Attempted retrieval of guidewire fragment using the twisting wire technique causes coronary perfusion: Case report.

RATIONALE: Guidewire fracture is one of the biggest risks of percutaneous coronary intervention, twisting wire technique is very useful for retrieving the fractured wire, but the potential risks have been inadequately reported. Herein, we present a case of retrieval of guidewire fragments using the twisting wire technique that causes coronary perfusion. PATIENT CONCERNS: A 37-year-old male patient was admitted to our hospital for elective percutaneous coronary intervention of the left circumflex coronary artery. CLINICAL FINDINGS: For chronic total occlusion of the distal left circumflex coronary artery, antegrade recanalization by wire escalation, and parallel wire techniques were attempted. However, we shockingly found that the BMW guidewire, anchored in the right coronary artery, spontaneously fractured from the proximal right coronary artery, and a lengthy fragment of the guidewire remained in the coronary. DIAGNOSES, INTERVENTIONS, AND OUTCOMES: Many attempts were made to retrieve the remnant guidewire including the twisting wire technique, which leads to the perforation of the coronary. OUTCOMES: Finally, percutaneous retrieving procedures were stopped in favor of surgical extraction via a small coronary arteriotomy. This procedure was successful. LESSONS: To the best of our knowledge, the present case is the first reported spontaneous fracture of the guidewire. Leaving such a lengthy remnant guidewire in the artery, or leaving stenting over the wire, would impose a high risk of coronary thrombosis, perforation, and embolization. Yet, the perforation of the artery that occurred in this case, which could have had life-threatening consequences, resulted from our attempts to retrieve the guidewire using the twisting wire technique.

Experimental validation and clinical feasibility of 3D reconstruction of coronary artery bifurcation stents using intravascular ultrasound.

The structural morphology of coronary stents and the local hemodynamic environment following stent deployment in coronary arteries are crucial determinants of procedural success and subsequent clinical outcomes. High-resolution intracoronary imaging has the potential to facilitate geometrically accurate three-dimensional (3D) reconstruction of coronary stents. This work presents an innovative algorithm for the 3D reconstruction of coronary artery stents, leveraging intravascular ultrasound (IVUS) and angiography. The accuracy and reproducibility of our method were tested in stented patient-specific silicone models, with micro-computed tomography serving as a reference standard. We also evaluated the clinical feasibility and ability to perform computational fluid dynamics (CFD) studies in a clinically stented coronary bifurcation. Our experimental and clinical studies demonstrated that our proposed algorithm could reproduce the complex 3D stent configuration with a high degree of precision and reproducibility. Moreover, the algorithm was proved clinically feasible in cases with stents deployed in a diseased coronary artery bifurcation, enabling CFD studies to assess the hemodynamic environment. In combination with patient-specific CFD studies, our method can be applied to stenting optimization, training in stenting techniques, and advancements in stent research and development.

Delayed pericarditis following ethanol ablation of the vein of Marshall in the treatment of atrial fibrillation: a case report.

In this case report, we will discuss a 74-year-old female who presented with a chief complaint of abdominal pain, bloating, anorexia, and nausea for four days which preceded after catheter ablation and anhydrous ethanol infusion vein of Marshall (VOM) one month prior. She was admitted and treated as a general patient in the general ward. After hospital admission, a pericardiocentesis was guided by B-scan ultrasonography, resulting in the extraction of 20ml of pericardial effusion, followed by catheterization for drainage. The key takeaway in this report is that anhydrous ethanol infusion VOM may not always be without risks. Hence, during the procedure, it is imperative to carefully administer the appropriate volume of anhydrous ethanol into the VOM to prevent vessel damage and associated complications.

Understanding large vessel perforation requiring treatment with covered stent implantation: A case series.

Large vessel perforation during coronary intervention is a rare but potentially fatal complication, often requiring implantation of a covered stent for resolution. While technology is improving, the long-term patency of covered stents is less than drug-eluting stents, and implantation of covered stents should be used sparingly. Large vessel perforations are complex and often the perforation inflow is not located at the site of extravasation seen on angiography. This can lead to geographic miss when implanting covered stents and necessitate the implantation of additional covered stents which increases the risk for short- and long-term complications. We present a case series to further investigate the anatomy and mechanism of large vessel perforations and guidance on effective covered stent implantation.

Two stents' dislodgement in the left main coronary artery: a case report.

