolarization (commonest change), sinus bradycardia, and incomplete RBBB were the commoner features noticed, with a significantly higher presence in the endurance trained athletes. CONCLUSION: A high proportion of athletes undergoing competitive level sports training are likely to have abnormal ECG recordings. Majority of these are benign, and related to the physiological adaptation to the extreme levels of exertion. These changes are commoner during endurance training (running) than strength training (weightlifting).
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BACKGROUND: Iron deficiency anemia (IDA) is a prevalent hematological complication associated with gastrointestinal (GI) cancers due to an increased loss of iron and decreased iron absorption. The purpose of this systematic review is to evaluate the use of parenteral iron to treat IDA in patients with GI cancer. METHODS: PubMed, Cochrane, EMBASE, CINHAL and Scopus were searched from January 1, 2010 to September 29, 2023 with no language restrictions. We excluded editorials, case reports, abstracts, conference papers, and poster presentations. Studies were included if they discussed IDA, GI neoplasms, use of iron supplementation (with or without erythropoietin-stimulating agents [ESAs]), defined anemia and had an adult patient population. We assessed the efficacy of parenteral iron in comparison to other iron supplementation methods when treating IDA in patients with GI cancer. The Cochrane Risk of Bias Tool 2 (RoB 2) and the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) assessment tools were used to assess the quality of the included studies. Moreover, the Cochrane Effective Practice and Organization data collection form was used to collect pertinent study information. RESULTS: Our search yielded 3,969 studies across all databases. Twenty-one studies were included (6 randomized control trials; 15 non-randomized studies). Of the 15 studies evaluating hemoglobin (Hb) response, seven studies found an increase in Hb levels when patients were treated with IV iron. The 14 studies evaluating red blood cell (RBC) transfusion rates found conflicting differences in RBC transfusion needs when treated with IV iron. Studies analyzing health related outcomes typically found an increase in quality of life and decreased post-operative complications. DISCUSSION: This review demonstrates improved outcomes of IDA in patients with GI cancer treated with IV iron instead of other iron supplementation methods. Timely diagnosis and appropriate IDA management can greatly improve quality of life in this patient population, especially if myelosuppressive chemotherapy is required.
Subject(s)
Anemia, Iron-Deficiency , Gastrointestinal Neoplasms , Iron , Humans , Anemia, Iron-Deficiency/drug therapy , Gastrointestinal Neoplasms/complications , Gastrointestinal Neoplasms/drug therapy , Iron/administration & dosage , Iron/therapeutic use , Administration, IntravenousABSTRACT
Percutaneous coronary intervention (PCI) of calcified coronary arteries is associated with poor outcomes. Poorly modified calcified lesion hinders the stent delivery, disrupts drug-carrying polymer, impairs drug elution kinetics and results in under-expanded stent (UES). UES is the most common cause of acute stent thrombosis and in-stent restenosis after PCI of calcified lesions. Angiography has poor sensitivity for recognition and quantification of coronary calcium, thereby mandating the use of intravascular imaging. Intravascular imaging, like intravascular ultrasound and optical coherence tomography, has the potential to accurately identify and quantify the coronary calcium and to guide appropriate modification device before stent placement. Available options for the modification of calcified plaque include modified balloons (cutting balloon, scoring balloon and high-pressure balloon), atherectomy devices (rotational atherectomy and orbital atherectomy) and laser atherectomy. Coronary intravascular lithotripsy (IVL) is the newest addition to the tool box for calcified plaque modification. It produces the acoustic shockwaves, which interact with the coronary calcium to cause multiplanar fractures. These calcium fractures increase the vessel compliance and result in desirable minimum stent areas. Coronary IVL has established its safety and efficacy for calcified lesion in series of Disrupt CAD trials. Its advantages over atherectomy devices include ease of use on workhorse wire, ability to modify deep calcium, no debris embolization causing slow flow or no-flow and minimal thermal injury. It is showing promising results in modification of difficult calcified lesion subsets such as calcified nodule, calcified left main bifurcation lesions and chronic total occlusion. In this review, authors will summarize the mechanism of action for IVL, its role in contemporary practice, evidence available for its use, its advantages over atherectomy devices and its imaging insight in different calcified lesion scenarios.
Shock the rock with coronary intravascular lithotripsyPresence of coronary calcium during stenting is associated with the risk of stent under expansion. It's imperative to adequately modify this coronary calcium before placing the stent. Till recent past, the most effective method for calcium modification is debulking it with rotational artherectomy, which is associated with the risk of coronary perforation, slow flow or abrupt vessel closure. Recently, a balloon-based lithotripsy device has established its safety and efficacy for treating such lesions. Coronary intravascular lithotripsy (IVL) is an easy to use calcium modification device and is associated with almost negligible complications, when compared with artherectomy devices. In this review, we will discuss the mechanism of IVL action and its use in different scenarios of calcified coronary artery disease.
