Pseudoaneurysm and subsequent venous thromboembolism after subintimal angioplasty for chronic total occlusion in the superficial femoral artery.

Endovascular therapy (EVT) has been accepted as a minimally invasive treatment for peripheral artery disease, and its applicability has been widened with the development of techniques and devices. A long, totally occluded lesion in the superficial femoral artery (SFA) is one of the most challenging lesions for EVT due to technical difficulties in wire-crossing. Recently, intentional subintimal recanalization is often considered as an alternative option for long SFA occlusions. Previous studies have shown that subintimal approach achieved superior technical success rate and similar patency rate, compared to conventional intraluminal approach. However, there is limited information about complications of the treatment with subintimal approach. Deep vein thrombosis (DVT) due to direct compression by pseudoaneurysm in the SFA, which subsequently develops pulmonary embolism (PE), is considered as a rare complication of subintimal angioplasty for the occlusive SFA lesion. We herein present a case of a patient who developed pseudoaneurysm formation in the SFA after EVT. Although initial EVT was performed successfully with subintimal approach, DVT and PE were caused by the SFA pseudoaneurysm at sub-acute phase following the initial procedure. The pseudoaneurysm was treated with implantation of a covered stent sealing the entry point, disappearing with no endoleak. .

Catheter-induced aortocoronary dissection at the ostium of anomalous left coronary artery during percutaneous coronary intervention for acute inferior myocardial infarction.

We report a case of catheter-induced aortocoronary dissection at the ostium of anomalous left coronary artery (LCA) during percutaneous coronary intervention (PCI) for acute inferior myocardial infarction (MI). Urgent coronary angiography revealed the culprit lesion of MI was the proximal segment of the right coronary artery (RCA). The anomalous LCA arose from the right sinus of Valsalva the same as the RCA. Catheter-induced aortocoronary dissection at the ostium of RCA was extended to the ostium of anomalous LCA by contrast injection. The patient fell into hemodynamic collapse due to acute occlusion of the anomalous LCA. The patient underwent successful bailout stenting at the ostium of anomalous LCA under percutaneous cardiopulmonary support (PCPS). He was weaned from PCPS system five days after PCI and was discharged. This is the first report about bailout procedure for catheter-induced aortocoronary dissection at the ostium of anomalous LCA. .

Open sesame technique in percutaneous coronary intervention for ST-elevation myocardial infarction.

In patients with ST-elevation myocardial infarction (STEMI), delays in reperfusion attenuate the benefit of primary percutaneous coronary intervention (PCI) and associate with higher mortality rates. Although PCI operators are making their best effort in time saving for reperfusion, it is sometimes challenging and takes time to pass the guide wire across the target lesions. A totally occluded lesion in which a side branch was bifurcating at the proximal end of the occluded segment is one of the most technically challenging anatomies of the target lesion because it is difficult to identify the entry point of the occluded segment. A side branch technique, termed "Open Sesame Technique" (OST), has been previously introduced for chronic total occlusion (CTO) lesion in which a side branch was bifurcating at the proximal end of the occluded segment. We herein present two cases applying this technique in STEMI with totally occluded lesions at bifurcation as a culprit lesion, in which the entry point was not identified on the initial angiography. PCI were performed successfully using the OST in both cases, which resulted in saving procedural time and contrast volume without any complications. This technique can be effective not only in PCI for CTO lesions but also in primary PCI for STEMI cases with occluded bifurcation lesions.

Ruptured thoracic aortic aneurysm infected with listeria monocytogenes: a case report and a review of literature.

A 75-year-old male with a history of alcoholic liver cirrhosis, sigmoid colon cancer, and metastatic liver cancer was admitted to our institution with a complaint of a prickly feeling in his chest. On admission, a chest radiograph revealed a normal cardio-thoracic ratio of 47%. Echocardiography revealed pericardial effusion and blood chemical analyses revealed elevated C-reactive protein levels (14.7 mg/dL). On day 3, chest radiography revealed cardiomegaly with a cardio-thoracic ratio of 58% and protrusion of the left first arch. Contrast-enhanced chest computed tomography revealed a saccular aneurysm in the aortic arch with surrounding hematoma; thus, a ruptured thoracic aortic aneurysm was suspected. Emergency surgery was performed, which revealed a ruptured aortic aneurysm with extensive local inflammation. The diagnosis of an infected aortic rupture was therefore confirmed. The aneurysm and abscess were resected, followed by prosthetic graft replacement and omental packing. Histopathology of the resected aneurysm revealed gram-positive bacilli; and Listeria monocytogenes was confirmed as the causative organism by culture. Postoperative course was uneventful; on postoperative day 60, the patient was ambulatory and was discharged. Here we report the case of a male with a ruptured thoracic aortic aneurysm infected with L. monocytogenes.

