Sanjay Shah

Effect of basic fibroblast growth factor on myocardial angiogenesis in dogs with mature collateral vessels.

OBJECTIVES We sought to evaluate the potential of basic fibroblast growth factor (bFGF) to enhance coronary collateral perfusion in dogs with chronic single-vessel coronary occlusion. A secondary goal was to examine whether the salutary effects of bFGF treatment, previously proved effective in the short term, would be maintained in the long term (6 months). BACKGROUND bFGF, an angiogenic growth factor, is currently the subject of a Phase I trial in patients with ischemic heart disease. It has been shown to promote collateral development in dogs with progressive coronary occlusion when given during the period of natural collateralization. The effect of bFGF on quiescent collateral vessels, a subject of significant clinical importance, is uncertain. METHODS Dogs were subjected to ameroid-induced occlusion of the left circumflex coronary artery and randomized to bFGF (1.74 mg/day for 7 days), a regimen previously proved effective, or to saline solution. Maximal collateral perfusion was assessed 6 months later, and the dogs were reassigned to a course of bFGF or saline solution. Collateral perfusion was reevaluated after the second treatment course. RESULTS At 6 months, collateral function was identical in the groups treated initially with bFGF and saline solution. The subsequent course of bFGF did not induce further collateralization. CONCLUSIONS Although we previously demonstrated the salutary effects of this bFGF regimen in the short term (5 weeks), collateral flow in control dogs reached parity with that of bFGF-treated dogs after 6 months. bFGF did not induce further collateralization in dogs with mature collateral vessels, underscoring the priming role of ischemia for bFGF-induced collateral development.

Histopathologic changes of the radial artery wall secondary to transradial catheterization

Objective: The immediate effects of transradial access on the radial artery wall are unknown. In this study we sought to assess the histological changes induced by catheterization on the radial artery. Methods: Thirty-four patients undergoing coronary artery bypass grafting (CABG) had radial arteries harvested to serve as bypass conduits. The proximal and distal ends of the radial artery conduits were sectioned and embedded in paraffin. Both ends of all specimens were evaluated by a blinded pathologist for intimal hyperplasia, medial inflammation, medial calcification, periarterial tissue or fat necrosis, adventitial inflammation, adventitial necrosis, and adventitial neovascularization. Fisher’s exact test was used for statistical analysis. Results: Fifteen previously catheterized radial arteries (TRA group) were compared with 19 noncatheterized arteries (NCA group). The distal ends of the TRA group showed significantly more intimal hyperplasia (73.3% vs 21.1%; p = 0.03), periarterial tissue or fat necrosis (26% vs 0%; p = 0.02), and more adventitial inflammation (33.3% vs 0%; p = 0.01) than the distal ends of the NCA group. The distal ends of the TRA group also showed significantly more intimal hyperplasia (73.3% vs 26.6%; p = 0.03) and adventitial inflammation (33.3% vs 0%; p = 0.01) than the proximal ends of the same arteries. There were no histological differences in the proximal ends of the two groups. Conclusion: Transradial catheterization induces significant histological changes suggestive of radial artery injury limited to the puncture site in the form of intimal hyperplasia, medial inflammation, and tissue necrosis. Both the proximal and distal ends of the radial artery show a spectrum of atherosclerotic changes independent of its use for transradial catheterization.

Broken guidewire fragment: A simplified retrieval technique

We report a technique for retrieval of a broken angioplasty wire fragment from the coronary system using a more simplified technique that does not involve the use of a snare or any other retrieval tool. With the use of an additional angioplasty wire and a balloon catheter, we could safely remove the broken wire fragment from the coronary system and circulation in a very short time. Cathet. Cardiovasc. Intervent. 51:483–486, 2000.

Contralateral transradial approach for carotid artery stenting: A feasibility study†

Background: Carotid artery stenting (CAS) has become an accepted modality of treatment for revascularization of the internal carotid artery (ICA). CAS from femoral approach has got wide acceptance, however, it can be problematic due to access site complication as well as technical difficulties related to peripheral vascular disease and/or anatomical variations of the aortic arch. Small feasibility studies of CAS through ipsilateral transradial approach have been described in the literature. The purpose of the present study is to evaluate the feasibility of contralateral transradial approach as an alternative approach for CAS. Methods: Twenty patients (mean age: 65 ± 5, 17 male) underwent CAS using contralateral transradial approach. All had a CA stenosis greater than 80%. The target common carotid artery (CCA) was initially cannulated via the contralateral radial artery using a 5F Simmons 1 diagnostic catheter or a 5F TIG diagnostic catheter, which was then advanced to the external CA (ECA) over an exchange length of 0.032″ Terumo Glidewire or a 0.025″ Glidewire. Once the catheter was parked in the optimal position in ECA, the wire was removed and was replaced by 0.035″ Amplatz Super stiff Guide wire. Following that, the Simmons 1 or the TIG catheter was removed and 6F Pinnacle Sheath was exchanged and positioned in the distal CCA. CAS was performed using standard techniques with weight‐based heparin for anticoagulation. Results: CAS was successful in 16/20 (80%) patients, including 12/12 (100%) right CA, 4/8 (50%) left CA. Mean interventional time was 40 ± 5 min. The sheath was removed immediately after the procedure. There were no radial access site complications. One patient sustained a transient ischemic attack and recovered completely with complete resolution of symptoms within 1 hr. Median Hospital stay was 3 ± 0.5 days. Angulation of left CCA with the aortic arch was the technical cause of failure in the four unsuccessful cases. Conclusion: CAS using the contralateral transradial approach appears to be safe and technically feasible. The technique may be particularly useful in patients with right ICA lesions because of the favorable right CCA angle with the aortic arch.

