Surender Deora

Working through challenges of subclavian, innominate, and aortic arch regions during transradial approach

The aim of this review is to discuss different methods of working through subclavian, innominate, and aortic arch anatomical challenges to increase the success rate of transradial approach (TRA).

Working through complexities of radial and brachial vasculature during transradial approach

The aim of this review is to discuss different methods of working through radial artery (RA) and brachial artery (BA) vascular complexities to increase the success rate of transradial approach (TRA).

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.

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”

Saphenous Vein Graft Perforation During Percutaneous Coronary Intervention - A Nightmare to be Avoided

Percutaneous coronary interventions (PCIs) of saphenous vein grafts (SVGs) is challenging and is associated with adverse short- and long-term clinical outcome as compared to native coronary arteries. SVG perforation is rare but catastrophic and needs immediate attention. Various factors predisposing for SVG perforation are old degenerated graft, ulcerated plaque, severe fibrotic, or calcified lesion necessitating high pressure balloon or stent inflation, use of intravascular ultrasound (IVUS) or other atheroablative devices. Management includes prolonged balloon occlusion, reversal of anticoagulation, use of covered stent, and emergency pericadiocentesis if required.

Successful retrieval of broken coiled guidewire from left atrium during balloon mitral valvotomy: A rare complication

Abstract Balloon mitral valvotomy (BMV) is the procedure of choice for rheumatic mitral stenosis with favorable valve morphology. Fracture of 0.025 inch coiled guidewire during BMV is a very rare complication. The various factors which may cause this complication are utilization of reused hardware, improper placement of guidewire, abnormal angulation between guidewire and dilator with forceful septal dilation and rarely manufacturing defect. Here, we report successful retrieval of broken 0.025 inch coiled guidewire from left atrium during BMV using 10F Amplatzer long sheath without any complication.

Cardiac Epithelioid Leiomyosarcoma as Both Intracardiac and Pericardial Mass With Massive Pericardial Effusion: A Rare Presentation

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] A 26-year-old man presented with gradually progressive dyspnea for the last 1 year. Chest x-ray revealed cardiomegaly (A) . Echocardiography showed a dumbbell-shaped mass in the left atrium intermittently

Post myocardial infarction ventricular septal defect causing left ventricular intramyocardial dissecting hematoma: a very rare complication

A 73-year-old male smoker with a past history of type II diabetes mellitus and dyslipidemia was admitted with chest pain and dyspnea of 7-h duration. He was diagnosed as having anterior wall myocardial infarction and was thrombolyzed with streptokinase, as the patient and his relatives refused coronary angiography and percutaneous coronary intervention if needed. Two-dimensional transthoracic echocardiography (TTE) revealed severe left ventricular systolic dysfunction [ejection fraction (EF) *25 %] and a pulsatile cavity surrounded by a thin endomyocardial layer with wavy movement and no pericardial effusion (Fig. 1a; Supplementary Material Video 1). With slight tilting of the transducer, a small ventricular septal defect was seen communicating with the dissected cavity in the infarcted left ventricular myocardium (Fig. 1b, arrow; Supplementary Material Videos 2 and 3). Serial TTE revealed changes in the acoustic character of the hematoma from unorganized hematoma to partially organized at the time of discharge and nearly organized and resolving hematoma at 1-month follow-up (Fig. 2). The patient was hemodynamically stable, so was managed conservatively. An intramyocardial dissecting hematoma (IDH) is a rare complication following acute ST elevation myocardial infarction (STEMI). The actual incidence of IDH is not known, as only isolated case reports exist in the literature, but in an autopsy series of 106 patients of cardiac rupture, it was present in 21 % of cases [1]. It is caused by hemorrhagic dissection among the spiral myocardial fibers due to either the rupture of intramyocardial vessels or decreased tensile strength of the infarcted myocardium, as in our case, or acute increase of coronary capillary pressure [2, 3]. The outer wall of a neocavity is formed with pericardium and myocardium, while the inner wall is formed by a thin layer of myocardium and endocardium. It may be either contained and spontaneously resolve as in our case or may expand and rupture into adjacent structures. It has also been reported after chest trauma, cardiac surgery, inflammation, and endocarditis [4]. Persistent ST elevation more than 72 h after the index event should raise the suspicion of an IDH. TTE is not only useful for the early diagnosis of this complication, but, also, the acoustic character of hematoma helps in further management [5]. The main differential diagnosis is intramural thrombus, pseudoaneurysm, and dense trabeculations. In conclusion, post myocardial infarction ventricular septal defect causing left ventricular IDH is a very rare finding and serial TTE is a useful imaging modality to diagnose and for further follow-up of this rare cardiac complication. Electronic supplementary material The online version of this article (doi:10.1007/s12574-013-0173-1) contains supplementary material, which is available to authorized users.

Pseudo-ballooning of Radial Artery-An Artifact.

Transradial approach (TRA) for coronary intervention is rapidly increasing worldwide and therefore novel difficulties and complications are frequently observed. Most of these difficulties and complications can be dealt with new techniques and the procedure can be completed through the same artery and seldom needs change to femoral artery approach [1]. Among the various difficulties encountered through TRA, radial artery spasm either focal or diffuse is common and is observed in 14.7% of the cases [2]. Mostly the spasm is relieved completely by spasmolytic cocktails. Here, we describe a very unusual behavior of the radial artery where diffuse spasm was relieved only in the focal segment in spite of repeated spasmolytic cocktail. A 64-year-old hypertensive female presented with chest pain of 6 hours duration. She had significant past history of ischemic heart disease and underwent percutaneous coronary intervention (PCI) from right radial approach in left anterior descending coronary artery (LAD). A 12-lead electrocardiogram revealed no significant ST-T changes. Transthoracic echocardiography revealed mild left ventricular systolic dysfunction (LVEF ~ 40%). After informed consent, coronary angiography was planned through left radial approach as right radial artery was occluded because of the previous procedure. Left radial artery was punctured successfully but 0.025″ hydrophilic wire as well as floppy-tipped 0.014″ percutaneous transluminal coronary angioplasty (PTCA) wire could not be negotiated. Injection with diluted contrast through the cannula revealed diffuse spasm of the left radial artery [Table/Fig-1]. As a part of our protocol, 200 mcg of nitroglycerine and 5 mg of diltiazem was administered through the cannula but the radial spasm was not relieved, therefore the spasmolytic cocktail was repeated after 3 minutes. Contrast injection after second spasmolytic cocktail showed focal relief of diffuse spasm presenting an interesting image of ‘pseudoballooning’ of radial artery mimicking inflated PTCA balloon catheter [Table/Fig-2]. Despite administration of spasmolytic cocktail for third time, the diffuse spasm was not relieved and the coronary angiography was completed through femoral approach [Video-1]. [Table/Fig-1]: Diluted contrast injection through the intra-arterial cannula showing diffuse spasm of left radial artery [Table/Fig-2]: Repeat contrast injection after spasmolytic cocktail showing focal relief (Arrow) of diffuse spasm mimicking “pseudo-ballooning of radial artery”