Yoshito Kadoya

Two-Wire Technique With a Gooseneck Snare to Bail Out the Tip Separation of a Crosser Catheter

Tip separation of a Crosser catheter is a serious complication; however, there is limited information on bailout methods. Here, we describe a case of successful retrieval of the separated tip of a Crosser catheter using a 2-wire technique with a gooseneck snare. A 76-year-old woman with a history of hemodialysis and diabetes mellitus who developed ulcers on her right toes was diagnosed as having critical limb ischemia and underwent transfemoral antegrade endovascular treatment of the anterior tibial artery (ATA). A 0.014-inch guidewire was passed through the ATA chronic total occlusion, and then a Crosser catheter was advanced along the wire. During catheter withdrawal, the tip completely detached from the shaft and remained in the ATA. We passed another 0.014-inch guidewire into the distal ATA through the small space beside the tip. A gooseneck snare catheter was advanced to the distal side of the tip along the new wire, and subsequently the 2 wires were entrapped by the snare. The detached tip was finally retrieved with the entire system as a unit and successfully withdrawn into the guiding sheath with no complications. Interventionists should be familiar with the bailout method of this unfavorable complication. Our technique may be widely adapted for various situations involving this complication.

Successful Endovascular Treatment for Aortic Thrombosis Due to Primary Antiphospholipid Syndrome: A Case Report and Literature Review

A 60-year-old man with a history of Raynaud’s phenomenon presented with bilateral intermittent claudication and an ulcer on his right toe. The ankle–brachial index of the right and left legs was 0.77 and 0.75, respectively. Laboratory data showed prolongation of the activated partial thromboplastin time and a positive result on the lupus anticoagulant test. Computed tomography angiography revealed isolated infrarenal aortic stenosis with irregular surface and noncalcified plaques. Intravascular ultrasonography examination demonstrated a noncalcified, irregular, and mobile plaque, suggestive of abdominal aortic thrombosis. In addition to anticoagulant and dual antiplatelet therapy, endovascular treatment was performed. A total of three 40-mm-long balloon-expandable stents were successfully implanted on a 15-mm balloon. The final angiography showed good results except for minimal plaque shifting in the terminal aorta. Three months later, the ulcer resolved and a final diagnosis of primary antiphospholipid syndrome (APS) was made. Clinicians should recognize that APS can affect the abdominal aorta, leading to aortic thrombosis. Endovascular treatment may be the one good treatment option for this rare condition.

Lipohyperplasia of the ileocaecal valve

Abstract A 54-year old woman presented to the emergency department with a 7-day history of recurrent abdominal pain and diarrhoea. Computed tomography of the abdomen revealed a classic ‘target sign’ in the axial and sagittal view of the transverse colon, and a fat-density tumour with a pedicle in the coronal view. A diagnosis of intestinal intussusception was made. Histological assessment of the resected specimen revealed submucosal infiltration by adipose tissue, indicating lipohyperplasia of the ileocaecal valve.

Mid-aortic Syndrome: A Rare Cause of Juvenile Hypertension

A 49-year-old woman with a history of juvenile hypertension since 4 years of age was referred to our hospital. She had previously experienced a subarachnoid hemorrhage at 18 years of age. Her blood pressure (BP) had been wellcontrolled (under 130/90 mmHg) with antihypertensive treatment. Contrast-enhanced computed tomography showed a narrowing of the interrenal abdominal aorta with ostial stenosis of the right renal artery (Picture A: frontal view; Picture B: frontal view excluding the arc of Riolan; Picture C: posterior view). Collateral circulation had developed through the arc of Riolan (arrow heads). She had no history of either any systemic symptoms or elevated inflammatory markers. Therefore, a diagnosis of congenital mid-aortic syndrome (MAS) was made. MAS is characterized by the segmental narrowing of the descending thoracic and/or abdominal aorta (1), which is one of the important causes of juvenile hypertension. MAS patients with well-controlled BP have the potential to achieve a good prognosis without the need for aortic reconstruction by invasive intervention.

Rail-tracking calcification of lower limb arteries

Peripheral artery disease has increased worldwide in recent years. Revascularization of severely calcified vessels is a technically challenging problem. Clinicians should recognize that excessive arterial calcification can occur even in nonelderly patients with less arteriosclerosis risk, leading to severe lower limb ischemia.

Endovascular treatment of transplant renal artery stenosis based on hemodynamic assessment using a pressure wire: a case report