BACKGROUND: Stent dislodgement is a life-threatening complication that can result in coronary artery embolization, stent thrombosis, acute myocardial infarction, and even death. Severely angulated, heavily calcified, and previously stented coronary arteries are associated risk factors. With the development of different lesion preparation techniques and the drug eluting stent era, the reported incidence of stent dislodgement has decreased to < 1% in the last few years. CASE PRESENTATION: We report a case of a 64-year-old Moroccan man complicated during percutaneous intervention in the left main artery by the loss of two stents. This complication was successfully managed by passing the stent's balloon into the stent and then fully expanding it. In our case, the device's characteristics were involved and could play a role in such complications, but it is still not well understood. CONCLUSIONS: The main treatment option is stent retrieval with different available techniques. If retrieval of the stent is impossible, crushing it against the blood vessel wall could be considered.

Outcomes following coronary chronic total occlusion revascularization with drug-coated balloons.

OBJECTIVES: Despite the introduction of improved drug eluting stents (DES), the rate of repeat revascularization procedures following percutaneous coronary interventions (PCI) in coronary chronic total occlusions (CTO) remains high. By leaving vessels uncaged and limiting length of stented segments, drug-coated balloons (DCB) represent an appealing alternative to DES for CTO-PCI. Since data supporting the use of DCBs in CTO-PCI is scarce, we compared the outcomes of patients undergoing CTO-PCI involving DCBs vs DES only. METHODS: From 2 prospective registries, outcomes of patients undergoing CTO-PCI involving DCBs and those undergoing PCI with DES only were compared. Outcomes included major adverse cardiac and cerebrovascular events (MACCE) and cardiovascular death (CV-death). RESULTS: Overall, 157 patients were studied; 112 (71%) underwent CTO-PCI involving DCBs and 45 (29%) were treated with DES only. Mean J-CTO score was 1.84 ± 0.7. Most CTO-lesions involved the right coronary artery, 88 (56%), and 26 (17%) cases were in-stent occlusions. In the DCB group, 46 (41%) lesions were treated with DCBs alone. Mean lengths of the stented segments in the DCB vs DES cohorts were 59 ± 28 mm vs 87 ± 37 mm (P less than .001), respectively. After 12 months, the MACCE rate was higher in the DES only vs DCB group (26% vs 11%, P=.03). Length of the stented segment was an independent predictor for MACCE (HR 1.15 [95% CI, 1.05-1.26] per 10-mm stent length). CONCLUSIONS: Revascularization of CTO lesions involving DCBs appears safe and potentially lowers MACCE rates compared to treatment with DES alone. Importantly, using DCBs for CTO treatment may reduce total stent length, which determines PCI outcomes.

Evaluation of post-dilatation on longitudinal stent deformation and postprocedural stent malapposition in the left main artery by optical coherence tomography (OCT): an in vitro study.

BACKGROUND: The diameter of the ostial and proximal left main coronary artery can be greater than 5.0 mm. However, the diameters of the mostly available coronary drug-eluting stents (DESs) are ≤ 4.0 mm. Whether high-pressure dilatation can increase the diameter of stents from 4.0 to 5.0 mm and whether post-dilatation leads to longitudinal stent deformation (LSD) of 4.0-mm-diameter stents have rarely been studied. Therefore, this study aims to evaluate LSD and stent malapposition of six types of commercially available 4.0-mm-diameter stents in China in a 5.0-mm-diameter artificial blood vessel model by optical coherence tomography (OCT) in vitro. METHODS: The left main coronary artery was simulated by a truncated cone-shaped silicone tube. The internal diameters were 4.0 mm at one end of the silicone tube and 5.0 mm at the other end. Six different types of coronary stents widely used in China were selected for this study. Each stent was respectively implanted into the simulated blood vessel and dilated to a diameter of 4.2 mm according to the stent-balloon pressure compliance table. The stents were subjected to post-dilatation with a 5.0 × 15-mm noncompliant balloon. The LSD ratio of the longitudinal axis of each stent and stent malapposition were measured through OCT, and any fractures of the stents were determined. RESULTS: None of the six types of stents fractured following post-dilatation. The longitudinal axes of the BuMA and Excrossal stents were slightly shortened, while the other stents were elongated after high-pressure post-dilatation. All stents expanded to a diameter of 5.0 mm without incomplete stent apposition, except for the Nano Plus stent, which remained malapposed after high-pressure post-dilatation. CONCLUSION: All 4.0-mm-diameter stents can be expanded to a diameter of 5.0 mm by noncompliant balloon post-dilatation without stent strut fracture. Most stents were found to be well apposed after high-pressure post-dilatation. However, LSD was observed after post-balloon dilatation. Stent malapposition might be positively correlated with the percentage change in stent length.

High risk of coronary artery obstruction during TAVR, how to avoid it?