Subject(s)
Coronary Artery Disease , Lithotripsy , Vascular Calcification , Humans , Lithotripsy/adverse effects , Vascular Calcification/therapy , Vascular Calcification/diagnostic imaging , Coronary Artery Disease/therapy , Coronary Artery Disease/diagnostic imaging , Treatment Outcome , Percutaneous Coronary Intervention/adverse effects , Percutaneous Coronary Intervention/instrumentation , Stents , Coronary Vessels/diagnostic imaging , Risk Factors , Plaque, Atherosclerotic , Ultrasonography, InterventionalABSTRACT
Background Carotid artery stenting (CAS) has emerged as a less invasive alternative to carotid endarterectomy (CEA) for the prevention of future cerebrovascular events in patients with carotid artery stenosis. Despite multiple randomized controlled trials (RCTs) comparing CAS and CEA for carotid disease, real-world data outside the rigorous environment of trials is scarce. Methods The present study is a prospective observational study conducted at a tertiary care center, wherein all patients who underwent CAS between January 2007 and December 2019 were included. All patients were followed up for one year of the last enrolled patient at an interval of one, six, and 12 months and then yearly thereafter. The primary composite outcome was defined as a combination of periprocedural (until 30 days of procedure) major adverse cardiac and cerebrovascular events (MACCEs) and the long-term incidence of ipsilateral stroke. The secondary outcome included the rate of restenosis. Results A total of 115 patients (86 males and 29 females) (147 lesions) who underwent CAS between 2007 and 2019 were followed up for a median of 80.5 months. Seventy-seven (67.27%) patients were symptomatic, and 38/115 (33%) were asymptomatic. Periprocedural MACCEs were noted in six patients, and four patients had ipsilateral stroke on long-term follow-up; hence, the primary composite outcome was observed in 10 (8.7%) patients. Higher age was found to be significantly associated with the primary composite outcome (p-value = 0.005). Five (4.34%) patients were lost to follow-up, while four (3.48%) patients developed restenosis. Conclusion CAS is a safe and less invasive intervention in patients with significant carotid artery stenosis and is equally effective in preventing future strokes. The incidence of primary outcome rises with an increase in age.
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OBJECTIVES: To do a quantitative comparison of saline and contrast Frequency domain optical coherence tomography (FD-OCT) during percutaneous coronary intervention (PCI) optimisation. METHODS: 13 pairs of OCT runs were analysed, wherein each pair consisted of a contrast run and a heparinized saline run taken in the same coronary artery at the same position. Quantitative analysis was done comparing minimal lumen area (MLA), proximal reference diameter (PRD), distal reference diameter (DRD) and percentage area stenosis (AS) at the same anatomical location. Lesion morphologies, rendered stent view and 3D reconstruction were compared for image clarity. RESULT: The saline OCT runs resulted in comparable MLA (3.88 ± 2.59 mm2 with saline run vs 3.88 ± 2.71 mm2 with contrast run; p = 0.650), PRD (3.66 ± 0.52 mm with saline vs 3.65 ± 0.52 mm with contrast; p = 0.463), DRD (2.97 ± 0.22 mm with saline vs 2.99 ± 0.88 mm with contrast; p = 0.433), and AS (59.60 ± 18.62% with saline vs 59.18 ± 19.11% with contrast; p = 0.753) with respect to the contrast runs. The Bland Altman plots of the measured parameters indicate good agreement between saline and contrast OCT. Linear regression analysis indicated the absence of proportional bias All lesion morphologies (calcified, fibrotic, thin cap fibroatheroma, macrophages, cholesterol crystals and edge dissection), 3D reconstruction and rendered stent view were clearly demonstrable in the saline OCT runs. CONCLUSIONS: Using heparinized saline as flushing media in coronary FD-OCT may result in vessel dimensions that are comparable with contrast. Heparinized saline may be used as a contrast saving alternative for FD-OCT during PCI optimization.
Subject(s)
Coronary Artery Disease , Percutaneous Coronary Intervention , Constriction, Pathologic , Coronary Angiography , Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/pathology , Coronary Artery Disease/therapy , Coronary Vessels/diagnostic imaging , Coronary Vessels/pathology , Humans , Percutaneous Coronary Intervention/adverse effects , Predictive Value of Tests , Prospective Studies , Tomography, Optical Coherence , Treatment OutcomeABSTRACT
Coronary artery disease (CAD) is the leading cause of morbidity and mortality in the world. However, some fascinating advances in the field of cardiology have not only added years to people's life but life to years as well. Percutaneous coronary intervention (PCI), commonly known as coronary angioplasty is a nonsurgical procedure used to treat stenotic coronary arteries. In recent years, PCI has become the preferred modality of treatment for occluded coronary arteries. However, there has been growing interest in the quality of life (QOL) issues for those who undergo such procedures. Depression, anxiety, vital exhaustion, hostility, anger, and acute mental stress have been evaluated as risk factors for the development and progression of CAD. Further, they also have strong bearing toward recovery from an acute coronary event. The current article discusses the role of depression, anxiety, and QOL of patients undergoing PCI.
