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2021 ◽  
Vol 23 (Supplement_G) ◽  
Author(s):  
Andrea Moretti ◽  
Ilaria Dato ◽  
Maria Chiara Gatto ◽  
Marzia Schiavoni ◽  
Vincenzo Bernardo ◽  
...  

Abstract Aims Percutaneous coronary intervention (PCI) of heavily calcified coronary lesions still represents a challenge for interventional cardiologists, with higher risk of immediate complications, late failure due to stent underexpansion or malapposition and consequent poor clinical outcome. Rotational atherectomy (RA) is a well-known calcium debulking modality. However, when coronary plaques present a significant amount of circumferential deep calcium, RA alone may not be able to achieve adequate lesion preparation. The combined use of intravascular lithotripsy (IVL) and RA, a technique called ‘Rotatripsy’, can be an effective approach in order to enable optimal stent implantation. We present a case of a calcific right coronary artery (RCA) PCI successfully treated by ‘Rotatripsy’ technique. Methods and results A 78-years-old man presented to our emergency department complaining of acute chest pain and dyspnoea. The electrocardiogram revealed ST-segment elevation in aVR and a diffuse ST-segment depression. Transthoracic echocardiography showed left ventricular anterior, septal, and apical walls akinesia. An urgent coronary angiography showed a critical distal left main (LM) stenosis involving the left anterior descending (LAD) artery ostium and a heavy calcified dominant RCA with two tandem sub-occlusive stenosis in the mid segment (Figure 1A). An immediate PCI with two drug eluting stents (DES) in the LM and LAD was performed. The patient was scheduled two days later for RCA PCI. RCA was engaged via left radial approach with a 6-Fr AL1 guiding catheter and the lesions were crossed with a Sion Blue wire. Using a Finecross MG microcatheter, an extra-support Rotawire was placed distally in the RCA. However, after multiple rotablation with 1.5 mm burr (Figure 1B), the mid segment lesion (Figure 1C) was still undilatable with a 3.5 mm non-compliant balloon (NCB) at 22 atm showing a partial dog bone effect (Figure 1D). We decided to attempt adjunctive IVL for calcium debulking. Using a Finecross MG and the trapping technique, a Gran Slam wire was placed distally; a 4.0 mm IVL balloon was delivered at the undilatable lesion and 80 pulses were applied (Figure 1E). Once the IVL treatment was completed (Figure 1F), a 4.0 mm NCB was inflated to 20 atm to further dilate the segment with an optimal expansion (Figure 1G). Finally, a DES Synergy 4.0 × 48 mm was implanted (Figure 1H) and it was post-dilated with a 4.5 mm NCB inflated to 22 atm (Figure 1I) with a perfect angiographic result (Figure 1J). Conclusions Coronary calcifications can lead to stent underexpansion, which is related to a higher rate of future complications, such as restenosis or thrombosis. If conventional lesion dilatations are not effective, alternative techniques should be considered (cutting balloon, scoring balloon, RA, orbital atherectomy, IVL). In case of circumferential deep calcium plaques, RA may not be able to achieve an adequate lesion preparation. RA allows the treatment of intimal calcium and permits to cross balloons or stents through severe lesions. However, when adequate expansion of the balloons is not achieved after RA, Shockwave IVL, that is not usually able to cross critical stenosis due to its bulky profile, represents an optimal complementary device, in order to fracture deep calcium and facilitate stent delivery and optimal expansion. In this case, we have successfully used the hybrid approach called ‘Rotatripsy’, which combines RA and IVL, in order to avoid more aggressive RA, which would have required the use of 7-Fr guiding catheter setting and may have increased the risk of complications.


Author(s):  
Yusuke Morita ◽  
Junji Morita ◽  
Yusuke Kondo ◽  
Takayuki Kitai ◽  
Tsutomu Fujita ◽  
...  

2021 ◽  
Vol 23 (Supplement_G) ◽  
Author(s):  
Davide Giovannini ◽  
Gabriele Pesarini ◽  
Concetta Mammone

