Successful Percutaneous Rescue Treatment of Acute Carotid Stent Thrombosis Utilizing a Modified Embolic Protection Device.

Acute Carotid Stent Thrombosis (ACST) is a rare complication of Carotid Artery Stenting (CAS) with a potentially fatal outcome. We report a case of ACST occurring five minutes after the end of a successful CAS procedure that was promptly treated by carotid stent-in-stent implantation using a new percutaneous strategy based on the creation of a modified embolic protection device. Following the procedure, we did not observe brain lesions suggestive of acute cerebral ischemic events at the CT scan performed at 48 hours, as well as no neurological deficits in the following days.

[Staged rotational atherectomy in a patient with acute ST-elevation myocardial infarction: a case report and review of the literature]. / Aterectomia rotazionale e strategia "Rota-staged PCI" in un paziente con infarto miocardico acuto e sopraslivellamento del tratto ST: caso clinico e revisione della letteratura.

Rotational atherectomy represents an option to improve the treatment of calcified/undilatable coronary stenoses, but its use in ST-elevation myocardial infarction (STEMI) is controversial. We report the case of a patient with an occlusive and calcified coronary stenosis and its management not previously described. A 67-year-old man with STEMI was referred to our cath-lab. Coronary angiography showed a complex calcified and thrombotic occlusion of the right coronary artery. Vessel patency was obtained with balloon dilation, achieving clinical stability. The patient started dual antiplatelet therapy and was scheduled for a staged procedure using rotational atherectomy ("Rota-staged PCI"), performed 6 days later reaching optimal angiographic and clinical results. Our purpose was to manage this STEMI patient with an occluded and heavily calcified coronary artery in two times: a primary coronary angioplasty to quickly reopen the artery and an early staged PCI using rotational atherectomy to optimize the intervention (coronary dilation and stent deployment) minimizing the risk of stent underexpansion or acute complications.

Clinical and angiographic outcomes in elderly patients treated with endothelial progenitor cell capture coronary stents: results from a prospective single-center registry.

OBJECTIVE: To evaluate the outcomes in elderly patients treated with endothelial progenitor cell (EPC) capture stent, designed to promote rapid stent endothelialization, and dual-antiplatelet therapy for only 1 month. BACKGROUND: Although some registries showed that drug-eluting stents have better clinical outcomes and can reduce reinterventions in comparison to bare-metal stents in elderly patients, the subsequent prolonged dual-antiplatelet therapy needed after drug-eluting stent implantation can likely be interrupted because of intolerance or comorbidities in this subset of patients, with high risk of stent thrombosis. METHODS: One hundred consecutive patients ≥ 75 years with de novo lesions in native coronary arteries underwent EPC capture stent implantation. The study endpoints were major adverse cardiac events (MACE), binary restenosis and late lumen loss. RESULTS: Mean age was 79 ± 3 years (78% male), 28% had diabetes, and 81% had non-ST-elevation acute coronary syndrome. A total of 134 lesions were treated, 69% were type B2/C, and 143 EPC capture stents were implanted (1.4 stents per patient). At 1-year follow up, clinical outcomes were: all-cause death, 8%; myocardial infarction, 2%; clinically-justified target lesion revascularization (TLR), 22%; MACE, 28%; and definite stent thrombosis, 2% (2 cases in the same patient). Angiographic 6-month follow up showed a binary restenosis rate of 35% and a late lumen loss of 0.94 ± 0.86 mm. CONCLUSION: This study suggests that EPC capture stent is safe and feasible in patients ≥ 75 years of age, but clinically justified TLR and binary restenosis were frequently observed.

Multivessel spontaneous coronary artery dissection in a postpartum woman treated with multiple drug-eluting stents.

Multivessel spontaneous coronary artery dissection is a very rare cause of myocardial ischemia. Its optimal treatment is not yet well defined and is usually tailored to clinical features. We report a case of a postpartum woman with multivessel spontaneous coronary artery dissection and acute myocardial infarction, in whom the drug-eluting stenting of the only alleged 'culprit' vessel did not prevent the propagation of dissection from another vessel. Although the recommendations drawn from a single case report are not conclusive, we believe that when there is a multivessel spontaneous coronary artery dissection in a setting of acute myocardial infarction, all dissected coronary segments should be treated using stents.

Apical thrombus in a patient with takotsubo cardiomyopathy.

We report a case of apical thrombus formation among a group of 15 patients with takotsubo cardiomyopathy who were referred for a suspected acute coronary syndrome over a 2.5-year period. To the best of our knowledge, no data are available regarding the treatment of this syndrome. According to current literature and our reported experience, the use of anticoagulant therapy administered until complete resolution of wall motion abnormalities appears to be appropriate to treat apical thrombus formation and any possible subsequent embolism.

Two-year clinical follow up of coronary drug-eluting stent in patients at high risk for coronary restenosis.

