Tension Fecopneumothorax.

Fecopneumothorax causing tension (hemodynamic compromise) is an extremely rare situation, mostly as a result of blunt trauma. Here, we present an 86-year-old gentleman who presented with tension fecopneumothorax, with an interesting backstory as to the development of fecopneumothorax.

Retrograde percutaneous coronary intervention in a calcified and dissected left anterior descending artery using single catheter - To lose the patience is to lose the battle.

Percutaneous coronary intervention (PCI) after iatrogenic coronary dissection in a heavily calcified vessel is technically challenging and a retrograde approach helps in that scenario. "Reverse rota wiring" shortens the procedure time in retrograde PCI whenever rotational atherectomy is planned. A 70-year-old male patient with previous PCI to diagonal and left circumflex arteries and attempted PCI to left anterior descending (LAD) and right coronary arteries, presented with exertional angina. After documenting ischemia, PCI to LAD was scheduled. After failed initial antegrade attempts, retrograde wiring through the diagonal was done. Then reverse rota wiring and rotational atherectomy (RA) to LAD using 1.25 mm burr was done. Since the 1.25 mm rota burr was entrapped, the entire system was manually pulled back. Repeat retrograde wiring and RA using 1.5 burr was done since the intravascular ultrasound showed >270° calcium. After multiple balloon dilatations, stenting was done using two drug-eluting stents. Coronary perforation with cardiac tamponade occurred after stenting. After pericardiocentesis, perforation was sealed with a guidezilla-II assisted covered stent implantation and final thrombolysis in myocardial infarction (TIMI) 3 flow was achieved. The patient remained symptom-free at one-year follow-up. Operator skills and perseverance are essential for good outcome in complex PCIs. Learning objectives: 1.Retrograde percutaneous coronary intervention is useful in iatrogenic coronary dissection, when antegrade attempts to enter the true lumen fail.2.'Reverse rota wiring' is an alternative method to do rotational atherectomy after retrograde wire crossing. It shortens the procedure time and it is useful in heavily calcified lesions where balloon uncrossability is anticipated.

Absolute zero-contrast percutaneous coronary intervention under intravascular ultrasound guidance in chronic kidney disease patients - From despair to hope?

Background: Zero contrast percutaneous coronary intervention (PCI) reduces contrast induced acute kidney injury (CI-AKI), and it improves the outcome of chronic kidney disease (CKD) patients undergoing PCI. Objectives: We sought to assess the safety and short-term outcomes of 'absolute' zero-contrast PCI under intravascular ultrasound (IVUS) guidance in CKD patients. Methods: Data from all consecutive CKD patients who were included for absolute zero contrast PCI during the period of June 2020 to March 2021 were included in this analysis. Clinical characteristics, angiographic, IVUS and procedural data, and follow-up data were analyzed. Results: Totally 42 patients (66 vessels) with the mean age of 69.04 ± 11.9 years, were included for absolute zero-contrast PCI. The mean serum creatinine and estimated glomerular filtration rate (eGFR) were 2.67 ± 1.46 mgs% and 30.67 ± 12.26 ml/min/1.73 m2 respectively. The most common presentation was acute coronary syndrome (ACS) and the mean left ventricular ejection fraction (LVEF) and SYNTAX score were 43.7 ± 11.9% and 27.7 ± 14.1 respectively. Complex PCI including 14 (21.2%) left main coronary artery (LMCA) PCI (seven LMCA bifurcation PCI) and three chronic total occlusion (CTO) PCI were also done. Technical success was 92.4% without any major complications. Two patients died of non cardiac causes on follow up (3-12 months), and all the remaining were symptom free. Conclusion: IVUS guided 'absolute' zero-contrast PCI is feasible and safe CKD patients. Even in complex lesion morphologies, the procedure can be completed without any contrast and complications.

Retrograde Percutaneous Coronary Intervention in a Case of Takayasu Arteritis with Left Main Coronary Artery Chronic Total Occlusion.

Background: Takayasu arteritis (TA) frequently involves the coronary arteries, and restenosis is common after initial percutaneous coronary intervention (PCI). However, PCI remains a good option for patients who develop graft failure after coronary artery bypass graft surgery (CABG). Drug-coated balloons help in repeat revascularization after stent failure in TA. Case Presentation. A 31-year-old female with previous history of Takayasu arteritis (TA) and CABG with left internal mammary artery (LIMA) to left anterior descending artery (LAD) grafting in 2012, presented to us with exertional angina of 6-month duration. Her coronary angiogram showed total occlusion of the left main coronary artery (LMCA) ostium and atretic LIMA graft. Since the guiding catheter could not engage the LMCA, a retrograde approach was planned. After lesion crossing, the retrograde guidewire could not be externalized even after multiple attempts. Hence, a repeat antegrade approach was tried, and antegrade wire crossed through the channel created by the retrograde microcatheter. Then, intravascular ultrasound (IVUS) guided LMCA-LAD stenting was done. The patient was started on dual antiplatelets and prednisolone and was on regular follow-up. Three months later, the patient presented to us with non-ST elevation MI. Coronary angiogram showed critical in-stent restenosis of the LMCA stent, and optical coherence tomography (OCT) showed diffuse neointimal hyperplasia. OCT-guided PCI using sirolimus-coated balloon was done. On 8 months of follow-up, the patient remains symptom free. Conclusion: Coronary artery disease in TA may require repeated interventions due to stent/graft failure. Drug-coated balloons play a crucial role in repeat revascularization for stent failure in TA. Retrograde approach increases the technical success rate of PCI in LMCA-CTO.

