Kenji Wagatsuma

Percutaneous transluminal coronary angioplasty for morphologic left anterior descending artery lesion in a patient with dextrocardia. A case report and literature review.

A case report of percutaneous transluminal coronary angioplasty (PTCA) to treat coronary atherosclerotic lesions in a patient with dextrocardia associated with situs inversus totalis is presented. The patient was a sixty-two-year-old man who was admitted with a diagnosis of congestive heart failure. Cardiac catheterization was performed. Left ventriculography showed mild hypokinesis in segments 2 and 3 with ejection fraction of 63%. Coronary arteriography revealed 74% stenosis in segment 7 of the left anterior descending (LAD) artery. PTCA for this lesion was performed. Successful dilation was achieved with the residual stenosis in the LAD reduced from 74% to 34%. Performance of PTCA in patients with dextrocardia is extremely rare, and only 8 cases have been reported to date. However, by visualizing the procedure as a mirror image and choosing a guide catheter that permits good engagement, it appears possible to perform it like ordinary PTCA.

Short- and Long-Term Follow-up of Percutaneous Coronary Intervention for Chronic Total Occlusion through Transradial Approach: Tips for Successful Procedure from a Single-Center Experience

BACKGROUND  There are limited data regarding transradial percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). OBJECTIVE  To assess the feasibility and safety of transradial coronary intervention (TRI) for CTO lesions, we analyzed our experience in PCI treatment of CTO lesion through transradial approach for the past 6 years. METHODS  From January 2003 to May 2009, among 134 CTO lesions, on which we performed PCI, 120 lesions were performed from transradial approach. RESULTS  Technical success for transradial CTO was 80%. Complication of access bleeding was zero. The most commonly selected guiding wire was Wave 3 for right coronary artery (RCA) lesions (82%) and Voda left for Left Coronary Artery (LCA) lesions (91%). The average number of wires used during procedure was 2.2 ± 0.8. Tapered wire was used in 8% of the cases, Rotablator was performed in 4.1% of cases, and Tornus catheter was performed in 12.5% of cases. The mean procedure time was 83 ± 39 minutes. The mean volume of contrast medium used was 228 ± 92 mL. There were two coronary artery perforations during procedure and one in-hospital cardiac death. Patients were followed up for 36 ± 21 months; restenosis rate was 19.5%-26.7% for bare metal stent (BMS) and 9.8% for drug-eluting stents (DES). Overall major adverse cardiac events (MACE) rate was 11.7%. CONCLUSION  It was demonstrated that transradial PCI for CTO lesions is safe, minimizing vascular complications without increasing procedural time and contrast use.

Virtual histology intravascular ultrasound analysis of attenuated plaque and ulcerated plaque detected by gray scale intravascular ultrasound and the relation between the plaque composition and slow flow/no reflow phenomenon during percutaneous coronary intervention.

OBJECTIVE This study aimed to assess the plaque characteristics of attenuated and ulcerated plaques in virtual-histology intravascular ultrasound (VH-IVUS) and the incidence of slow flow/no reflow during percutaneous coronary intervention (PCI). BACKGROUND The attenuated and ulcerated plaques are thought as embolic prone plaque; however, the plaque characteristics are unclear. METHODS Subjects were 119 patients 121 lesions undergoing VH-IVUS before coronary stenting. These lesions were divided into the 15 lesions showing attenuated plaque, 24 lesions showing ulcerated plaque, and 82 lesions revealing neither attenuated nor ulcerated plaque (the control group). RESULTS Fibro-fatty tissue in the attenuation group was significantly larger than the control group (27.5 ± 9.5% vs 13.9 ± 8.2%, P < 0.01, 3.5 ± 1.9 mm(2) vs 1.6 ± 1.2 mm(2), P < 0.01). Necrotic core in ulceration group was significantly larger than the control group (20.7 ± 9.0% vs 15.9 ± 9.0%, P < 0.05, 2.5 ± 1.3 mm(2) vs 1.7 ± 1.0 mm(2), P < 0.01). Dense calcium in ulceration group was significantly larger than the control group (12.3 ± 6.4% vs 8.3 ± 7.1%, P < 0.05, 1.4 ± 0.7 mm(2) vs 0.9 ± 0.8 mm(2), P < 0.01). In the ulceration group, the necrotic core area of acute coronary syndrome was significantly larger than the stable angina pectoris (3.0 ± 1.4 mm(2) vs 1.8 ± 1.0 mm(2), P < 0.05). The incidence of slow flow/no reflow was significantly higher in the attenuation and ulceration group than the control group (20.0% [3/15], 20.8% [4/24] vs 4.9% [4/82], P < 0.05, 0.05). CONCLUSION The attenuated plaque had significantly larger fibro-fatty tissue. The ulcerated plaque had significantly larger necrotic core and dense calcium. The lesions with the attenuated and the ulcerated plaque had more frequent slow flow/no reflow during PCI.