BACKGROUND: Coronary artery obstruction after percutaneous aortic replacement is a complication with high short-term mortality secondary to the lack of timely treatment. There are various predictors of coronary obstruction prior to valve placement such as the distance from the ostia, the degree of calcification, the distance from the sinuses; In such a situation some measures must be taken to prevent and treat coronary obstruction. CASE PRESENTATION: An 84-year-old male, with severe aortic stenosis and high surgical risk, who was treated with TAVR. However, during the deployment of the valve he presented hemodynamic instability secondary to LMCA obstruction. The intravascular image showed obstruction of the ostium secondary to the displacement of calcium that he was successfully treated with a chimney stent technique. CONCLUSIONS: The high degree of calcification and the left ostium near the annulus are conditions for obstruction of the ostium at the time of valve release; In this context, provisional stenting prior to TAVR in patients at high risk of obstruction should be considered as a safe prevention strategy to achieve the success of the procedure.

Comparative Evaluation of Alcohol Septal Ablation: Left Anterior Descending Versus Non-left Anterior Descending Artery Approaches.

Alcohol septal ablation (ASA) is performed for symptomatic drug-refractory hypertrophic obstructive cardiomyopathy to reduce the left ventricular outflow tract pressure gradient (LVOTPG) by injecting ethanol into a septal branch that perforates the septal bulge. The target septal branches usually arise directly from the left anterior descending (LAD) artery; however, vessels from a non-LAD artery can be selected in some cases. This study aimed to compare the effectiveness and safety between ASA performed using a septal branch arising from a non-LAD artery and a branch arising from the LAD artery. This single-center, retrospective, observational cohort study comprised patients with hypertrophic obstructive cardiomyopathy who underwent ASA at the Gifu Heart Centre between 2011 and 2022. The effectiveness and safety of ASA using the 2 artery types were compared. The primary end points were LVOTPG and procedure success, determined as LVOTPG <30 mm Hg after 1 year. Of 33 patients (mean age 66.4 ± 13.0 years, 13 men), 18 patients who underwent ASA using only LAD branches and 15 patients who underwent ASA using only non-LAD branches demonstrated no significant difference in the decrease in LVOTPG during the follow-up period (-99.1 ± 47.4 mm Hg/year vs -75.7 ± 39.2 mm Hg/year, respectively, p = 0.19). The procedure success at 1 year was not significantly different between the 2 groups (93.3% and 84.6%, respectively, p = 0.58). ASA performed using septal branches from non-LAD arteries could be an alternative treatment approach when appropriate septal branches are missing or desirable effects cannot be obtained from ASA using LAD branches.

Funny coronary arteriole perforation causes tamponade post-primary percutaneous coronary intervention.

An emergency transradial coronary angiography in a 68-year-old woman demonstrated sub-total occlusion of the proximal left anterior descending artery.

Intraoperative indocyanine green imaging as an adjunctive technique to reduce any circumflex artery damage during mitral valve surgery: a feasibility study.

Iatrogenic injuries to the circumflex coronary artery during mitral valve surgery are probably underestimated (reported rates of 0.3-1.8%). This complication arises from the artery's close proximity to the mitral annulus, particularly at the anterolateral commissure. The study aimed to assess this risk in a patient group prone to such injury. The surgical procedure utilized a minimally invasive approach and indocyanine green-based fluorescence imaging. This technique allows a real-time visualization of the circumflex artery, aiding precise placement of annular sutures and minimizing the risk of injury. The method, applied in 6 patients, integrates preoperative assessments with intraoperative fluorescence imaging, ensuring accurate arterial depiction and preventing iatrogenic damage. The study highlights the safety and efficacy of fluorescence imaging, especially in identifying vessel anomalies, indicating potential applications in various cardiac procedures.

Safety and efficacy results of percutaneous renal stent implantation in patients with acute coronary syndrome with ectatic and aneurysmatic coronary arteries.

