Chih-Hung Lai

Spontaneous coronary artery dissection causing acute myocardial infarction and cardiac arrest in a 25-year-old male:

A 25-year-old previously healthy male presented to our emergency room with acute chest pain and ventricular arrhythmia-related cardiac arrest. ST elevation myocardial infarction was diagnosed and coronary angiography revealed diffuse critical narrowing from the proximal to the distal left anterior descending artery. Diffuse intramural hematoma was demonstrated on intravascular ultrasound. Two stents were placed to cover the whole dissection length and flow was successfully restored. Spontaneous coronary artery dissection can be a fatal event and could be mistaken for atherosclerotic plaque or coronary spasm rather than luminal compression on coronary angiography and intravascular imaging is helpful in this condition.

Feasibility and clinical outcomes of rotational atherectomy for heavily-calcified side branches of complex coronary bifurcation lesions in the real-world practice of the drug-eluting stent era

OBJECTIVES To evaluate the outcomes of rotational atherectomy for heavily-calcified side branches of coronary bifurcation lesions. BACKGROUND Side-branch (SB) preservation is clinically important but technically challenging in heavily-calcified non-left main true bifurcation lesions. SB rotational atherectomy (SB RA) is sometimes mandatory but the clinical outcomes are not well studied. METHODS We retrospectively studied the outcomes of patients who underwent RA at our institute for heavily calcified, balloon-uncrossable or-undilatable SB lesions over an approximately 5-year period (January 2011 to September 2016). RESULTS Two hundred and forty-four patients underwent main vessel only RA (SB-MV + RA group) and another 48 patients underwent SB RA (SB + MV ± RA group) for 49 side branches. The demographic variables were comparable between the two groups. However, patients underwent SB RA experienced more SB perforations and greater acute contrast-induced nephropathy (CIN). Among the SB RA patients, 30 (62.5%) underwent RA for both SB and MV (SB + MV + RA subgroup), whereas the other 18 underwent SB only RA (SB + MV-RA subgroup). Patients in these two subgroups could be completed with similar procedural, fluoroscopic durations, and contrast doses. The long-term MACE rate of SB RA was 27.1% over a mean follow-up period of 25.1 months with no differences between the two subgroups. CONCLUSIONS RA for SB preservation in complex and heavily-calcified bifurcation lesions was feasible with high success rate and quite favorable long-term outcomes in the drug-eluting stent (DES) era. Given the higher rates in SB perforation and acute CIN, we recommend that SB RA should be conducted by experienced operators.

Successful treatment of inadvertent subclavian artery cannulation by arterial closure device

To the Editor, Central venous catheterization (CVC), a common procedure in perioperative and critical care settings, is associated with a mechanical complication rate of up to 34%, including an arterial puncture incidence of 5%. Inadvertent cannulation of the subclavian artery is particularly challenging to address because its deep location and overlying structures make it difficult to address with compression or, if needed, a surgical approach. Immediate removal and compression after large-bore catheter insertion can lead to serious complications, including stroke and death. A catheterbased approach widely used to address femoral arterial puncture may offer a safe alternative for treating subclavian artery injury. We present a case of inadvertent subclavian artery cannulation managed with a percutaneous arterial closure device. A 54-year-old male patient presented for trans-oral robotic operative management (with neck dissection) of a left-side stage III hypopharyngeal cancer. After anesthesia induction and endotracheal intubation, right subclavian vein access was obtained (using a surface landmark approach) with an 18G needle. After non-pulsatile backflow appeared to be venous, an 8-Fr CVC was placed over a guidewire. Pulsatile flow was then observed from the CVC side port, however, indicating inadvertent subclavian artery cannulation. The catheter was left in place, and a cardiovascular surgeon was consulted. Because the surgical approach for repair was anticipated to be difficult, percutaneous treatment was chosen. Angiography, with contrast injection via the CVC, confirmed the puncture site (Figure A). The cardiologist then performed a percutaneous endovascular repair using an arterial closure device (Angio-seal VIP 6-Fr system; St. Jude Medical; Minnetonka, MN, USA) that was inserted via the puncture site and sealed the wound successfully (Figure B). After the intervention, follow-up radiography of the chest showed no hemothorax or pneumothorax. The next day, ultrasonography of the site revealed a patent artery with good flow (Figure C). One month later, computed tomography also showed normal patency of the right subclavian artery and absorption of the previously placed closure device. Inadvertent arterial injury following CVC insertion with a large-bore catheter (C 7 Fr) has led to serious complications, including hematoma, arteriovenous fistula, pseudoaneurysm, hemothorax, stroke, and even death. Despite the many methods that have been reported to prevent arterial placement of CVCs (i.e., ultrasound guidance, pressure waveform analysis, blood gas analysis, manometry), inadvertent arterial cannulation can still occur. Once inadvertent arterial cannulation is recognized, management of arterial injuries depends on many factors, including patient stability, catheter diameter, and whether the catheter is still in place. Pull and compression methods have been reported to be associated with significantly more instances of morbidity and mortality than surgical or S.-L. Chang, MD H.-C. Lai, MD, PhD C.-J. Hung, MD Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan

Balloon in the septum: imaging presentation of septal pseudoaneurysm and therapeutic considerations.

