Successful Retrieval of Intravascular Stent Remnants With a Combination of Rotational Atherectomy and a Gooseneck Snare

Stent migration from the delivery balloon catheter is a rare but serious complication during percutaneous coronary intervention, particularly when a part of the stent stretches into the aorta. We report an unusual case of stent migration treated with a combination of a gooseneck snare and rotablation. A part of the stent was overstretched and unrolled into the aorta and the rest of the stent remained implanted in the coronary artery. The stent was captured with a gooseneck snare but could not be retrieved because it was connected to a stent remnant implanted in the coronary artery. The stent strut was cut with rotablation, and the stent was successfully removed through the femoral sheath.

Head-up Tilt Test in Subjects with No History of Syncope or Presyncope

BACKGROUND AND OBJECTIVES: Head-up tilt test is increasingly being used to diagnosis neurocardiogenic syncope. But the protocol of head-up tilt test has not been settled. The purpose of this study was to evaluate the effect of isoproterenol provocation during head-up tilt test in normal volunteers with no prior history of syncope or presyncope. METHOD: Head-up tilt test was performed with 53 volunteers (age 309, male 27, female 26) in the fasting state. After supine heart rate and blood pressure were obtained, each volunteer was tilted to the 70 degree upright position for 30 minutes using a motorized tilt table with a footboard. If the test was negative in the baseline tilt, intravenous isoproterenol was started at 1g/min and then increased by 1g/min every three minutes to a maximum of 5g/min while maintaining 70 degree upright position. The end points of test were positive response, intolerance to isoproterenol, heart rate >150beat/min and completion of the protocol. When an end point was reached, the volunteer was rapidly returned to the supine position. RESULTS: Positive response to head-up tilt test was noted in 14 cases (26%). The pattern of positive response was vasodepressive in all cases. There was no significant side effect of isoproterenol. There was no significant difference between positive and negative response group in terms of age, sex, peak infusion rate of isoproterenol and hemodynamic response. The positive response rate at 2 g/min , 3 g/min, 4 g/min and 5 g/min of isoproterenol infusion was 1.9%, 9.7%, 23.7% and 32.5%, respectively. CONCLUSION: Head-up tilt test at 70 degree angle with isoproterenol infusion provided an adequate specificity.

Safety of Percutaneous Right Coronary Intervention without Temporary Pacemaker: Prospective Study

BACKGROUND: The prophylactic use of temporary pacemaker during coronary intervention has been markedly decreased since 1980's. There is, however, few systematic report focusing on right coronary intervention in which temporary pacemaker would be most beneficial. Moreover, there has been marked development in coronary intervention recent years that risk and benefit of prophylactic pacemaker should be reconsidered. METHOD: We performed right coronary artery intervention without prophylactic use of temporary pacemaker in 100 successive patients in Samsung Medical Center. Patients with previous AV block and rotational atherectomy cases were excluded. The incidence of all complications and changes of blood pressure as well as heart rate during coronary intervention were examined prospectively. RESULTS: The lesion type was B2 or C in 52% and intracoronary thrombus was found in 18% of patients. Nevertheless, there was neither life threatening bradycardia nor new onset arrhythmia in any patient during right coronary intervention. CONCLUSION: These data suggest that omission of prophylactic use of temporary pacemaker may be safe in right coronary intervention only if excluding previous patients with high degree atrioventricular block and rotational atherectomy cases. This approach may reduce procedure time and cost as well as pacemaker-associated complications.

Clinical Follow-up of Excimer Laser Coronary Angioplasty for In-stent Restenosis

BACKGROUND AND OBJECTIVES: revious studies have shown a high restenosis rate after balloon angioplasty for diffuse in-stent restenosis. Debulking strategy has been expected to be helpful to reduce the restenosis rate. This study evaluated the safety and long-term clinical event rate after excimer laser coronary angioplasty (ELCA) and adjunctive balloon angioplasty for in-stent restenosis. MATERIALS AND METHOD: We included 29 in-stent restenotic lesions treated in 28 patients (18 men, 10 women, mean age 60+/-2 years) admitted to Samsung Medical Center between June 1997 and August 1998. Quantitative coronary angiography was performed and clinical characteristics, acute complications, 30-day and 8-month major cardiac adverse event rate was analyzed. RESULTS: Initial success rate was 97%. We stopped the ELCA procedure in one lesion located in the proximal left anterior descending artery due to bradycardia and hypotension. In the 28 lesions successfully treated with ELCA and adjunctive balloon angioplasty, the minimal luminal diameter increased from 0.7+/-0.1 mm before ELCA to 1.9+/-0.1 mm after ELCA and to 2.7+/-0.1 mm after adjunctive balloon angioplasty (p<.0001). The acute luminal gain after ELCA was 60%. The diameter stenosis decreased from 75+/-2% before ELCA to 36+/-2% after ELCA and to 15+/-2% after adjunctive balloon angioplasty (p<.0001). There was no in-hospital death, Q wave acute myocardial infarction (AMI), emergency coronary artery bypass graft (CABG), but non-Q AMI was noted in 1 case (3%). During the followed-up period of 8 months, there were 1 death (4%) due to congestive heart failure, 1 nonQ-AMI (4%) and 7 target lesion revascularization (26%) among the successfully treated 27 patients, but there was no CABG, Q-AMI. Combined event rate at the 8-month follow-up was 33% and target lesion revascularization rate at 8-month follow-up was 26%. CONCLUSION: The ELCA and adjunctive balloon angioplasty seems to be safe and effective for the treatment of in-stent restenosis. A prospective randomized trial comparing ELCA versus other ablative technique is required.

