Cardiovascular Revascularization Medicine: Interesting Cases最新文献

Spontaneous coronary artery dissection (SCAD) is a non-traumatic spontaneous separation of a coronary wall that can present as acute myocardial infarction. Here, we present a 60-year-old female with sudden onset of retrosternal chest pain and ST-segment elevation myocardial infarction (STEMI) secondary to spontaneous dissection of the left anterior descending (LAD) coronary artery. The patient was successfully managed with primary percutaneous coronary angioplasty (PPCI) with advanced coronary intervention techniques including intravascular coronary imaging technology and microcatheter assisted luminal wiring.

Chronic total occlusion percutaneous coronary intervention has lower success rates in patients with prior coronary artery bypass graft surgery. Patent or occluded bypass grafts serve as conduits for retrograde recanalization, but a common cause of failure is the acute angulated graft insertion making wiring difficult, with recurrent wire and microcatheter prolapse, if not impossible. We present a case with difficult retrograde wiring and tracking around a retroflexed graft insertion site that was successfully addressed using a strategic balloon to anchor the microcatheter – the “microcatheter anchor technique (MAT)”.

We present an interesting case of a 73 years-old male who was referred for mid-right coronary artery (RCA) chronic total occlusion (CTO) intervention given continuous angina symptoms with coronary angiogram revealing mid-RCA CTO with a left to right collaterals from LAD and concomitant moderate stenosis in the mid-LAD. Hemodynamic assessment of this lesion pre-PCI using non-invasive angiogram-based, wireless FFR was performed. Following successful CTO revascularization, a substantial immediate improvement in non-invasive angio-FFR assessment was observed with wireless angio-based FF measurement of 0.96 (normal ≥0.80) compared to the pre-intervention value of 0.86. This suggests that angiography-based wireless FFR may be a valuable tool for assessing the hemodynamic significance of donor artery stenosis in CTO cases, potentially offering a less invasive and more accessible alternative to traditional methods.

A patient with a HeartMate 3 left ventricular assist device complicated by an extrinsic outflow graft obstruction was treated with a percutaneous approach using large covered stents in overlapping fashion from the proximal portion of the outflow graft at the bend relief into the LVAD rotor.

Balloon rupture during the course of balloon aortic valvuloplasty (BAV) is an uncommon occurrence that can potentially lead to severe complications. We describe a case in which a balloon rupture occurred during BAV, resulting in challenges in retracting the balloon into the sheath. This issue was successfully addressed through an endovascular approach, thereby avoiding the necessity for surgical intervention.

We present a case and outline key procedural considerations for bailout solutions.

Percutaneous coronary intervention for true bifurcation lesions is challenging because they have a poor prognosis due to side branch (SB) complications. The modified jailed balloon technique (MJBT) is useful for significant SB protection. However, even with the MJBT, provisional stenting in true bifurcation lesions does not dispel the risk of SB occlusion because re-crossing the guidewire through the stent struts into the SB remains a challenge, particularly when SB dissection occurs after stent implantation. Recently, the rewiring of dissected branches along the jailed balloon (real JAB) technique has been reported as a bailout method for this issue. We present the first series of successful provisional stenting cases in five patients with true bifurcation lesions using the real JAB technique in combination with the MJBT.

Transradial arterial access for cardiac catheterization is an overall safe procedure but is associated with infrequent complications. Although very rare, the potential disability resulting from transradial access site complications can be profound, especially in cases involving the dominant hand. In this case report, we present a right-handed patient who underwent cardiac catheterization via right transradial access complicated by chronic neuropathic pain and weakness of the right forearm and hand. The degree of pain and weakness prevented him from returning to work, demonstrating the potential for rare but significant morbidity associated with radial access.

Background

Left main coronary artery vasospasm is rare with a limited number of cases previously reported. Coronary artery vasospasm manifests as chest pain, which can result in acute coronary syndrome, ventricular arrhythmias, and death. While cannabis remains the most abused psychoactive substance, its association with coronary artery vasospasm remains unclear.

Case summary

A 46-year-old-female, with a history of recurrent angina and cannabis use, presented with severe chest pain. She suddenly entered ventricular fibrillation and was emergently cardioverted. Electrocardiogram showed ST segment elevations in leads aVR, V1, and V2 with reciprocal changes. Emergent coronary angiography revealed severe spasms of both the left main coronary artery and the left anterior descending artery. Intravenous nitroglycerin was initiated and her coronary artery vasospasms improved.

Discussion

Coronary artery vasospasm, due to cannabis, can be attributed to amplified catecholamine release causing vasoconstriction, presenting as decreased blood flow in coronary vessels, and increased myocardial oxygen demand due to a dose-dependent increase in cardiac output. Decreased anginal threshold combined with stimulation of pro-atherogenic CB1 receptors and hyper-sympathetic activity further propagates the risk of acute coronary syndrome.

Conclusion

Young patients presenting with coronary artery vasospasm should prompt the exclusion of cannabis as a contributing cause. Further studies are indicated to assess cannabis's impact on coronary vasculature.

The field of endovascular procedures has seen notable recent advancements. However, despite being considered an uncommon complication, stent migration is emerging as a growing concern. This case report describes a 56-year-old man who was diagnosed with a new onset of atrial fibrillation in the setting of a migrated iliac vein stent into the right atrium.

Percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) is challenging. The complexity of the lesions increases the risk of procedure-related complications. Here, we report a case of a patient who presented with simultaneous donor-vessel stent thrombosis and contained coronary perforation of the septal collateral artery during total occlusion PCI.