Coronary pseudoaneurysm is a rare complication of coronary intervention. We present a case with progression of coronary pseuodoaneurysm after a retrograde coronary intervention. According to the previous literature, conservative treatment with imaging follow-up is often adequate as an initial management of septal collateral perforation or pseudoaneurysm. However, in our case, the follow-up echocardiography and coronary angiography demonstrated rapid progression of the coronary pseudoaneurysm as a balloon-like cavity within the septum. Close imaging follow-up would be beneficial in case of complex coronary intervention to allow early treatment in case of pseudoaneurysm progression.

Percutaneous intervention to correct central venous port catheter malposition

The use of central venous port access is increasing due to the requirements of multimodal intravenous therapy.1 However, catheter malposition in smaller veins can lead to vein thrombosis, phlebitis and pain. Herein, we report our experience with the use of percutaneous interventions to correct migrated port catheter malposition. Minimally invasive percutaneous interventional correction of malposition could be an alternative to extraction and re-implantation of malpositioned port catheters.

Rescue intervention after three days of renal ischemia caused by acute complicated type B aortic dissection

Complicated type B dissection is associated with a high mortality rate due to malperfusion syndrome or progression of the dissection for which aggressive therapy with an endovascular or surgical intervention is recommended. Herein, we present a patient who received a successful percutaneous rescue intervention after three days of renal ischemia caused by a complicated type B dissection. This type of rescue of percutaneous intervention with branch vessel stenting appears to be useful in treating malperfusion syndrome caused by aortic dissection, even after a period of organ ischemia.

Iatrogenic Subclavian Artery Perforation Rescued by Operator-Modified Graft Stent

Subclavian artery (SCA) perforation is a rare complication while performing SCA intervention. In our present report, a 73-year-old female, with stenosis of the left SCA and situs inversus, presented with exercise-induced left arm weakness. The SCA stenosis was treated with direct stenting with a balloon-expansible Express LD 10×25 mm stent. However, it caused iatrogenic SCA perforation and hemothorax. The perforation was sealed by endovascular repair with operator-modified Endurant II graft stent, which complicated with occlusion of left common carotid artery. And, the carotid artery was rescued by another stent. The graft stent, which was originally designed for abdominal aortic aneurysm, can be modified to suitable length and take as a rescue stent of large vessel with iatrogenic perforation. Due to strong radial force of graft stent, preservation of large side branches should been watched out.

Modified drug-eluting balloon angioplasty to treat high-risk carotid in-stent restenosis

Carotid artery stenting is commonly used to treat carotid artery stenosis. However, carotid in-stent restenosis remains a challenging problem. Herein, we report a difficult case of recurrent severe carotid in-stent restenosis with total contralateral internal carotid artery occlusion treated with repeat drug-eluting balloon inflations. The outcome after one year of follow-up showed a good result.

Endovascular Treatment of Concomitant Obstructions of a Denver Drainage Catheter and Superior Vena Cava in a Patient With Liver Cirrhosis

With the increased use of intravascular catheters and devices, they have become the major non-malignant cause of superior vein cava (SVC) syndrome. We report a patient with liver cirrhosis who had received a peritoneovenous drainage catheter for refractory ascites, and then developed SVC syndrome because of concomitant occlusions of both the SVC and the drainage catheter. The patient regained patency of both the occluded vessel and the drainage catheter through percutaneous transluminal venoplasty, and there was dramatic improvement of clinical symptoms and good performance of the drainage catheter. Percutaneous intervention may be a feasible and effective therapy for SVC syndrome and intra-catheter thrombosis-related dysfunction.

Dramatic and early response to low-dose steroid in the treatment of acute eosinophilic myocarditis: a case report

BackgroundEosinophilic myocarditis encompasses a variety of etiologies and the prognosis varies. For patients with a hypersensitive response to medications, high-dose corticosteroids and discontinuation of culprit medications are the main treatments.Case presentationWe reported a young man with biopsy-proven eosinophilic myocarditis which was possibly induced by Chinese herbal medicine. His heart failure and left ventricular hypertrophy improved soon after low-dose corticosteroid.ConclusionLow-dose corticosteroid may be effective in selected patients with eosinophilic myocarditis. Early echocardiographic follow-up is mandatory for evaluation of the clinical response.