Aortic valve papillary fibroelastoma associated with acute cerebral infarction: a case report.

An 80-year-old woman with a history of congestive heart failure, atrial fibrillation, and hypertension was transferred to our institution with hematemesis. Her drug regimen included 2 mg warfarin potassium/day to prevent thromboembolic events. Transthoracic echocardiography (TTE) performed at 78 years of age revealed a mass attached to the noncoronary cusp and a cardiac tumor was suspected. The patient declined surgery and was meticulously followed up with periodic TTE. Upper gastroendoscopy revealed a gastric ulcer with an exposed blood vessel; anticoagulant therapy was ceased. On day 15 of admission, acute cerebral infarction occurred. Heparin sodium and warfarin potassium were administered rapidly, and her symptoms improved. TTE revealed no alteration of the mobile, string-like mass attached to the noncoronary cusp. Cardiac tumor was considered the cause of cerebral infarction, and the patient consented to surgical therapy. Pathological examination of the resected tumor suggested papillary fibroelastoma (PFE). Although no guidelines exist for PFE management, a mobile, cardiac tumor necessitates surgical resection to prevent thromboembolic events, even when small in size.

A case report of coronary arteriovenous fistulas with an unruptured coronary artery aneurysm successfully treated by surgery.

A 58-year-old female with a history of Wolff-Parkinson-White syndrome presented at our institution with palpitations and chest pain. Electrocardiography revealed paroxysmal supraventricular tachycardia with a heart rate of 188 beats/min. Antiarrhythmic drugs were ineffective, and tachycardia was resolved by electrical cardioversion. Transthoracic echocardiography revealed abnormal vessels around the right coronary artery (RCA) and pulmonary artery (PA); in addition, we suspected coronary arteriovenous fistula (CAVF). Coronary angiography and coronary computed tomography revealed dilated fistula vessels, with a 1 cm saccular aneurysm around the RCA, originating from the proximal RCA and left anterior descending artery into the main trunk of PA. Therefore, we confirmed the diagnosis of CAVF with an unruptured aneurysm. We surgically ligated and clipped the fistula vessels and resected the aneurysm. The resected aneurysm measured 1 × 1 cm in size. Pathological examination of the resected aneurysm revealed hypertrophic walls comprising proliferating fibroblasts cells thin elastic fibers. Very few atherosclerotic changes manifested in the aneurysm walls. We report the case of a patient with CAVF and an unruptured coronary artery aneurysm who was successfully treated by surgery.

Comparison of preventive effect on cardiovascular events with different statins. -The CIRCLE study-.

BACKGROUND: Although statins vary in their effectiveness in lowering low-density lipoprotein cholesterol (LDL-C) and increasing high-density lipoprotein cholesterol (HDL-C) levels, there is little evidence that the degree of these changes can explain cardiac risk reduction in Japan. Our objective was to compare the efficacy of statins on serum lipid levels and to explore the association between those changes and cardiac events in patients after percutaneous coronary intervention (PCI). METHODS AND RESULTS: The 743 consecutive patients who underwent PCI from 2001 to 2008 were retrospectively investigated. Treatment with either atorvastatin or pitavastatin significantly reduced LDL-C compared with pravastatin or no statin. In contrast, only pitavastatin treatment significantly increased HDL-C (13.4 ± 22.9%, P=0.01 vs. no statin). Each statin significantly prevented major adverse cardiac events (MACE) compared with no statin, and pitavastatin was the most effective of all. Multivariate-adjusted analysis revealed that percent changes of both LDL-C and HDL-C independently predicted the incidence of MACE (hazard ratio [HR]: 1.015; 95% confidence interval [CI]: 1.010-1.020, HR: 0.988; 95%CI: 0.981-0.996, respectively). This relationship was preserved in patients with a baseline HDL-C level ≤ 45 mg/dl, but not HDL-C level > 45 mg/ml. CONCLUSIONS: The extent of changes in LDL-C and HDL-C with statin treatment would independently alter the risk of cardiac events in Japanese patients for secondary prevention. Statins with varying lipid-modifying ability might provide differing prognosis in patients after PCI.