Balloon-assisted tracking of a guide catheter through difficult radial anatomy: A technical report

A small caliber or significant tortuosity of radial artery may create difficulty in negotiating a 6F or 7F guide catheter while performing intervention through transradial approach. We describe a technique that helps tracking a guide catheter in such demanding situation for successful completion of procedure without increasing the chance of perforation and dissection.

Transradial approach for stenting of vertebrobasilar stenosis: A Feasibility Study

Background: Endovascular intervention of vertebrobasilar stenosis is a relatively new but alternative modality of management, supported by very few studies and case reports. Femoral approach has been used in all. The purpose of present study is to evaluate feasibility of the radial artery as an alternative approach for vertebral artery stenting (VAS) and basilar artery stenting (BAS). Methods: Forty‐seven patients (mean age 70 ± 5, 38 male) underwent VAS and BAS. VAS was offered in 42 and BAS was offered in five patients. All the patients were symptomatic having stenosis greater than 75%. The target vertebral artery (VA) was cannulated using a 6Fr Internal Mammary Artery (IMA) guide catheter using ipsilateral radial approach. 0.014″ floppy tip coronary guide wire was advanced and parked across the culprit stenosis. Pre dilation was done using a 2 × 12 mm2 or a 2.5 × 12 mm2 PTCA catheter and balloon mounted 2.5 × 13 mm2 or 3 × 13 mm2 bare metal stent was deployed using 8–10 atm pressure for all chronic lesions. For acute occlusions, the procedure was divided in two stages. In first stage, the lesion was dilated using PTCA catheter (1.5 × 12 mm2) at 4–6 atm pressure just to establish the distal flow. After 24 hr, the patient was brought back and the culprit lesion was stented using 8–10 atm pressure. The procedure was staged to prevent hyperperfusion brain injury. Results: VAS was successful in 42/42 (100%) patients. BAS was successful in five out of five (100%) patients. However, three patients had transient periprocedural stroke which recovered completely within 6 hr and one patient developed intracerebral hemorrhage (ICH) who died after 24 hr. Hyper perfusion brain injury was the cause for ICH. Conclusion: VAS and BAS using the transradial approach appear to be safe, technically feasible, and reproducible. Technical ease of cannulation of vertebral artery with IMA guide catheter using ipsilateral transradial approach should make it more convenient when compared with femoral approach.© 2009 Wiley‐Liss, Inc.

Bioresorbable vascular scaffold for coronary in-stent restenosis: A novel concept

The management of patients with significant in-stent restenosis (ISR) with drug-eluting stent is still not well defined. Various treatment modalities include plain old balloon angioplasty (POBA), metallic stent, cutting or scoring balloon and drug-eluting balloon (DEB). Bioresorbable vascular scaffold (BVS) is the latest technology for the treatment of de novo coronary artery lesions. The use of BVS in ISR is based on the rationale of local drug delivery as achieved by DEB without the permanent bi-layer of metal and also stabilizes dissection flaps and prevents acute recoil as provided by metallic stent. To the best of our knowledge this is the first case report of the use of BVS in patient with ISR.

Cannulating LIMA graft using right transradial approach: two simple and innovative techniques.

Angiography and intervention of a LIMA (left internal mammary artery) graft cannot be performed easily while working through right transradial approach (TRA), because of complexity in anatomical relations of right and left subclavian arteries with arch of aorta. We demonstrate two simple and innovative techniques for the same using right TRA.

Balloon-assisted deep intubation of guide catheter for direct thromboaspiration in acute myocardial infarction — A technical report

⁎ Corresponding author at: Department of Cardiology, Business Park, SG Highway, Ahmedabad-380054, In fax: +91 79 26842288. E-mail addresses: drsdeora@gmail.com (S. Deora), d tejaspatel@tcvsgroup.org (T. Patel). 1 This author takes responsibility for all aspects of th bias of the data presented and their discussed interpret 2 Tel.: +91 9924134369; fax: +91 79 26842288. 3 Tel.: +91 79 26466161; fax: +91 79 26842288.

Double or split right coronary artery: still a diagnostic dilemma for this rare coronary anomaly.

A 52-year-old hypertensive male was admitted in our institution with chest pain for 8 hour duration. 12-lead electrocardiogram revealed significant ST depression in leads V5-6 and I, aVL. Twodimensional echocardiography showed normal left ventricular systolic function (LVEF ~60%). Serum biochemistry was normal except significantly raised cardiac enzymes and troponin. Coronary angiography bymultidetector-row computed tomography (MDCT) revealed significant coronary lesions in the right and left coronary arteries. Right coronary artery (RCA) after common origin from right sinus of Valsalva and bifurcates into anterior and posterior branches [Fig. 1A]. Anterior RCA supplies free wall of the right ventricle and distal half of the interventricular septum whereas posterior RCA supplies right atrioventricular groove and basal interventricular septum after reaching to the crux [Fig. 1B]. After informed consent, conventional coronary angiography through right transradial approach revealed significant left coronary artery disease. Selective right coronary angiography confirmed the MDCT findings of right main coronary artery (RMCA) bifurcating into anterior and posterior RCA [Fig. 2A, B; S Video 1, 2]. There was significant stenotic lesion in the posterior RCA. Percutaneous coronary interventionwasdonewith successful stentingof LADandposteriorRCA with TIMI III flow [Fig. 2C, D; S Video 3, 4]. Patient was discharged in hemodynamically stable condition. Double RCA is a very rare coronary anomaly and incidence varies from 0.01% in conventional coronary angiographic series to 0.07% in coronary angiography by MDCT [1,2]. There are varied schools of thoughts for naming and definition of this anomaly. The first case was reported by Gupta et al. as “supernumerary right coronary artery” [3]. Barthe et al. reported it as “double RCA”, Egred et al. as “duplicated RCA”