Retrospective analysis of OCT on MB characteristics and 1-year follow-up of the ISR incidence after the DES implantation in patients with MB

We used optical coherence tomography (OCT) to analyze the "half-moon" like phenomenon and its characteristics and observe 1-year follow-up of the in-stent restenosis (ISR) incidence after the drug eluted stent (DES) implantation in patients with the myocardial bridge (MB). Patients were retrospectively analyzed from January 2013 to December 2019. We used OCT to check 45 patients with MB and found a visible muscle layer (VML) around the vessel adventitia with the same or high density compared to the vessel media layer. There was not any significant difference in maximal thickness, maximal arch, and total length between the half-moon layer and the visible muscle layer groups (p > 0.05). Maximal thickness, arch, and total length of the half-moon layer were significantly positively related to VML, respectively (r = 0.962, 0.985, 0.742, p < 0.01). Of these 626 patients with MB seen by OCT, only 300 could be checked out by coronary angiography (CAG). Besides, the larger the thickness and arch of the VML around the vessel adventitia, the more severe the MB in these patients (p < 0.05). After the OCT use, there was no coronary perforation in these patients with MB covered with DES. After 1-year follow-up, ISR in MB covered with DES showed a notable difference among no MB, mild MB, moderate MB, and severe MB groups (p < 0.05), and ISR in DES aggravated with the MB severity. However, ISR in MB with and without covered with DES had no significant difference among the 4 groups (p > 0.05). OCT could evaluate MB characteristics accurately compared to IVUS and had a higher rate of detecting MB than CAG. Moreover, it is safe and effective to guide DES covering the mild MB segment in patients with severe coronary lesions detected by the OCT.

Prevalence and Characteristics of Acquired Coronary Fistulas After Successful Revascularization of Chronic Total Occlusion

Background and Objectives: Acquired coronary fistulas (ACFs) are rare coronary artery abnormalities in patients with chronic total occlusion (CTO). It has been found after revascularization, and it may cause fluster during the CTO percutaneous coronary intervention (CTO PCI). How to distinguish between ACFs and coronary perforation (CP) is very important for CTO operators. Chronic total occlusion reopening may reveal the microchannel of the adventitial vascular layers. Some of ACFs have been seen after revascularization. This study aimed to investigate the characteristics of ACFs after successful CTO PCI.Methods: The clinical and procedural characteristics, medical history, and findings in electrocardiography (ECG), echocardiography, and coronary angiography were collected from 2,169 consecutive patients undergoing CTO PCI between January 2018 and December 2019 and analyzed retrospectively.Results: About 1,844 (85.02%) underwent successful CTO PCI with complete revascularization. Acquired coronary fistulas were found in 49 patients (2.66%): the majority of patients with ACFs were men (81.63 vs. 60.78%; p = 0.016) and younger (62.8 vs. 66.69 years; p = 0.003), and had a history of myocardial infarction (MI) or Q-wave (69.39 vs. 54.21%; p = 0.035); 38 (77.55%) patients had multiple fistulas (≥3), and ACFs affected multiple branches of the CTO vessel (≥3) in 29 (59.18%) patients. None had pericardial effusion, tamponade, and hemodynamic abnormality before or after PCI.Conclusion: Acquired coronary fistulas after successful CTO PCI are mainly present in young and male patients with a history of MI, and they often involve multiple fistulas and distal CTO vessels.

214 Covered stent in a chest trauma: congenital coronary arterial fistula or traumatic coronary perforation?

Aims Coronary arterial fistula consists in a communication between a coronary artery and a cardiac cavity. It is tipically a congenital condition, but it can also be a result of invasive cardiac procedure. Although chest truama generally evolve to massive pericardial effusion, in some cases it can determine also a coronary perforation, with a consequent coronary arterial fistula. Methods and results A 22-year-old male patient, with no cardiovascular history, was admitted after a road accident, reporting pelvis break, 17 costal break, and sternal break, with consequent chest pain. On admission the patient had a heart rate of 100 b.p.m. and a blood pressure of 130/80 mmHg. Elettrocardiogram (ECG) reported ST elevation in antero-septal derivations (V1–V4). Echocardiogram showed a global left ventricular (LV) ejection fraction of 55%, with an apical-septal akinesia, with a minimal anterior pericardial effusion, not emodinamically significant. So, an emergency coronary angiography was performed, showing a fistula of the distal segment of the left anterior discendent coronary (LAD). In this case there were two possible options, a previously unknown congenital coronary arterial fistula, or a traumatic coronary perforation, determining a coronary arterial fistula. Considering the possibility of a traumatic coronary perforation, with the consequent risk of rapid pericardial effusion worsening, the decision was to perform percutaneous coronary intervention (PCI) with a covered stent (Biotronik Papyrus 2.5 × 20 mm, 8 atm), with a good final result, with total occlusion of fistula. Conclusions At 1 month follow-up, the patient was asymptomatic for dyspnoea or chest pain, with a heart rate of 70 b.p.m. and a blood pressure of 130/80 mmHg. ECG showed no anomalies in ST-T tract.

Looped wire advancement—not always safe! Fat—not so useless! a case series

Background Coronary artery perforation (CAP), although rare, can often be a life-threatening complication of percutaneous coronary intervention. Looped wire tip or buckling of wire is conventionally considered safer due to reduced risk of migration into smaller branches and false lumen. Occasionally, buckling can indicate the entry of tip into dissection plane, or the advancement of looped wire can cause small vessel injury leading to perforation. Distal coronary perforation can be life threatening and coil, foam, and thrombin injection are some of the material widely used for sealing it. Case summary We hereby report three different cases illustrating the vessel injury that the looped wire can cause in the distal vasculature related to various mechanisms like high elastic recoil tension, dissection by the non-leading wire tip, or hard wire lacerating the fragile small branches. All these mechanisms lead to distal coronary perforation leading to cardiac tamponade. Each case also illustrate the novel technique of autologous fat globule embolization for the management of distal CAP. Discussion Distal coronary perforation is often due to guidewire-related vessel injury and is more common with hydrophilic wires. Looped wire tip can sometime indicate vessel injury and its advancement further down the coronary artery may result in serious vessel injury and perforation. Management of distal coronary perforation is challenging, and here we demonstrate the steps of using the readily available autologous fat globules by selectively injecting them into the small coronary artery to control the leak.

Stent-graft and double-guiding catheter technique to rescue iatrogenic coronary perforation

IntroductionCoronary artery perforation (CAP) is an infrequent, yet life-threatening complication of percutaneous coronary interventions, posing a major risk of cardiac tamponade and mortality.Material and methodsWe report on effective management of Ellis type III CAP with use of double-guiding catheter technique and stent-graft implantation.ResultsProlonged balloon inflation via the first guiding catheter allows for temporary closure of the bleeding site. At the same time, stent-graft is inserted via the second guiding catheter to seal the perforation. After rapid deflation of the balloon, the stent is immediately advanced and expanded.ConclusionsThe procedure minimises the time between deflation of the balloon and implantation of the stent-graft, allowing for successful bleeding cessation.