Yousuke Taniguchi

How Should We Perform Rotational Atherectomy to an Angulated Calcified Lesion

Rotational atherectomy to an angulated calcified lesion is always challenging. The risk of catastrophic complications such as a burr becoming stuck or vessel perforation is greater when the calcified lesion is angulated. We describe the case of an 83-year-old female suffering from unstable angina. Diagnostic coronary angiography revealed an angulated calcified lesion in the proximal segment of the right coronary artery. We performed rotational atherectomy to the lesion, but intentionally did not advance the rotational atherectomy burr beyond the top of the angulation. We controlled the rotational atherectomy burr and stopped it just before the top of the angulation to avoid complications. Following rotational atherectomy, balloon dilatation with a non-compliant balloon was performed, and drug-eluting stents were successfully deployed. In this manuscript, we provide a review of the literature on this topic, and discuss how rotational atherectomy to an angulated calcified lesion should be performed.

When a Burr Can Not Penetrate the Calcified Lesion, Increasing Burr Size as Well as Decreasing Burr Size Can Be a Solution in Rotational Atherectomy

In rotational atherectomy (RA), several burr sizes are available, such as 1.25 mm, 1.5 mm, 1.75 mm, or ≥ 2.0 mm. It is important to select an appropriate burr size for each lesion because rotational atherectomy has several unique complications regarding burrs such as entrapment or perforation. When a burr cannot penetrate the lesion, downsizing of the burr is generally recommended. Also, if the smallest burr (1.25 mm) cannot penetrate the lesion, a change to a more supportive or larger French guiding catheter has been recommended. We describe the case of a 68 year-old female who was referred to our department for percutaneous coronary intervention to the calcified stenosis in the middle of the left anterior descending coronary artery. We used the smallest burr (1.25 mm) and a supportive 7 Fr guiding catheter to penetrate the lesion. However, the smallest burr could not pass the lesion even after 14 sessions (total ablation time: 339 seconds). We intentionally increased the burr size from 1.25 mm to 1.5 mm. The 1.5 mm burr successfully passed the lesion without any perforation or burr entrapment. In this manuscript, we discuss why increasing the burr size was successful for this severely calcified lesion that was not penetrated by the smallest burr.

The incidence of slow flow after rotational atherectomy of calcified coronary arteries: A randomized study of low speed versus high speed.

The purpose of this randomized trial was to compare the incidence of slow flow between low‐speed and high‐speed rotational atherectomy (RA) of calcified coronary lesions.

Veno-Arterial Extracorporeal Membrane Oxygenation with Conventional Anticoagulation Can Be a Best Solution for Shock Due to Massive PE

While most of pulmonary thromboembolism (PE) cases can be managed by thrombolytic and anticoagulation therapy, massive PE remains a life-threatening disease. Although surgical embolectomy can be a curative therapy for massive PE, peri-operative mortality for hemodynamically collapsed PE is extremely high. We present a case of hemodynamically collapsed massive PE. We avoided either thrombolytic therapy or surgical embolectomy, because the patient had recent cerebral contusion. Therefore, we managed the patient with the combination of veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and conventional anticoagulation, which dramatically improved the patients hemodynamics. In conclusion, the combination of V-A ECMO and conventional anticoagulation may be the preferred first line therapy for the patients with cardiogenic shock following massive PE.

A case of severely calcified neoatherosclerosis after paclitaxel eluting stent implantation

A 79-year-old male who had a history of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) received coronary angiography (CAG), because of angina pectoris. CAG showed in-stent restenosis of the paclitaxel-eluting stent (PES). Since the devices could not pass the lesion, we performed rotational atherectomy. Although we could not identify the calcified lesion by the optical frequency domain imaging (OFDI) findings because of strong attenuation, the intravascular ultrasound (IVUS) image showed the superficial calcification. On the other hand, strong attenuation in OFDI suggested the presence of foamy macrophage, which was essential for the diagnosis of neoatherosclerosis. We could obtain a favorable result by deploying another drug-eluting stent. While an earlier report showed the calcified neoatherosclerosis following bare-metal stent implantation, we clearly showed the calcified neoatherosclerosis following PES implantation.