BackgroundTransplant renal artery stenosis (TRAS) is a serious complication after renal transplantation, leading to hypertension, deterioration in renal function, and/or graft loss. The incidence of TRAS reportedly varies from 1 to 23%, depending on its definition or diagnostic tools. The hemodynamic definition or therapeutic indication of TRAS is unclear.Case presentationA 66-year-old man with a history of diabetes, chronic kidney disease, and angina presented with a 2-week history of dyspnea and leg edema. He had undergone living-donor kidney transplantation for end-stage renal disease secondary to diabetic nephropathy 7xa0years earlier. He developed acute deterioration in renal function after the administration of an angiotensin II receptor blocker and required emergency hospitalization owing to acute congestive heart failure with pulmonary edema. A vasodilator and loop diuretics were administered following his admission, and the patient’s symptoms resolved quickly. Further investigation, including magnetic resonance angiography and ultrasonography, revealed severe stenosis of the transplant renal artery. Renal arteriography and pressure gradient measurement using a 0.014-inchxa0pressure wire were performed. The systolic pressure gradient was 40xa0mmHg, and the resting Pd/Pa ratio (ratio of mean distal to lesion and mean proximal pressures) was 0.90 without hyperemia. Hemodynamically significant stenosis was suspected. Intravascular ultrasonography revealed vessel shrinkage in the stenotic area, suggestive of the end-to-end anastomosis site. Pre-dilation using a 4-mm balloon, implantation of a 6-mm self-expandable stent, and post-dilatation using a 5-mm balloon were performed. Although the moderate stenosis persisted angiographically, the systolic pressure gradient dropped to 20xa0mmHg with the mean systolic pressure ratio increased to 0.95, which was considered an acceptable result. One month after the procedure, the patient’s renal function and blood pressure control had significantly improved.ConclusionsHemodynamic assessment using a pressure wire is useful in determining the appropriate therapeutic indication and endpoint of endovascular treatment of TRAS.

Fatal heart failure caused by severe pulmonary regurgitation, tricuspid regurgitation and late-onset mitral stenosis in an adult patient with Noonan syndrome: a case report

BackgroundIn patients with Noonan syndrome (NS), cardiac disorders such as pulmonary valve stenosis (PS) or hypertrophic cardiomyopathy (HCM) are common. While some patients can develop heart failure associated with HCM, the long-term outcome of adult patients with NS is reported to be good. Fatal outcomes of heart failure in patients with NS but without HCM are rare.Case presentationWe report a 25-year-old Japanese woman diagnosed with NS in adulthood. She exhibited short stature and minor facial dysmorphism and was diagnosed with PS at 1xa0year of age. After surgical valvuloplasty for PS at 6xa0years of age, her general condition became stable without specific medical treatment. She discontinued regular medical follow-up for PS. At 21xa0years of age, she developed acute decompensated heart failure, which was mainly right-sided heart failure due to severe pulmonary regurgitation (PR) and tricuspid regurgitation (TR). There was no evidence of HCM or PS recurrence. On the basis of the history of PS and characteristic physical features including short stature, webbed neck, and hypertelorism, she was clinically diagnosed with NS. At 25xa0years of age, she developed heart failure of both sides due to PR, TR and late-onset severe mitral stenosis (MS). The etiology of MS was uncertain. Owing to the patient’s condition, surgical options were considered to be extremely high risk. She was treated with optimal medical treatment as well as the occasional abdominal cavity drainage for recurrent ascites; however, she died of decompensated heart failure at 27xa0years of age.ConclusionsWe describe an adult patient with NS without HCM who died of heart failure caused by severe PR, TR and MS. Clinicians should recognize that ongoing or late-onset cardiac disorders can develop in patients with NS, and lead to fatal heart failure. Optimal medical follow-up to monitor cardiac function and early identification of heart failure are important.

Intraluminal Fibrous Webs in Brachial Artery Fibromuscular Dysplasia

An 80-year-old woman diagnosed as having severe aortic stenosis underwent pre-operative coronary angiography through the left radial artery for transcatheter aortic valve implantation. A 0.025-inch guidewire was advanced into the left brachial artery for sheath insertion. Upper extremity angiography

Newly Designed Side-Grooved Guiding Sheath for the Endovascular Treatment of Superficial Femoral Artery Chronic Total Occlusion

A 72-year-old man with a history of diabetes presented with right intermittent claudication. The ankle-brachial index of the right leg was 0.38. Computed tomography angiography showed chronic total occlusion (CTO) of the right superficial femoral artery (SFA) ([Figurexa01A][1]). Ipsilateral antegrade

“Pseudo aortoiliac bifurcation” leading to significant plaque shifting in the endovascular treatment of an aortoiliac bifurcation lesion: a case report

BackgroundPlaque shifting is a serious complication of endovascular treatment (EVT) for aortoiliac bifurcation lesions. It is challenging to predict the occurrence of unfavorable plaque shifting correctly.Case presentationWe report the case of an 88-year-old Japanese woman who experienced constant pain at rest in her left leg. The ankle-brachial pressure index of her left leg was 0.57. Computed tomography (CT) angiography revealed severe stenosis of the left common iliac artery (CIA) and total occlusion of the left external iliac artery (EIA). We diagnosed the patient with acute exacerbation of a chronic limb ischemia and administered endovascular treatment (EVT) to treat the left CIA and EIA. The results of initial angiography agreed with those of CT angiography. After placing a self-expandable stent for the left CIA lesion, significant unfavorable plaque shifting occurred. From a comparison between pre- and post-stenting angiography, we realized that the plaque protrusion into the terminal aorta had formed a “pseudo aortoiliac bifurcation” that was situated more proximally compared to the true bifurcation. We had incorrectly assessed the height of the aortoiliac bifurcation and exact plaque position and had underestimated the risk of plaque shifting because of this misunderstanding. The patient ultimately developed fatal cholesterol embolization after EVT.ConclusionsPlaque protrusion into the terminal aorta can form a “pseudo aortoiliac bifurcation”, causing the wrong estimation of the height of the aortoiliac bifurcation; “angiographically”, the highest point is not always the true bifurcation. Careful assessment of initial angiography to detect the true aortoiliac bifurcation and exact plaque position is essential to avoid unfavorable plaque shifting.