The expanding role of percutaneous mechanical thrombus debulking and extraction in the treatment of critical pulmonary embolism.

Massive and sub-massive pulmonary embolism require expeditious management of the cumulative deleterious effects caused by rapidly deteriorating hemodynamic condition, severely compromised cardiac performance, and associated respiratory failure that carry a predictable catastrophic outcome. The FlowTriever thrombectomy system as applied in 34 patients for massive and submassive pulmonary embolism resulted in 90% success rate including adequate reduction of the PA pressures, improved RV performance, increased CI, improved BP, and heart rates and decreased the need for vasopressors support within 24 hr. The role of percutaneous mechanical thrombus debulking and extraction continue to expand, and the yield of the FlowTriever thrombectomy system should be considered when determining which intervention is best suited to patients with massive and submassive pulmonary embolism.

Nitroglycerin and the enduring principles of coronary procedures.

The benefits of nitroglycerin are numerous, from ensuring accurate interpretation of diagnostic angiograms to treatment of coronary spasm and support of PCIs in simple or complex lesion types. The founders of the field were convinced that no coronary arteriography should be considered complete unless a vasodilator is used at some point during the study. This recommendation is valid. The guidelines should change to include administration of intracoronary nitroglycerin.

Synergistic ELCA-aspiration-DES thrombus removal strategy-embolus impact in high-risk plaque: A case report.

RATIONALE: Thin-cap fibroatheroma (TCFA) and red thrombus are suggested as a high-risk of embolic complications during percutaneous coronary intervention (PCI). Intracoronary aspiration procedures occasionally result in either an insufficient thrombus removal or provide no significant effects on TCFA. PATIENT CONCERNS: A 76-year-old male underwent coronary angiography for chest pain. DIAGNOSES: Coronary angiography revealed a tight stenosis at the right coronary artery which resulted in treatment by PCI. Optical frequency domain imaging (OFDI) delineated a red thrombus with TCFA. INTERVENTIONS: To avoid embolic complications, excimer laser coronary angioplasty (ELCA) was applied with intracoronary aspiration before drug-eluting stent (DES) implantation. OUTCOMES: The red thrombus was vaporized by ELCA in an energy-intensity dependent manner and subsequently removed by intracoronary aspiration. The fibrous cap of TCFA was dissected with the material beneath the cap ablated by ELCA and extensively removed by intracoronary aspiration. DES implantation and postdilatation achieved an optimal result without flow compromise. This combined synergistic strategy of ELCA-aspiration-DES yielded a successful outcome. LESSONS: A synergistic embolus removal strategy combining ELCA, aspiration and DES implantation is a promising option for the treatment of high-risk plaque with potential embolic complications.

CTO revascularization: Obstacles and options in balloon nonpenetrable lesions.

CTO lesions resisting balloon crossing are located in moderate/severe tortuous coronary arteries contain more moderate/severe calcification burden and carry a higher J-CTO score as compared with balloon crossable CTO lesions. CTO lesions resisting balloon crossing do not constitute a homogenous group. In 25% of the patients, the resisting CTO was caused by stent restenosis and thrombus is an integral component of CTO in addition to calcium and fibrosis. The excimer laser and rotational/orbital atherectomy are among useful debulking technologies capable of creating a "pilot recanalization channel" in the CTO that enables completion of the revasularization.

Contemporary anticoagulation therapy in patients undergoing percutaneous intervention.

The proper use of anticoagulants is crucial for ensuring optimal patient outcomes post percutaneous interventions in the cardiac catheterization laboratory. Anticoagulant agents such as unfractionated heparin, a thrombin inhibitor; low-molecular weight heparins, predominantly Factor Xa inhibitors; fondaparinux, a Factor Xa inhibitor and bivalirudin, a direct thrombin inhibitor have been developed to target various steps in the coagulation cascade to prevent formation of thrombin. Optimal anticoagulation achieves the correct balance between thrombosis and bleeding and is related to optimal outcomes with minimal complications. This review will discuss the mechanisms and appropriate use of current and emerging anticoagulant therapies used during percutaneous interventions.

Spontaneous coronary artery dissection in a young man with a factor v leiden gene mutation: a case report and review of the literature.

Spontaneous coronary artery dissection is a rare but increasingly recognized cause of acute myocardial ischemia in young adults, especially in women. We report a case of spontaneous coronary dissection in a young healthy man who was also a carrier of the factor V Leiden gene mutation.

Atherosclerotic inferior mesenteric artery stenosis resulting in large intestinal hypoperfusion: a paradigm shift in the diagnosis and management of symptomatic chronic mesenteric ischemia.

Symptomatic chronic mesenteric ischemia results from intestinal hypoperfusion and is classically thought to result from involvement of two or more mesenteric arteries. The celiac artery and superior mesenteric artery are most frequently implicated in this disease process, and their involvement usually results in symptoms of small intestinal ischemia. Symptomatic chronic mesenteric ischemia resulting predominantly from inferior mesenteric artery involvement has largely been overlooked but does gives rise to its own, unique clinical presentation with symptoms resulting from large intestinal ischemia. We present four patients with atherosclerotic inferior mesenteric artery stenosis with symptomatic chronic mesenteric ischemia that have unique clinical presentations consistent with large intestinal ischemia that resolved following percutaneous endovascular treatment of the inferior mesenteric artery stenosis. These cases represent a novel approach to the diagnosis and management of this disease process and may warrant a further subclassification of chronic mesenteric ischemia into chronic small intestinal ischemia and chronic large intestinal ischemia.