Super-selective intracoronary injection of Rho-kinase inhibitor relieves refractory coronary vasospasms: A case report

Coronary spastic angina (CSA) may become refractory when pa-tients discontinue medication, resume smoking, are overworked, areunder mental stress, or are hyperventilation [1]. Calcium channelblockers (CCBs) are effective standard therapeutic agents for CSA. Insomecases,however,acombinationofmedicationssuchasCCBs,nitro-gen, and nicorandil fails to relieve CSA. We report a case of refractoryCSA,whichwaseventuallyrelievedbysuper-selectiveintracoronaryin-jection of a Rho-kinase inhibitor, fasudil.An84-year-oldmancomplainedofchestpainatrest,andwastrans-ferred to our hospital. He was diagnosed with CSA in 2008, and hadreceived treatment with two CCBs (diltiazem and nifedipine) andnicorandil. However, he discontinued these medications 2 days priorto the onset of his chest pain. An electrocardiogram (ECG) showed ST–T elevations in leads V3–V6 (Fig. 1A). Laboratory data showed a whiteblood cell count of 9250/mm

Refractory variant angina with a seasonal trend treated with sarpogrelate hydrochloride

A 68-year-old man was referred to our hospital for the evaluation and treatment of chest discomfort and syncope. He was diagnosed with variant angina by prolonged ischemic episode with ST-segment elevation in leads II, III, and aVF. His symptoms had a seasonal trend and occurred only from April to September. In other seasons, he had no symptoms even with no medication. He had a history of nasal polyps and allergic rhinitis. His symptoms increased in frequency and intensity, and the attacks were not fully controlled by multiple drug therapy. Sarpogrelate hydrochloride, however, resulted in complete resolution of his symptoms. Further examination revealed that he was allergic to mites, Dermatophagoides farina, which were prevalent mainly from April to September. The allergic mechanism was suggested to be involved in the seasonal variety in angina attacks. <Learning objective: We present a 68-year-old male with variant angina. Seasonal variation in his frequency of the attacks suggested the involvement of allergic reactions. While medications including calcium channel blockers and nitrates failed to suppress the angina attack, adding sarpogrelate, a selective 5-HT2A antagonist, significantly prevented symptoms of recurrent coronary vasospasm. Allergic mechanism was suggested to be involved in the pathogenesis of coronary vasospasm in this case.>.

Spontaneous Recanalization of the Obstructed Right Coronary Artery Caused by Blunt Chest Trauma

Blunt chest trauma can cause a wide variety of injuries including acute myocardial infarction (AMI). Although AMI due to coronary artery dissection caused by blunt chest trauma is very rare, it is associated with high morbidity and mortality. In the vast majority of patients with AMI, primary percutaneous coronary interventions (PCI) are performed to recanalize obstructed arteries, but PCI carries a substantial risk of hemorrhagic complications in the acute phase of trauma. We report a case of AMI due to right coronary artery (RCA) dissection caused by blunt chest trauma. The totally obstructed RCA was spontaneously recanalized with medical therapy. We could avoid primary PCI in the acute phase of blunt chest trauma because electrocardiogram showed early reperfusion signs. We performed an elective PCI in the subacute phase when the risk of bleeding subsided. Since the risk of severe hemorrhagic complications is greater in the acute phase of blunt chest trauma as compared with the late phase, deferring emergency PCI is reasonable if signs of recanalization are observed.

Minimization of door‐to‐balloon time for ST‐elevation acute myocardial infarction: a case report

It is of utmost importance to minimize the door‐to‐balloon time for the initial treatment of ST‐elevation acute myocardial infarction. In this case report, we made all kinds of efforts to minimize procedures in the emergency department (ED minimization) as well as in the catheter laboratory without sacrificing safety.

IgG4-related effusive constrictive pericarditis

A 72-year-old man with no remarkable medical history presented with appetite loss and progressive dyspnoea for 4 weeks. He had leg oedema, hepatomegaly, jugular venous distension, and bilateral pleural effusion on chest radiography. Laboratory data revealed elevated immunoglobulin G and G4 (IgG 2024 mg/dL, IgG4 177 mg/dL) and C-reactive protein …