OBJECTIVE: To evaluate the long-term follow up of patients at high risk for coronary restenosis. BACKGROUND: Drug-eluting stents (DES) have been proven to reduce restenosis and reintervention compared with bare-metal stents (BMS). Although the safety of DES is not different from that of BMS in the short-to-medium term, concern has arisen about the potential for late stent thrombosis related to delayed endothelialization of the stent struts. METHODS: Among 495 patients who underwent percutaneous coronary intervention between June 2004 and March 2005, we retrospectively identified a subset of 150 patients (30%) at high risk for coronary restenosis on the basis of angiographic characteristics who were treated with DES. We assessed the incidence of major adverse cardiac events (MACE) during a 2-year follow-up period. The risk of MACE was estimated by computing the hazard ratio and the 95% confidence interval using the Cox regression method. RESULTS: At baseline, 31% of the patients had diabetes mellitus, 43% had previous myocardial infarction (MI), and 12% had ST-elevation acute MI as the cause of admission. The most frequent selection criteria observed were the presence of a long lesion (73% of patients) and the execution of multivessel angioplasty (43% of patients). Overall, 284 lesions were treated (1.9 lesions/patient) and 318 stents were implanted (2 stents/patient). Two-year cumulative incidence of the combined endpoint of death or MI, target vessel revascularization (TVR), MACE and target lesion revascularization were 7.3%, 10%, 16% and 7.3%, respectively. Significant predictors of MACE at 2 years were total occlusion, number of lesions treated and age. Significant predictors of TVR at 2 years were bypass graft treatment, total occlusion, number of stents implanted and number of lesions treated. Stent thrombosis occurred in 3 patients (2%). CONCLUSION: In these real-world patients at high risk for coronary restenosis, the use of DES was associated with a low incidence of cardiac events.

Primary coronary angioplasty in a patient with anomalous origin of the right coronary artery from the left sinus of Valsalva.

We report a rare case of primary coronary angioplasty in a patient with acute myocardial infarction due to thrombotic occlusion of an anomalous right coronary artery arising from the left sinus of Valsalva. The non-invasive method of ischaemia localisation, such as ST-segment elevation on the electrocardiogram, was useful in identifying the infarct-related artery. A major factor was the selection of the guiding catheter to access the anomalous right coronary artery and also to obtain good angiographic visualisation and adequate support for percutaneous coronary intervention.

Intraventricular obstruction in a patient with tako-tsubo cardiomyopathy.

We describe a case of a 70-year-old woman who developed chest pain and shortness of breath not related to a stress. The patient, with history of hypertension, presented T-wave inversion and prolonged QTc interval at admission electrocardiogram, peak troponin I level was normal, and no signs of myocarditis were found. Angiography demonstrated the "apical ballooning" without any obstructive coronary artery disease; on pullback of the pigtail catheter from the left ventricular apex to the basal tract, a 35 mm Hg gradient was observed. The echocardiographic evaluation showed asymmetric septal wall thickening of 19 mm, systolic anterior motion of the anterior mitral leaflet, juxtaposition of the septum to the mitral chordal apparatus, no significant left ventricular outflow tract gradient, moderate-to-severe mitral regurgitation and a pulmonary systolic pressure of 40 mm Hg. Rest (201)tallium myocardial perfusion scintigraphy SPECT showed a perfusion defect in the left ventricular apex. At 1-month echocardiographic and scintigraphic follow-up, left ventricular wall motion and myocardial perfusion returned completely normal. Nine months after the acute event the patient remained asymptomatic. We hypothesize that septal ventricular hypertrophy and intraventricular obstruction could be related to the development of some of the cases of tako-tsubo cardiomyopathy.

A case of transient left mid ventricular ballooning.

We describe a case of an 85-year-old woman who presented with chest pain after a crisis of bronchial asthma. On admission, the electrocardiogram showed ST-segment elevation in leads II, III, and aVF. Peak troponin I level was 3.0 ng/dl (normal value <0.4 ng/dl). Angiography demonstrated ballooning of the mid portion of the left ventricle without involvement of the apex. No obstructive epicardial coronary artery disease was present. After 8 days, left ventricular wall motion improved and returned completely to normal at 1-month echocardiographic follow-up.

Transient impairment of myocardial perfusion in a patient with apical ballooning syndrome.

We describe a case of a 76-year-old woman who presented with chest pain after a violent argument. On admission the electrocardiogram showed 1-mm ST segment elevation in II, III, aVF, V3-V6 leads; the subsequent electrocardiogram showed T-wave inversion in the same leads. Peak troponin I level was 7.3 ng/dl (normal <0.4 ng/dl). Emergency angiography demonstrated the so-called "apical ballooning", in the absence of any obstructive coronary artery disease. A myocardial contrast echocardiogram performed 5 days later showed a large perfusion defect in the akinetic apical region of the left ventricle; at 1-month follow-up myocardial perfusion and left ventricular wall motion became completely normal. In patients with apical ballooning syndrome a catecholamine-mediated endothelial injury might be responsible of a microvascular coronary dysfunction which causes myocardial ischemia and subsequent myocardial stunning.

Clinical features of transient left ventricular apical ballooning.

This report describes the clinical characteristics of 8 consecutive patients with transient left ventricular apical ballooning identified among 389 patients (2%) admitted to a tertiary referral hospital with suspected acute coronary syndromes over a 1-year period. Among these patients, 2 cases appeared to be caused by acute myocarditis and 1 case by head trauma with intracranial bleeding. In the remaining 5 cases, no apparent cause was found. All patients but 1 were postmenopausal women (mean age 60 +/- 13.5 years). Preceding strong emotional or physical stress was present in 6 patients. The presenting symptom in 7 patients was chest pain. Four patients had significant ST-segment elevation, and the remaining 4 had T-wave inversions on their admission electrocardiograms. Mean peak troponin I was moderately elevated (3.7 +/- 4.5 ng/dl). The mean echocardiographic left ventricular ejection fraction was 40 +/- 10% on admission and increased significantly to 63 +/- 4% at 1-month follow-up (p <0.0001). All patients but 1 had abnormal corrected Thrombolysis In Myocardial Infarction frame counts (>27 frames) in >or=1 major epicardial coronary artery. All patients were alive and without major adverse cardiac events at 6-month follow-up. In conclusion, transient left ventricular apical ballooning should be considered in the differential diagnosis of patients presenting with suspected acute coronary syndromes, because it may account for approximately 2% of hospital admissions.