The Role of Helicobacter pylori and NSAID in Patients with Benign Gastric Ulcer / 대한내과학회지

OBJECTIVES: H. pylori infection and NSAID are very important risk factors for peptic ulcer. This study was conducted to investigate the H. pylori positivity rate and the rate of NSAID ingestion in the patients with benign gastric ulcer(BGU), to investigate which test and which site are the most adequate to reduce the false positivity rate of H. pylori, and finally to investigate the role of H. pylori and NSAID in BGU bleeding. METHODS: This study was conducted for the 180 patients with BGU, and H. pylori was diagnosed by any of CLO test, Gram stain of touch print and H&E stain in the antrum and body. In addition, age, sex, ingestion history of NSAID within 4 weeks before gastroscopy, past BGU history, smoking, alcohol and BGU bleeding were investigated. RESULTS: 1) The H. pylori infection rate of patients with BGU in Korea was 82.8%, and the rate of NSAID history was 26.1%. The patients with BGU who have only NSAID history were 8.3%, and the 91.1% of the patients had either H. pylori infection or NSAID history. 2) The most sensitive test for H. pylori infection among CLO test, Gram stain of touch print and H&E stain in the antrum or body was CLO test in the body. 3) Depending on H. pylori positivity, the rate of NSAID history in the H. pylori negative group was 48.4%, which was higher than that of H. pylori positive, 21.5%(p=0.002). In addition, the rate of past BGU history in the H. pylori positive group was 47.0%, which was higher than that of H. pylori negative, 12.9%(p<0.001). 4) Depending on the history of NSAID, the H. pylori positivity rate in NSAID positive group was 68.1%, which was lower than that of NSAID negative, 88.0%(p=0.002). The female percentage of NSAID positive was 40.4%, which was higher than that of NSAID negative, 16.5% (p<0.001). The rate of BGU bleeding in the NSAID positive was 27.7%, which was higher than that of NSAID negative, 14.3%(p=0.039). 5) The rate of NSAID history of bleeding group was 40.6%, which was higher than that of non-bleeding group, 23.0%(p=0.039). However, there was no signifi cance in the correlation of H. pylori positivity rate to the bleeding. 6) The H. pylori positivity and NSAID history showed no correlation with bleeding in the group below age sixty. While in the age over or equal to sixty the H. pylori positivity had no correlation with bleeding, but the rate of NSAID history was 72.7% for the patients with bleeding, which is in contrast with the 25.5% for the patients without bleeding(p=0.003). CONCLUSION: From these results, the H. pylori infection rate of the patients with BGU in Korea was 82.8%, and the best method for H. pylori detection was CLO test in the body. H. pylori infection had no corre lation with the bleeding, but NSAID ingestion increased bleeding tendency, particularly in the group of the age over or equal to sixty.

A Case of Toxic Epidermal Necrolysis Concomittantly Presented with GI Bleeding and Its Gastrofiberscopic Findings / 대한소화기내시경학회지

Toxic epidermal necrolysis (T~EN) is a severe mucocutaneous disease characterized by epidermal necrosis possibly extended to the entire body surface and involving multiple internal organs. Digestive tract may be involved too, but there is few report about gastrointestinal lesion in patient with TEN. Recently we experienced a case of TEN with gastrointestinal bleeding in previously healthy 32-year-old woman. The condition developed three days after the initiation of treatment with NSAID and progressed caudally, involving 60 percent of the skin surfaces. During a period of admission gastrointestinal bleeding was noticed. The gastrofiberscopy showed diffuse superficial mucosal lesion with oozing from swollen friable and erythematous mucosa. The skin lesion was progressed inspite of withdrawal of causative agents. The patient was expired due to combined septic shock 10 days later. We report this case with gastrofiberscopic findings and a brief review of literature.