[Successful deployment of a stent graft in the popliteal artery for pseudoaneurysm after acupuncture: a case report].

A 71-year-old man was admitted to our hospital because of swelling and pain in his right calf developing after acupuncture for intermittent claudication. Computed tomography with contrast medium revealed a large hematoma with contrast medium leakage in his right calf. Emergent angiography demonstrated a pseudoaneurysm of the right popliteal artery with severe stenosis. Intravascular ultrasound showed lumen narrowing with a large amount of concentric plaque and disruption of the vessel wall communicating to a large cavity outside. A polytetrafluoroethylene-covered Jostent graft was deployed into the stenotic lesion across the opening into the pseudoaneurysm cavity. Subsequent angiography showed no leakage of contrast medium. This unique case of pseudoaneurysm caused by acupuncture in the popliteal artery was treated successfully by endovascular repair.

[Limitation on efficacy of sirolimus-eluting stent implantation in patients on hemodialysis].

BACKGROUND: Patients receiving chronic hemodialysis develop complicated coronary lesions with tortuosity and calcification, which make stent delivery or expansion difficult. Restenosis rates are also higher than in patients without hemodialysis. Furthermore, there is a risk of polymer rubbing from the surface of a sirolimus-eluting stent(SES)placed across a calcified lesion. This study investigated the efficacy of SES for patients on hemodialysis compared with bare metal stent (BMS). METHODS AND RESULTS: Forty-two patients on hemodialysis underwent percutaneous coronary intervention for 46 de novo lesions treated with SES (SES group). Seventy-four patients with 78 de novo lesions were treated with BMS (BMS group). The mean age was 65.8 +/- 9.3 yr in the SES group, and 65.0 +/- 8.7 yr in the BMS group. The mean hemodialysis period was significantly longer in the SES group (9.2 +/- 7.9 vs 6.5 +/- 7.7 yr, p < 0.01). Angiographic characteristics and acute results showed no significant difference between the two groups. At 6 months follow-up, late loss was significantly smaller in the SES group (0.60 +/- 0.97 vs 1.60 +/- 1.15 mm, p < 0.05). Binary restenosis and target lesion revascularization were similar (34% vs 43%, 25% vs 36%, respectively, p = NS). Major adverse cardiac events, composite of death, myocardial infarction, and target vessel revascularization were also similar (23% vs 36%, p = NS). CONCLUSIONS: Our study could not demonstrate the superiority of SES implantation in patients with hemodialysis compared to BMS implantation, which suggests the limitations of using SES.

[Sudden death due to pulmonary tumor embolism from testicular tumor: a case report].

A 40-year-old man undergoing treatment for testicular tumor with para-aortic lymph node metastasis was transferred to our department because of pulmonary embolism. Thrombolysis therapy improved his respiratory state and deep venous thrombi disappeared. However, cardiopulmonary arrest occurred suddenly. Autopsy showed tumor cell invasion into the intima of the pulmonary artery and dissection with thrombosis. Thrombi had fresh components above organizing components. Sudden death due to pulmonary tumor embolism from testicular tumor is rare. In this case, the sudden death resulted from thrombosis in the pulmonary artery, not from emboli from the deep vein.

[Sensitivity and related factors in iodine-123-beta-methyl-p-iodophenyl-pentadecanoic acid myocardial scintigraphy to detect stable effort angina pectoris].