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Calcified lesions often result in undilatable lesions, balloon dog-boning, poor device delivery as well as underexpanded stents (UES). This leads to an increased risk of acute and chronic stent failure. A 49-year-old man was admitted with anterior wall myocardial infarction and angiogram showed a diffuse calcific left anterior descending artery/diagonal lesion, which was stented with two overlapping drug-eluting stents. Angiogram after post-dilatation showed UES. Optical coherence tomography (OCT) confirmed UES with 58% expansion, minimum stent area (MSA) of 2.91 mm2 and 360° calcium arc around the stent. This UES was dilated with a ultra high-pressure balloon (UHPB) at 40 atmosphere, that led to calcium fracture and increased MSA to 7.42 mm2 and stent expansion to 97%. While OCT-guided lesion modification prior to stenting is ideal, OCT-guided assessment and management is also invaluable post-percutaneous coronary intervention. In the event of stent underexpansion, UHPB may be used as an initial management strategy.
Subject(s)
Angioplasty, Balloon, Coronary/methods , Coronary Stenosis/surgery , Drug-Eluting Stents , Tomography, Optical Coherence , Vascular Calcification/surgery , Coronary Angiography , Coronary Stenosis/complications , Coronary Stenosis/diagnostic imaging , Humans , Male , Middle Aged , Percutaneous Coronary Intervention , Prosthesis Design , ST Elevation Myocardial Infarction/drug therapy , ST Elevation Myocardial Infarction/etiology , Thrombolytic Therapy , Vascular Calcification/complications , Vascular Calcification/diagnostic imagingABSTRACT
BACKGROUND: Coronary artery perforation (CAP), although rare, can often be a life-threatening complication of percutaneous coronary intervention. Looped wire tip or buckling of wire is conventionally considered safer due to reduced risk of migration into smaller branches and false lumen. Occasionally, buckling can indicate the entry of tip into dissection plane, or the advancement of looped wire can cause small vessel injury leading to perforation. Distal coronary perforation can be life threatening and coil, foam, and thrombin injection are some of the material widely used for sealing it. CASE SUMMARY: We hereby report three different cases illustrating the vessel injury that the looped wire can cause in the distal vasculature related to various mechanisms like high elastic recoil tension, dissection by the non-leading wire tip, or hard wire lacerating the fragile small branches. All these mechanisms lead to distal coronary perforation leading to cardiac tamponade. Each case also illustrate the novel technique of autologous fat globule embolization for the management of distal CAP. DISCUSSION: Distal coronary perforation is often due to guidewire-related vessel injury and is more common with hydrophilic wires. Looped wire tip can sometime indicate vessel injury and its advancement further down the coronary artery may result in serious vessel injury and perforation. Management of distal coronary perforation is challenging, and here we demonstrate the steps of using the readily available autologous fat globules by selectively injecting them into the small coronary artery to control the leak.
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Objectives: In this study, we intend to analyze the feasibility and efficacy of very low frame rate fluoroscopy (VLFF) protocol using a combination of 3.8 and 7.5 fps while performing Percutaneous Coronary Intervention (PCI). Methods: A retrospective cohort including 193 patients undergoing PCI under the VLFF protocol (Post-VLFF group) was compared with a retrospective cohort of 133 patients, who underwent PCI prior to implementation of VLFF protocol (Pre-VLFF group). In the Pre-VLFF group, all PCIs were performed using fluoroscopy frame rate of 15 fps. In the Post-VLFF group, 3.8 fps was used to guide catheter engagement, coronary lesion wiring, pre-and post-dilation, and 7.5 fps was used for lesion assessment and stent placement. Increasing use of fluoroscopic storage in place of cineangiography was also encouraged. Cine acquisition in both groups was performed at 15 fps. Primary endpoint was radiation exposure measured by Air Kerma. Secondary endpoints were procedure related outcomes and patient related outcomes (Major Adverse Cardiac Events including all-cause mortality, Target Lesion Failure, Myocardial Infarction, and Stroke). RESULTS: Post-VLFF group showed 74.7% reduction in Air Kerma as compared to Pre-VLFF group (433 ± 27 mGy vs. 1,714 ± 140 mGy; p < 0.0001), with no increase in the fluoroscopy time (15.38 ± 0.98 min Post-VLFF vs. 17.06 ± 1.29 min Pre-VLFF; p = 0.529) and contrast volume (116.5 ± 4.9 ml Post-VLFF vs. 116.7 ± 6 ml Pre-VLFF; p = 0.700). Both groups had comparable procedural success and complications rates as well as incidence of MACE. Conclusions: The very low frame rate fluoroscopy protocol is a feasible, effective, and safe method to significantly reduce the radiation exposure during PCI without any compromise on procedural and patient outcomes.