Abstract Methods and results A 64-year-old man with prior PCI and stent of proximal LAD due to an anterior ST-elevation myocardial infarction (STEMI) presented with exertional angina (CCS III), despite optimal medical therapy (OMT). The echocardiogram showed a dilatated left ventricle with anterior and apical akinesia and a severely reduced left ventricle ejection fraction. Coronarography was performed and a chronic total occlusion was found at the proximal edge of the stent previously implanted in the proximal LAD, with a thin tapered entry (J-CTO score 1). Moderate angiographic disease was present in the circumflex (LCX) and in the right coronary artery (RCA). Interventional collaterals were absent. Dobutamine stress echocardiogram was performed to unmask myocardial viability. Indeed, during intravenous Dobutamine administration, we registered an increase in the left ventricle function, whereas only apex remained still akinetic. Accordingly, the patient underwent LAD CTO PCI using a 7 Fr EBU 4.0 guiding catheter, via right femoral artery access. The RCA ostium was engaged with a 6 Fr Judkins right 4.0 guiding catheter, via right radial artery access. Antegrade wire escalation technique was attempted. Due to scarce support, a 7 Fr Guidion guiding catheter extension and a Corsair microcatheter were placed in the proximal LAD. Antegrade crossing was very difficult due to intrastent high plaque burden. The occlusion was crossed with an Asahi Conquest Pro 9 guidewire. Subsequently, an Asahi Gaia third guidewire was advanced through the intrastent segment and then in the distal part of LAD. The advance of microcatheter was challenging but successfully achieved taking advantage of the low profile, high torqueability and trackability of the Asahi Corsair Pro microcatheter. Microcatheter tip injection confirmed the correct position in the vessel’s true lumen. An Asahi Grand Slam guidewire was placed in the distal LAD to provide extra support for delivery of interventional devices. The lesion was pre-dilated with progressively larger balloon, starting from a 1.1 mm diameter semi-compliant over-the-wire balloon (OTW). Two stents were implanted with a minimal overlap at the distal edge of the proximal stent (Resolute Onyx 3.0 × 38 mm and 2.5 × 24 mm). The result was improved with stents high-pressure post-dilatation and with selective intracoronary adenosine and nitroglycerin administration with final Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow. The total amount of contrast media used was 210 ml. The total procedure time was with 125 min with 45 min of fluoroscopy. No complications occurred. Conclusions CTO PCI still represents one of the most challenging subsets of coronary interventions despite the improvement in technology and techniques. Although data regarding percutaneous PCI CTO are still inconsistent, successful CTO recanalization has been associated with relief of angina and ischemia-related dyspnoea (Werner at al., 2018). In stable patients CTO PCI has been associated with a lower risk of death, stroke, and coronary artery bypass grafting and less recurrent angina pectoris in some registry studies (Christakopoulos et al., 2015). Additionally, CTO PCI increased left ventricle function in a subgroup of patients with LAD CTO (Henriques et al., 2016). Conversely, randomized multicentre failed to demonstrate a superiority of CTO PCI medical to OMT in terms of major adverse cardiac events (MACE) and all-cause mortality.


2021 ◽  
Vol 14 (11) ◽  
pp. e245688
Author(s):  
Prashanth Reddy ◽  
Mudassar Kamran ◽  
Satya Narayana Patro

An elderly patient presented with acute-onset right-sided weakness and aphasia. A large penumbra was noted in the left middle cerebral artery (MCA) territory without any infarct core. The patient was noted to have a carotid–carotid bypass. This posed certain technical challenge in accessing the intracranial circulation across the carotid bypass; however, the guiding catheter with soft distal segment was successfully navigated coaxially over the aspiration catheter across the bypass and intracranial circulation was accessed for mechanical thrombectomy. Complete recanalisation and reperfusion were achieved with significant neurological recovery of the patient post-thrombectomy. The aim of this report is to emphasise on this rarely encountered situation in thrombectomy and its successful management. The procedure should not be delayed or deferred due to lack of operator experience.


2021 ◽  
Vol 17 (6) ◽  
pp. 1800-1803
Author(s):  
Ewa Ostrowska ◽  
Aleksandra Gąsecka ◽  
Tomasz Mazurek ◽  
Janusz Kochman

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.


2021 ◽  
pp. 159101992110527
Author(s):  
Kazuaki Aoki ◽  
Yoichi Miura ◽  
Naoki Toma ◽  
Yume Suzuki ◽  
Masashi Fujimoto ◽  
...  

