Percutaneous Coronary Intervention in an Octogenarian With Anomalous Origin Arising From Right Sinus: A Rare Case Report.

Anomalous coronary artery origins are not common in routine clinical practice. The incidence of coronary anomalies in patients undergoing coronary angiography is less than 1%. The greatest challenges faced in the management are delays in identification and difficulty engaging the anomalous coronary artery. Operator experience in promptly identifying the anomaly and selection of the appropriate catheter is critical for successful intervention. We are presenting a case of acute inferior and posterior wall myocardial infarction (MI) with an anomalous origin of the left circumflex artery from the right coronary sinus. Learning objective is that percutaneous coronary intervention (PCI) in an anomalous left circumflex can be technically difficult because selective cannulation of the vessel may not be easy. An anomalous left circumflex artery has a rare presentation of ST-elevation myocardial infarction (STEMI). Complicated STEMI with cardiogenic shock is not commonly seen in anomalous coronary artery origin from the right sinus. Percutaneous intervention in patients with STEMI with an anomalous left circumflex artery has a high risk and is technically challenging.

Successful device retrieval using simple balloon method during cardiac procedures.

OBJECTIVES: Although rare, incidents of broken/dislodged fragment of various angioplasty hardwares, including catheters, guidewires, angioplasty balloons, and stents, are being increasingly reported in recent years. Since these broken fragments may cause life-threatening consequences for a patient, it is vital for an interventional cardiologist to be acquainted with different retrieval techniques. Here, we are reporting our observations of several incidents of device dislodgement/fracture during cardiac interventions and their retrieval using simple balloon method. METHODS: We present a study of eight patients in whom we attempted to retrieve dislodged/fractured cath-lab hardwares during cardiac interventions, using simple balloon method. These cases include two cases of balloon, three cases of stent, and three cases of guidewire dislodgement/fracture. RESULTS: Fractured/dislodged cath-lab hardwares were successfully retrieved using a simple balloon method in six out of eight cases (75%), without any need of other retrieval hardwares. We observed no major complications in any patient. CONCLUSIONS: The balloon-assisted retrieval method is a simple, safe, and cost-effective way to avoid complications of endothelial injury, myocardial infarction, emergency coronary artery bypass graft, and sudden cardiac death. This study, particularly the context of retrieval technique used in each case, will offer valuable information to fellow interventional cardiologists.

Tough, but not impossible - Retrieval of large atrial septal occluder devices embolized to left atrium.

Atrial septal defect (ASD) is a congenital heart defect that is being increasingly treated using percutaneous interventions. However, these techniques are not devoid of complications. One such complication is device embolization. Removal of such closure device poses tremendous risk and consequent complications both by percutaneous retrieval and surgical removal. Herein, we present two cases of ASDs that were closed using atrial septal occluder, but the devices were subsequently embolized into left atrium. These devices were then percutaneously retrieved without any further complication or injury.

Coronary stent concertina in proximal left anterior descending artery: An unusual case.

Since the emergence of stents, there has been persistent improvement in flexibility and deliverability of stents with modifications in its design and number of connectors. This has unfortunately created negative effect on longitudinal strength of stent resulting into a recently recognized and unaccustomed complication, longitudinal stent deformation (LSD). It is an abrupt shortening of the stent along its longitudinal axis, usually after deployment, due to various reasons. We present a case of LSD in Promus Element stent implanted at proximal left anterior descending artery. The stent shortening was about 25%-30% of its actual length. As this led to exposure of a part of lesion, it was successfully managed by overlapping another stent.

Incidental Detection of Arteria Lusoria During Transradial Coronary Intervention.

Transradial access has become popular and preferred approach in coronary interventions due to high success rate, low risk of complications and patients' comfort. However various anatomical variations and anomalies may pose technical challenge. Arteria lusoria is an uncommon condition which is technically challenging and may warrant cross-over to alternate access. We report a middle aged male presenting with acute coronary syndrome in which arteria lusoria was incidentally detected during right transradial coronary intervention.

Use of CT Angiogram in Interventions Involving Coronary Artery Anomalies: A Case Series.

BACKGROUND: Coronary artery anomalies are rare, accounting for about 0.3-1.3% of patients undergoing diagnostic coronary angiography. Interventions in these cases are still rare, and therefore pose technical challenges during intervention. CT Angiography provides a non-invasive means of assessment of coronary artery disease and also shows the anatomy of the coronary tree. This helps in knowing the origin of the coronaries and also to plan selection of hardware. There are no specific guidelines for use of guiding catheters and guide wires in anomalous coronary artery intervention. CASE REPORT: We report a series of 5 patients presenting with effort angina who had anomalous coronary arteries with coronary stenosis diagnosed by CT angiography. Three patients received percutaneous intervention, 1 patient underwent CABG, and 1 patient received medical management. CONCLUSIONS: CT Angiography provides a useful tool for showing the coronary anatomy and for selecting the guiding catheter and the guide wire that remain the mainstay of interventions in coronary artery anomalies.

Percutaneous device closure of patent ductus arteriosus with pulmonary artery hypertension: long-term results.

UNLABELLED: Device closure of patent ductus arteriosus (PDA) is treatment of choice. But device closure in presence of pulmonary artery hypertension (PAH) remains a challenge. Data on patient selection, technical considerations, and complications are limited. AIM: To know the challenges and efficacy of device closure of PDA with PAH. MATERIALS AND RESULTS: Out of 1,325 cases of device closure of PDA, 246 (18.6%) with PAH formed the study material. To test the feasibility, chosen device is used to occlude PDA for ten minutes without oxygen inhalation. The device is released only if PAH reduced. PAH decreased in all except in 1 patient after closure with muscular ventricular septal occluder (MVSDO), pulmonary artery pressure (PAP) transiently increased (became supra-systemic), without significant reduction in aortic pressure. Device embolized in 8 patients (3.3%). Percutaneous retrieval was done in 4 (by snare in 2 and by fixing the cable to device in 2) and replaced with bigger devices. The surgical removal of the embolized MVSDO and ligation was done in 4 cases. All patients were on oral sildenafil and bosentan until PAP regressed to normal. Follow up was from 6 months to 9 years. No residual shunt in any patient on follow-up. The PAP regressed to normal in all except 5 cases (2.03%) of Down's syndrome with systemic PAP. CONCLUSIONS: Device closure of PDA with PAH is feasible, safe in all age groups. Temporary PDA occlusion with device is effective and time saving for evaluating pulmonary vascular reactivity. Device embolization in aorta is higher with severe PAH. Novel method of retrieval is effective.