OBJECTIVES: This study evaluated the sensitivity and the related factors in iodine-123-beta-methyl-p-iodophenyl-pentadecanoic acid (BMIPP) scintigraphy to detect stable angina. METHODS: The subjects were 198 patients with stable angina who underwent BMIPP before percutaneous coronary intervention or coronary bypass graft surgery. Patients with unstable angina, myocardial infarction, congestive heart failure, cardiomyopathy and vasospastic angina were excluded. After investigation of the sensitivity of BMIPP, the patients with single-vessel disease without collateral flow were classified into the normal (123)I-BMIPP uptake group (normal group)or decreased (123)I-BMIPP uptake group (decreased group), and various factors were compared between the two groups. RESULTS: Sensitivity was 61% overall, 58% in single-vessel disease, 69% in double-vessel disease, 53% in triple-vessel disease, 43% in only left main vessel disease, and 89% in left main and other vessel disease (NS). In single-vessel disease, the sensitivity was 40% in 75% coronary artery stenosis, 58% in 90% stenosis, 89% in 99% stenosis, and 69% in total occlusion (p = 0.003). Comparing the deoreased and normal groups, diabetes mellitus was more frequent in the normal group (14.6% vs 39.5%), minimal lumen diameter was smaller (0.75 +/- 0.37 vs 0.98 +/- 0.49 mm) and lesion length was longer in the decreased group (15.4 +/- 4.9 vs 11.6 +/- 5.5 mm). Logistic multivariate analysis showed that the independent factors were diabetes mellitus [odds ratio 0.20, 95% confidence interval (CI) 0.04-0.87, p = 0.03], minimal lumen diameter (odds ratio 0.10, 95% CI 0.02-0.48, p = 0.003) and lesion length (odds ratio 1.12, 95% CI 1.00-1.25, p = 0.03). CONCLUSIONS: BMIPP is useful in stable angina patients because of the acceptable sensitivity. Diabetes mellitus, minimal lumen diameter and lesion length were independent factors associated with decreased BMIPP uptake.

Prevalence and clinical course of the juveniles with Brugada-type ECG in Japanese population.

BACKGROUND: Although many studies on Brugada syndrome have been done, with many reports of genetic findings and clinical features, little evidence exists to support the role of this syndrome in sudden cardiac death in a juvenile population. We sought to determine the prevalence and clinical course in children exhibiting Brugada-type ECG in a community-based population. METHODS: Our study population comprised 21,944 subjects (11,282 boys and 10,662 girls) who underwent ECG during their first-year elementary school health examinations between 1992 and 2001 in Izumi City, Osaka. Brugada-type ECG was defined as demonstrating ST-segment elevation (coved or saddle-back type, J wave amplitude > or =0.2 mV) in the right precordial leads. We also divided Brugada-type ECGs into three types according to a consensus report. Type 1: coved ST-segment elevation displaying high J wave amplitude followed by a negative T wave; Type 2: high take-off and gradually descending ST-segment elevation (remaining > or =1 mm) followed by a positive or biphasic T wave; and Type 3: ST-segment elevation of <1 mm of both types. RESULTS: Four subjects showed Brugada-type ECG (0.02%) (2 boys and 2 girls). Only one subject, a girl, met Type 1 criteria (0.005%). No history of structural heart disease was documented in these four subjects. During 6.8 +/- 1.0 years of follow-up, no episode of unexpected sudden death, syncopal attack, and fatal arrhythmia occurred. CONCLUSIONS: The prevalence of Brugada-type ECG in a juvenile population was extremely low. To investigate when the typical Brugada-type ECG might be manifested, it could be necessary to check ECGs after adolescence.

Circadian variation of plaque rupture in acute myocardial infarction.

Studies have reported a circadian variation in the onset of acute myocardial infarction (AMI). Pathologic studies have revealed that plaque rupture is 1 of the major causes of AMI, but none of these has looked specifically at the circadian variation of plaque rupture. The aim of this study was to use intravascular ultrasound (IVUS) to investigate the circadian variation of plaque rupture in AMI. This study included 174 consecutive patients with AMI who underwent preinterventional IVUS. All patients were assigned to either a rupture group or a nonrupture group according to the preinterventional IVUS. In the 81 patients (47%) in the rupture group, the frequency of the onset of AMI increased significantly in the period from 6 A.M. to 12 P.M. compared with all other time periods (p <0.05). The clinical features of AMI in the rupture group were characterized as occurring significantly more at rest (67% vs 31%, p <0.01) and after significantly less preinfarction angina (22% vs 57%, p <0.01) compared with the nonrupture group. A different circadian variation was identified in the nonrupture group, characterized as a significant nocturnal nadir (12 to 6 A.M. compared with all other periods, p <0.05). The circadian variation of AMI is the result of a morning increase in incidence of plaque rupture.

In-stent restenosis and lesion morphology in patients with acute myocardial infarction.

We investigated the correlation between lesion morphology with preintervention intravascular ultrasound and in-stent restenosis in 72 patients with acute myocardial infarction (AMI). Multivariate logistic regression analysis showed that the presence of ruptured plaque was the only predictive factor of in-stent restenosis after primary stenting for AMI.