Percutaneous coronary intervention in unprotected left main coronary artery stenosis: Mid-term outcomes of a single-center observational study.

BACKGROUND: Percutaneous coronary intervention (PCI) is an appropriate alternative to coronary artery bypass grafting (CABG) for revascularization of unprotected left main coronary artery (ULMCA) disease in patients with low-to-intermediate anatomic complexity or when the patient refuses CABG even after adequate counselling by heart team. We assessed the safety, in-hospital and mid-term outcomes of ULMCA stenting with drug-eluting stents (DES) in Indian patients. METHODS: Our study was a retrospective analysis of patients who had undergone ULMCA PCI at a tertiary center, between March 2011 and February 2020. Clinical characteristics, procedural data, and follow-up data were analyzed. The primary outcome was a composite of major adverse cardiovascular and cerebrovascular events (MACCE) during the hospital stay and at follow-up. The median follow-up was 2.8 years (interquartile range: 1.5-4.1 years). RESULTS: 661 patients (mean age, 63.5 ± 10.9 years) had undergone ULMCA PCI. The mean SYNTAX score was 27.9 ± 10.4 and the mean LVEF was 58.0 ± 11.1%. 3-vessel disease and distal lesions were noted in 54% and 70.6% patients, respectively. The incidence of in-hospital MACCE was 1.8% and the MACCE during follow-up was 11.5% (including 48 [8.4%] cardiac deaths). The overall survival rates after one, three, five, and nine years were 94%, 88%, 84%, and 82%, respectively. The multivariate analysis revealed that age >65 years and high SYNTAX scores were independent predictors of mid to long-term mortality. CONCLUSION: ULMCA PCI with DES is safe and has acceptable in-hospital and mid-term outcomes among patients with low-to-intermediate SYNTAX score.

Retrograde chronic total occlusion percutaneous coronary intervention using single catheter: A single centre registry.

OBJECTIVES: To analyse the feasibility, safety and procedural outcomes of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) through retrograde approach using single catheter. METHODS: Our study was a retrospective observational study that enrolled patients who underwent retrograde CTO PCI using a single catheter between June 2016 and February 2020. Clinical success was defined as successful completion of CTO PCI without associated in-hospital major clinical complications like death, myocardial infarction, stroke or urgent revascularisation. Technical success was defined as successful completion of CTO PCI using single catheter and minimum diameter stenosis of <30% with thrombolysis in myocardial infarction (TIMI) flow grade 3, without significant side branch occlusion, flow-limiting dissection, distal embolization, or angiographic thrombus. RESULTS: Totally 102 patients underwent retrograde CTO PCI during the study period. Out of which, 15 cases were attempted using single catheter. Mean age of the population was 59.1 ± 8.9 years (males: 86.7%) and the left ventricular ejection fraction (LVEF) was (61% ± 9.1%). Mean number of diseased arteries was 2.1 ± 0.7, length of the CTO was 25.5 ± 7.4 mm and J-CTO score was 2.3 ± 0.7. We achieved a technical success rate of 73.3% using single catheter, and the overall clinical success (Including single catheter and ping pong) was obtained in 86.7% cases. One patient (6.7%) developed cardiac tamponade and none of study population required dialysis for contrast induced acute kidney injury (CI-AKI) CONCLUSIONS: Retrograde CTO PCI using single catheter is a technically challenging procedure when compared with other CTO PCI. Our study demonstrated acceptable outcomes which is comparable to other antegrade and retrograde CTO PCI registries.

Zero-Contrast Left Main Bifurcation PCI in an Elderly Patient with Chronic Kidney Disease.

Patients with chronic kidney disease develop acute kidney injury (AKI) following percutaneous coronary intervention (PCI). We report a case highlighting the benefits of zero-contrast left main bifurcation PCI in an 82-year-old male with non-ST elevation myocardial infarction and contrast-induced AKI following coronary angiography. The patient was on routine follow-up, and he was stable and asymptomatic at nine months follow-up.