BACKGROUND: For the treatment of stenotic lesions developing in dilated coronary arteries, it is difficult to find an appropriately sized coronary stent given that the vessel diameter is too large. This poses a greater problem, especially in patients who require urgent intervention, such as acute coronary syndrome. OBJECTIVE: We aimed to evaluate the efficacy and safety of renal stents implanted in ectatic/aneurysmatic coronary arteries in such patients. METHODS: In total, 18 patients (renal stent group) who underwent renal stent implantation in ectatic/aneurysmatic coronary arteries requiring percutaneous coronary intervention (PCI) and 45 patients who underwent large-sized bare-metal coronary stent (BMCS) implantation (BMCS group) at our center were included in the study. The primary endpoints were MACE (myocardial infarction and cardiovascular mortality), and the secondary endpoints were restenosis and all-cause mortality. RESULTS: In the study patients with a mean follow-up of 25.3 ± 14.6 months (1-48 months), the control coronary angiography duration was 24.6 ± 14.8 months for the renal stent group and 22.8 ± 15.7 months for the BMCS group (p = 0.06). The MACE was observed in 2 (11.1%) patients in the renal stent group and 4 (8.9%) patients in the BMCS group (HR: 1.39 (0.24-7.82), p = 0.70). The secondary composite outcome was identified in 4 (22.2%) patients in the renal stent group and 6 (13.7%) patients in the BMCS group (HR: 1.93 (0.53-6.91), p = 0.31). No significant differences in primary and secondary outcomes were noted between the groups. CONCLUSION: Renal stents used during PCI in patients with acute coronary syndrome with ectatic/aneurysmatic coronary arteries have similar efficacy, and mid-term follow-up results those noted for BMCS. These findings support that renal stents can be used in ectatic and aneurysmatic coronary arteries when necessary. CLINICAL TRIAL REGISTRATION: This study has been registered on ClinicalTrials.gov (NCT05410678).

Multiarterial vs Single-Arterial Coronary Surgery: 10-Year Follow-up of 1 Million Patients.

BACKGROUND: Although many options exist for multivessel coronary revascularization, controversy persists over whether multiarterial grafting (MAG) confers a survival advantage over single-arterial grafting (SAG) with saphenous vein in coronary artery bypass grafting (CABG). This study sought to compare longitudinal survival between patients undergoing MAG and those undergoing SAG. METHODS: All patients undergoing isolated CABG with ≥2 bypass grafts in The Society of Thoracic Surgeons Adult Cardiac Surgery Database (2008-2019) were linked to the National Death Index. Risk adjustment was performed using inverse probability weighting and multivariable modeling. The primary end point was longitudinal survival. Subpopulation analyses were performed and volume thresholds were analyzed to determine optimal benefit. RESULTS: A total of 1,021,632 patients underwent isolated CABG at 1108 programs (100,419 MAG [9.83%]; 920,943 SAG [90.17%]). Median follow-up was 5.30 years (range, 0-12 years). After risk adjustment, all characteristics were well balanced. At 10 years, MAG was associated with improved unadjusted (hazard ratio, 0.59; 95% CI 0.58-0.61) and adjusted (hazard ratio, 0.86; 95% CI, 0.85-0.88) 10-year survival. Center volume of ≥10 MAG cases/year was associated with benefit. MAG was associated with an overall survival advantage over SAG in all subgroups, including stable coronary disease, acute coronary syndrome, and acute infarction. Survival was equivalent to that with SAG for patients age ≥80 years and those with severe heart failure, renal failure, peripheral vascular disease, or obesity. Only patients with a body mass index ≥40 kg/m2 had superior survival with SAG. CONCLUSIONS: Multiarterial CABG is associated with superior long-term survival and should be the surgical multivessel revascularization strategy of choice for patients with a body mass index of less than 40 kg/m2.

Impact of stent strut link location in proximal balloon edge dilation technique for bifurcation percutaneous coronary intervention.

The single-stent strategy has generally been accepted as the default approach to bifurcation percutaneous coronary intervention. We have proposed the proximal balloon edge dilation (PBED) technique to prevent stent deformation during side branch (SB) dilation. This bench study aimed to evaluate the impact of stent link location and stent design on stent deformation, obstruction by stent struts at a jailed SB ostium, and incomplete stent apposition in the proximal optimization technique (POT)-PBED procedure. A coronary bifurcation model was used. We intentionally set the absence or presence of stent link on the carina (link-free or link-connect) under videoscope observation and compared stent parameters between 3- and 2-link stents (n = 5 each, n = 20 total). In the link-free group, the SB jailing rate of 3-link stents was significantly higher than that of 2-link stents (15.5 ± 5.1% vs. 6.6 ± 1.2%, p = 0.009). In the link-connect group, the SB jailing rate of 3-link stents was significantly lower than that of 2-link stents (30.0 ± 4.5% vs. 39.0 ± 2.6%, p = 0.009). In the bifurcation segment, the rate of incomplete stent apposition was significantly lower for 3-link stents of the link-connect group than for 2-link stents of the link-connect group (3.3 ± 4.2% vs. 19.0 ± 7.8%, p = 0.009). For both stent designs, ellipticity ratio was higher for link-connect group than link-free group. Link location as well as stent cell design greatly impacted stent deformation during the POT-PBED procedure.