Feasibility of right coronary artery first ergonovine provocation test.

BACKGROUND: Intracoronary (IC) provocation angiography is recommended when variant angina is suspected. However, specific procedure-related factors remain uncertain. METHODS: Intracoronary ergonovine infusion was used for the provocation test. About 10, 20, and 40 µg of ergonovine were sequentially injected into the right coronary artery (RCA). During a negative or intermediate response or depending on the clinician's discretion, the left coronary artery (LCA) was injected with incremental doses of 20, 40, and 80 µg of ergonovine or vice versa. If significant coronary spasm or positive clinical findings were noted, the test was stopped immediately and IC nitroglycerine was injected. RESULTS: We reviewed a total of 725 patients (male: 402; mean age: 58.5 years). Spasm-positive response was observed in 269 patients (37.1%), intermediate response in 113 patients (15.6%), and negative response in 343 patients (47.3%). The right radial artery approach was used in most cases (92.6%), and the RCA first approach was mainly chosen (95.0%). The provocation results in the RCA and LCA (93.4%, 381/408) were highly consistent, and the clinically significant discrepancy rate (RCA positive/LCA negative or RCA negative/LCA positive) was 1.5% (6/408). The RCA-alone provocation test can identify spasm-positive response in 93.4% of the patients (228/244). The mean procedure time was 39.9 ± 11.0 min, and approximately 3.3% (24/725) of the patients developed acute complications. CONCLUSIONS: The RCA-first IC ergonovine provocation test is feasible, and the RCA-alone spasm provocation could be acceptable except in an intermediate response, highly clinically suspected cases, or high-risk patients.

Segmental bile duct leakage after hepatic resection managed with percutaneous ablation by N-butyl cyanoacrylate.

A biloma is a rare abnormal accumulation of intrahepatic or extrahepatic bile caused by a traumatic or spontaneous rupture of the biliary tree. The reported incidence of postoperative biloma ranges from 4.8% to 7.6%. Biliary drainage is usually important and necessary for the treatment of biloma, but sometimes bile leakage fails to improve despite prolonged conservative drainage. We report a case of postoperative refractory biliary leakage managed with percutaneous ablation by N-butyl cyanoacrylate.