Objective The risk of embolization to distal territory or to new territory in mechanical thrombectomy remains a major issue despite advancements in technological device. This condition can be caused by a large and firm dropped thrombus without passing through a guiding catheter during stent retriever or aspiration catheter withdrawal. This report introduced a novel technique referred to as retrograde angiography to detect dropped thrombus. Methods The retrograde angiography to detect dropped thrombus technique is a kind of retrograde angiography that consists of a contrast medium injection via a distal microcatheter and aspiration through an inflated balloon-guiding catheter. This method was used to detect dropped thrombus at the balloon-guiding catheter tip when back flow was blocked from the balloon-guiding catheter after stent retriever or aspiration catheter withdrawal. We retrospectively reviewed four consecutive patients who underwent the retrograde angiography to detect dropped thrombus technique during mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion in the anterior circulation between January 2018 and January 2021. Results Three of four patients had dropped thrombus, which was diagnosed with the technique and retrieved completely with subsequent procedures while maintaining the balloon-guiding catheter inflated. None of the patients experienced embolization to distal territory/embolization to new territory, and a successful reperfusion was achieved in all four cases. Conclusions The retrograde angiography to detect dropped thrombus is a technique to detect a dropped thrombus at the balloon-guiding catheter tip and allows us to retrieve it with subsequent mechanical thrombectomy procedures while maintaining the balloon-guiding catheter inflated and it may be useful for reducing the risk of embolization to distal territory/embolization to new territory.


Author(s):  
Marco Araco ◽  
Angelo Quagliana ◽  
Giovanni Pedrazzini ◽  
Marco Valgimigli

Abstract BACKGROUND Complex and high-risk coronary intervention (CHIP-PCI) and PCI in cardiogenic shock complicating acute coronary syndrome is increasingly performed under mechanical circulatory support—so called protected PCI. Among the available options, Impella CP heart pump (ABIOMED) is percutaneously inserted over the femoral artery and typically requires a second arterial access to perform PCI, which further enhances the risk of vascular and bleeding complications. The single-access technique allows Impella CP placement and PCI performance through the same vascular access. When a 7-french system is desirable, only a long and entirely hydrophilic coated sheath has been previously used, which is not available in Europe. CASE SUMMARY A 85-year-old patient admitted with NSTE-ACS, severely reduced left ventricular function and three-vessel coronary artery disease underwent single access CHIP-PCI under Impella CP support. After a failed attempt to insert a standard 7-french long femoral sheath alongside the Impella catheter, we successfully introduced a 7.5-french sheathless guiding catheter and delivered the planned percutaneous treatment with the benefits conferred by a 7-french—rather than 6 - lumen catheter, without the need for an additional arterial access. DISCUSSION This is, to the best of our knowledge, the first case of CHIP-PCI performed under Impella support utilizing the single-access technique with a 7.5-french sheathless guiding catheter. Beyond advantages of the single-access technique in sparing time and avoiding vascular complications associated with gaining a second arterial access, the lower outer diameter of the sheathless catheter compared with standard 7-french sheaths may allow improved limb perfusion and lower chance of interference with the impella CP catheter.


2021 ◽  
pp. 112-117
Author(s):  
Hiroyasu Inoue ◽  
Masahiro Oomura ◽  
Yusuke Nishikawa ◽  
Mitsuhito Mase ◽  
Noriyuki Matsukawa

<b><i>Introduction:</i></b> Mechanical thrombectomy (MT) is usually performed on biplane (BP) angiosuites. When the BP angiosuite is not available, the single-plane (SP) angiosuite may be a substitute. However, the feasibility of MT performed on the SP angiosuite is yet to be elucidated. Therefore, we investigated the alternative effect of the SP angiosuite on the detailed division of procedure time, recanalization rate, and outcome in patients with anterior circulation infarction. <b><i>Methods:</i></b> The subjects included 80 consecutive patients with anterior circulation infarction who underwent MT at our hospital between May 2015 and December 2020. Demographics and characteristics of the BP and SP groups were assessed and compared. The time from puncture to guiding catheter placement (P-G), time from guiding catheter placement to recanalization (G-R), and time from puncture to recanalization (P-R) were also extracted. A good outcome was defined as a modified Rankin scale score ≤2 at 3 months. <b><i>Results:</i></b> Of the 80 patients, 67 and 13 were treated with BP and SP angiosuites, respectively. There were no differences in age, sex, complications, Alberta Stroke Program Early CT Score, National Institutes of Health Stroke Scale score at onset, occlusion site, rate of recombinant tissue-type plasminogen activator administration, stroke subtype, recanalization rate, and complications between the 2 groups. The rate of a good outcome was not different between the 2 groups. P-G was significantly longer in the SP group than in the BP group, whereas there was no significant difference in G-R and P-R between the 2 groups (P-G: BP 29.9 ± 21.8 vs. SP 48.5 ± 43.6 min, <i>p</i> = 0.04). <b><i>Conclusion:</i></b> MT performed on the SP angiosuite tended to prolong the time for guiding catheter placement. However, there was no difference in the overall procedure time, recanalization rate, or outcome between BP and SP angiosuites. Therefore, if the BP angiosuite is not available, the use of the SP angiosuite should be encouraged.


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