C-reactive protein and lesion morphology in patients with acute myocardial infarction.

BACKGROUND: Elevated serum C-reactive protein (CRP) is of clinical significance in the management of acute coronary syndromes, but there have been few in vivo studies detailing the relation between lesion morphology and elevated CRP in the setting of acute myocardial infarction (AMI). In this study, we investigated the relation between lesion morphology as seen under preintervention intravascular ultrasound (IVUS) and CRP in the acute phase of AMI. METHODS AND RESULTS: Our patient population comprised 90 consecutive patients with AMI who underwent preintervention IVUS within 6 hours of the onset of symptoms. Patients were divided into an elevated CRP group (> or =3 mg/L) or a normal CRP group on the basis of serum CRP levels. There were no differences in patient characteristics or angiographic findings. We observed significantly more plaque rupture in the elevated CRP group than in the normal CRP group (70% versus 43%, P=0.01). A multivariate logistic regression model revealed that the presence of ruptured plaque alone correlated with elevation of serum CRP (P=0.02; odds ratio, 3.35; 95% CI, 1.22 to 9.18). CONCLUSIONS: Elevated CRP may be related to the presence of ruptured plaque. Our results suggest that in the setting of AMI, elevated CRP levels may reflect the inflammatory activity of a ruptured plaque.

No-reflow phenomenon and lesion morphology in patients with acute myocardial infarction.

BACKGROUND: The no-reflow phenomenon is associated with poor functional and clinical outcomes for patients with acute myocardial infarction (AMI). In the era of primary intervention, accurately identifying lesions at high risk of no reflow is of crucial importance. At present, no study into the relationship between lesion morphology and no reflow has been performed. The aim of this study was to investigate the relationship between preintervention intravascular ultrasound (IVUS) lesion morphology and the no-reflow phenomenon. METHODS AND RESULTS: This study comprised 100 consecutive patients with AMI who underwent preintervention IVUS and were successfully recanalized with primary balloon angioplasty or stenting. IVUS was again performed to identify and exclude any mechanical vessel obstruction in cases of thrombolysis in myocardial infarction flow grade 0, 1, or 2 after intervention in the absence of angiographic stenosis. Angiographic no reflow was seen in 13 patients (13%). Univariate analysis indicated that hypercholesterolemia, fissure and dissection, lipid pool-like image, lesion, and reference external elastic membrane cross-sectional area correlate with the no-reflow phenomenon. Multivariate logistic regression analysis showed that lipid pool-like image (P<0.05; odds ratio 118; 95% CI, 1.28 to 11 008) and lesion elastic membrane cross-sectional area (P<0.05; odds ratio 1.55; 95% CI 1.01 to 2.38) are independent predictive factors of no-reflow phenomenon after reperfusion for AMI. CONCLUSIONS: Large vessels with lipid pool-like image are at high risk for no reflow after primary intervention for AMI. Also, plaque content may play a role in damage to the microcirculation after primary intervention for AMI.

Use of preintervention intravascular ultrasound in patients with acute myocardial infarction.

This study was designed to determine whether preintervention intravascular ultrasound (IVUS) imaging can assist in predicting the likelihood of acute coronary occlusion after primary angioplasty. Primary angioplasty is in widespread use for the treatment of acute myocardial infarction (AMI), although its usefulness is sometimes compromised by postprocedural acute coronary occlusion. If preintervention IVUS could be used to predict acute coronary occlusion, the task of determining treatment strategies for AMI would be significantly eased. Preintervention IVUS was performed without complications in 46 patients with AMI using manually prepared contrast medium. Coronary angiography was performed 1 hour after successful percutaneous transluminal coronary angioplasty. Acute coronary occlusion was seen in 13 of 46 patients (28%). There were no differences in the clinical characteristics and angiographic results between the patients with and without occlusion. In patients with acute occlusion, the incidence of eccentric plaque (85% vs 36%, p <0.01) and echolucent area (92% vs 15%, p <0.01) was significantly higher than in the occlusion-free patients. Most of the echolucent areas were associated with eccentric plaques (88%). Eccentric plaques characterized by echolucent areas are prone to acute occlusion after primary balloon angioplasty for AMI. Preintervention IVUS is both a safe and a useful adjunct to primary angioplasty.