Impact of diabetes on long term follow-up of elderly patients with chronic total occlusion post percutaneous coronary intervention

Background The prognosis of elderly patients with chronic total occlusion (CTO) and diabetes mellitus (DM) treated with percutaneous coronary intervention (PCI) is not known. Objective To investigate the effect of diabetes on long-term follow-up of CTO after PCI in elderly patients. Methods A total of 153 elderly patients (age > 65 years old) with CTO lesions which were successfully treated with PCI were enrolled. Fifty one patients with diabetes and 102 without diabetes were compared for long-term outcomes (mean follow up: 36 ± 12 months). Major adverse cardiac events (MACE) which include death, myocardial infarction or target lesion revascularization (TLR) were considered as a combined endpoint. Results The combined endpoint occurred in 29.4% of diabetes patients, and 11.3% of the patients without diabetes (P < 0.05). The Cox proportional hazards model identified: drug eluting stent (DES) or bare metal stent (BMS) (HR: 0.13, 95% confidence interval (95% CI): 0.03–0.62, P = 0.004), DM (HR: 6.69, 95% CI: 1.62–15.81, P = 0.01) and final minimal lumen diameter (MLD) (HR: 0.37, 95% CI: 0.13–0.90, P = 0.03 ) as independent predictors of MACE, DM with renal impairment (HR: 6.64, 95% CI: 1.32–33.36, P = 0.02), HBA1C on admission (HR: 1.79, 95% CI: 1.09–2.94, P = 0.02), as independent predictors of MACE at long term follow-up. Conclusions The study demonstrates that DM is a predictive factor for MACE in elderly CTO patients treated with PCI, type of stent, final minimal lumen diameter and DM with renal impairment, and HBA1C level on admission are predictors of MACE.

Efficacy and issues of emergent percutaneous transluminal coronary angioplasty : comparison of clinical results in younger and elderly patients

The authors investigated the efficacy and prognosis of emergency percutaneous trans luminal coronary angioplasty (PTCA) in elderly patients. A study was conducted on the early and late prognosis of the study group composed of 66 younger patients < sixty-five years in Group A and 46 elderly patients ≥ seventy years in Group B who underwent reperfusion therapy, including PTCA, for acute myocardial infarction (AMI). No difference was seen in the initial success rate of 82% for Group A and 85% for Group B, or in the vessel patency in the predischarge coronary arteriogram (CAG) with 84% for Group A and 87% for Group B. However, in-hospital mortality was 3% for Group A and 11% for Group B. The patient restenosis rate in the 4.2 months follow-up CAG was 28% for Group A and 50% for Group B. The lesion restenosis rate was 30% for Group A and 53% for Group B (P < 0.05), and the late period mortality rate was 3% for Group A and 11% for Group B. Although there was no difference in the initial success rate of reperfusion through PTCA for AMI in the elderly as compared with the younger patient group, poorer results were seen in the restenosis rate and mortality rate.

