Multivessel spontaneous coronary artery dissection in a patient with severe systolic hypertension: a possible association. A case report.

Spontaneous coronary artery dissection (SCAD) is an uncommon cause of myocardial ischemia and infarction. Hypertension has not been associated with SCAD. The authors report multivessel SCAD in an elderly woman with severe systolic hypertension. They postulate that hypertension of this degree may play a pathophysiologic role in the causation of SCAD.

Dual-balloon progressive coronary dilatation catheter: design and initial clinical experience.

As newer interventional devices continue to enter the marketplace, balloon angioplasty remains the standard by which all devices are judged with regard to both safety and efficacy. It has been observed that predilating a stenosis with a small balloon followed by dilatation with an optimally sized larger balloon creates a more controlled arterial injury, reduces complications, and thus improves success rates. Exchanging two balloons for each lesion, however, increases the complexity and cost of the procedure in addition to increasing the amount of time required and the amount of radiation exposure. Therefore an "over-the-wire" dual-balloon catheter was developed with a small distal balloon and a larger proximal balloon on a 2.9F shaft to allow progressive coronary dilatation with a single device, without necessitating a balloon catheter exchange. The device was used successfully in 45 of 47 patients (78 lesions). The two failures were related to an inability to cross the lesion in one and failure of the device in the other. Twenty-one patients (47%) underwent a multivessel procedure. There were 29 left anterior descending/diagonal, 17 circumflex/marginal, 20 right coronary artery/posterior descending artery, and 10 vein graft lesions. The device was successfully delivered in the native anatomy to 12 distal, 27 mid, and 27, proximal lesions of which nine were osteal, for a procedural success rate of 97%. The mean stenosis was reduced from 80.7 +/- 11.5% to 15.2 +/- 11.9%. There were no major dissections, only 9 (11.2%) minor dissections, and no myocardial infarctions.(ABSTRACT TRUNCATED AT 250 WORDS)

Angioplasty of the septal perforators: acute outcome and long-term clinical efficacy.

Critical stenosis of a large septal perforator artery can cause significant myocardial ischemia. Since septal perforators are generally not accessible for bypass grafting, balloon angioplasty offers an excellent alternative for revascularization of these vessels. The short-term outcome and long-term clinical follow-up angioplasty of the septal perforator was evaluated retrospectively in 21 patients. Fourteen of the 21 (66%) had previous myocardial infarction, 9 of 21 (43%) had previous coronary bypass surgery, 10 of 21 (48%) had previous percutaneous transluminal coronary angioplasty (PTCA), and 6 of 21 (28%) had congestive heart failure. Additional PTCA of one or more vessels was undertaken in all patients. Primary success of PTCA of the septal perforator was achieved in 20 of 21 (95%) patients. The mean stenosis was improved from 89.8 +/- 10% to 18.4 +/- 11.7%. No acute closure, emergency coronary bypass, or myocardial infarction was observed or needed during hospital stay. At long-term follow-up (18 +/- 9 months), event-free survival was 95%. No cardiac death occurred. In 86% of cases, there was significant improvement in anginal class at 2 years. Five of the six patients with congestive heart failure showed marked improvement in functional class at 2 years. In conclusion, balloon angioplasty of the large septal perforator artery is technically feasible, with a high success rate, and does not increase the rate of acute complications of the procedure. Along with PTCA of other arteries, it provides long-term relief of angina in a majority of symptomatic patients with complex multivessel disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Progressive coronary dilation: an angioplasty technique that creates controlled arterial injury and reduces complications.

The incidence of dissection or acute closure during coronary angioplasty has remained unchanged in spite of increased operator experience and technologic advances. To test the hypothesis that progressive coronary dilation, that is, predilation of the stenosis with a smaller balloon (2.0 or 2.5 mm) and then maximal dilation with an optimally sized (3.0, 3.25, 3.5, 3.75, or 4.0 mm) balloon may produce controlled injury and thus reduce the incidence of major complications, the procedural success rate and acute complications of progressive coronary dilation were analyzed in 1087 patients (1486 vessels) and compared with other large series. To determine whether progressive coronary dilation would improve success rates for complex lesions, the last 167 vessels were also prospectively characterized by American College of Cardiology/American Heart Association criteria. Of the 1248 vessels with partial occlusions, the success rate was 98.7%. Attempts to dilate total occlusions in 16% (353) of vessels yielded a success rate of 88%. The primary success rates for types A, B, and C lesions were 100%, 97%, and 91%, respectively. Multivessel angioplasty with progressive coronary dilation was done in 32.4% of cases. Acute closure, major dissection, emergency coronary bypass, periprocedural myocardial infarction, and in-hospital death were noted in 1.4%, 1.3%, 0.7%, 0.8%, and 0.09% of the patients, respectively; the incidence was significantly lower than in previously reported series. Mean residual stenosis was 20.0% +/- 10.6%. Thus progressive coronary dilation by controlled injury to the plaque offers a high primary success rate; low residual stenosis; and markedly lower incidence of acute closure, major dissection, emergency coronary bypass, and death in dilation of both simple and complex lesions.

Right atrial compression in postoperative cardiac patients: detection by transesophageal echocardiography.

Four patients developed hypotension after heart surgery. Hemodynamic measurements revealed elevated right atrial pressure with normal pulmonary capillary wedge pressure. Conventional transthoracic two-dimensional echocardiography was technically suboptimal for detection of pericardial effusion. In each patient transesophageal echocardiography demonstrated significant compression of the right atrium by a localized mass. At reoperation atrial compression by an organized hematoma was found and in each instance successfully drained. Thus, transesophageal echocardiography is superior to transthoracic echocardiography in evaluating critically ill postoperative hypotensive patients and can differentiate isolated right atrial tamponade from other causes of hemodynamic deterioration such as prosthetic valve dysfunction or left ventricular systolic dysfunction, or both.

Management of patients with renal and ureteric calculi presenting with chronic renal insufficiency.

Of 403 patients with renal and ureteric calculi treated during the last 4 years, 64 presented with features of chronic renal insufficiency: 59 of these underwent surgery. Good pre-operative preparation and conservative renal surgery restored normal renal function in 14 patients and 27 improved significantly. The remainder either did not improve or continued to have progressive renal failure. It is emphasised that these patients are considerably worse off compared with their counterparts with normal renal function. The overall mortality rate was 17%. Patients whose post-operative serum creatinine levels did not stabilise to less than 884 mumol/l seemed to make poor progress in the follow-up period.