A novel technique of chronic total occlusion retrograde wire crossing by wiring into the antegrade microcatheter

We described a novel transradial retrograde wiring technique to treat chronic total occlusion (CTO) of the left anterior descending artery. When both retrograde wire and kissing wire technique failed to cross the CTO lesion, an antegrade microcatheter was placed in the CTO lesion. Then, a retrograde wire was manipulated into the antegrade microcatheter and subsequently exchanged and wire externalized. This technique appears to be feasible and safe alternative for retrograde wire crossing of the CTO lesion. It is a less traumatic modified version of controlled antegrade and retrograde subintimal tracking (CART) technique that can be attempted before embarking on CART or reverse CART strategy.

Transcatheter atrial septal defect closure in a patient with paradoxical brain emboli: who should treat it and who should be treated?

This report presents the case of a 51-year-old female who was admitted to a local hospital because of a persistent headache. A diagnosis of multiple cerebral infarctions was thereafter made, but there was no evidence of either atherosclerosis or atrial fibrillation. The case was thought to be a cryptogenic stroke, however, Doppler ultrasonography of the lower extremities showed venous insufficiency. Transesophageal echocardiography revealed a secundum atrial septal defect (ASD) with a left to right shunt. Therefore, the final diagnosis was paradoxical brain emboli, and transcatheter ASD closure was successfully performed by cardiologists without any sequelae.

Coronary arterial complications after percutaneous coronary intervention in Behçet's disease

Behcets disease is a multisystemic vascular inflammatory disease, but concurrent cardiac diseases, such as acute myocardial infarction, are rare. Several complications may arise after coronary intervention for coronary lesions that interfere with treatment, and the incidence of coronary arterial complications due to invasive therapy remains unclear. Further, the long- term outcomes in patients with Behcets disease after stenting for acute myocardial infarction have not been described. The present report describes a 35-year-old Japanese man with Behcets disease who developed acute myocardial infarction. A coronary aneurysm developed at the stent- ing site of the left anterior descending coronary artery, along with stenosis in the left anterior descending segment proximal to the site. Although invasive therapy was considered, medication including immunosuppressants was selected because of the high risk of vascular complications after invasive therapy. The coronary artery disease has remained asymptomatic for the 4 years since the patient started medication. This case underscores the importance of considering the

Treatment of non-left main bifurcation lesions using the sirolimus-eluting stent: A comparison of chronic outcomes of cross-over single stenting and crush stenting

BACKGROUND It is said that the chronic outcomes of the two-stent technique for bifurcation lesions are inferior to that of cross-over single stenting. However, there are many cases where true bifurcations are difficult to treat by single stenting and, in particular, strategies for bifurcation lesions that are not left main trunk (LMT) bifurcations are still not clear. OBJECTIVE This study aims to compare the usefulness of crush stenting with that of cross-over single stenting using the sirolimus-eluting stent (SES) on bifurcation lesions with the exclusion of LMT bifurcations. METHODS Subjects were 92 consecutive patients (100 lesions) who underwent cross-over single stenting or crush stenting using SES for bifurcation lesions with the exclusion of LMT bifurcations. The patients were divided into 33 patients with 34 lesions, in whom the stent was implanted in the main vessel alone with the kissing balloon technique performed for the main vessel and side branch (Single-stenting group; S group), and 59 patients with 66 lesions, in whom the stent was implanted through crush stenting (Crush-stenting group; C group). The two groups were compared for target lesion revascularization (TLR) and major adverse cardiac events (MACE). RESULTS There were no differences for TLR, with this conducted in the main vessel in 5.9% of S group and 4.5% of C group. There was no difference between the groups in MACE with 9.1% in S group and 8.5% in C group. No significant difference was seen in MACE-free survival rate in the chronic phase with 93.9% for S group and 94.9% for C group (P=NS). CONCLUSION No differences in chronic clinical outcomes were revealed in a comparison between cross-over single stenting and crush stenting. Good clinical outcomes were achieved by both cross-over single stenting and crush stenting in the treatment of non-left main bifurcation lesions.