RESUMEN
BACKGROUND: Intravascular lithotripsy (IVL) showed to be effective in dilating heavily calcified de novo coronary lesions but little is known about its performance in under-expanded stents management. Aim of this study was to assess the feasibility, effectiveness and safety of IVL for the treatment of stent underexpansion refractory to balloon dilatation. METHODS: A multicentre, retrospective cohort analysis was performed in patients undergoing IVL to treat under-expanded stents following non-compliant balloon expansion failure. Primary endpoint was successful IVL dilatation defined as IVL balloon delivery and application at the target site followed by an increase of at least 1 mm2 in minimal stent cross-sectional area (MSA) on intracoronary imaging or an increase of at least 20% in minimal stent diameter (MSD) by quantitative coronary analysis (QCA). RESULTS: Thirty-nine under-expanded stents (34 patients) were included. Two cases (5.1%) of multiple stent layers and one (2.5%) acutely under-expanded stent were treated. The median IVL balloon diameter was 3.1 mm (IQR: 2.5-3.5 mm) while the number of pulses emitted was 56.7 (IQR: 30-80). IVL was successful in 34 cases (87.1%), with significant improvement in MSD (post: 3.23 mm [IQR: 3-3.5 mm] vs. pre: 0.81 mm [IQR: 0.35-1.2], p < 0.00001) and MSA (post: 7.61mm2 [IQR: 6.43-7.79mm2] vs. pre: 3.35 [IQR: 2.8-4 mm2], p < 0.00001). Non-fatal peri-procedural ST-elevation myocardial infarction occurred in one case (2.5%) due to IVL balloon rupture. No cardiac death, target lesion revascularization and stent thrombosis occurred in-hospital and at 30-day follow-up. CONCLUSIONS: Bailout IVL was feasible, efficacious and safe to improve refractory stent under-expansion.
Asunto(s)
Litotricia , Stents , Calcificación Vascular , Angiografía Coronaria , Humanos , Sistema de Registros , Estudios Retrospectivos , Resultado del Tratamiento , Calcificación Vascular/terapiaRESUMEN
BACKGROUND: Coronary calcified lesions may limit optimal stent deployment resulting in stent underexpansion, increasing the risk of thrombosis. The Shockwave Lithoplasty System, a new technology combining a balloon angioplasty catheter with the use of sound waves, it is able to break calcium deposits without affecting vascular soft tissue. CASE PRESENTATION: An 80-year-old Caucasian man with ST elevation myocardial infarction underwent emergent coronary angiography showing complete intrastent thrombosis at the proximal trait of LAD. After thrombus removal, it was evident that stent under-expansion at its proximal edge was caused by vascular calcification. Coronary shockwave lithoplasty was chosen to treat this lesion. After calcium deposits disruption we were able to obtain complete stent expansion. CONCLUSION: Our case demonstrates the usefulness and safety of the lithoplasty system in the context of ST elevation myocardial infarction.
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Estenosis Coronaria/terapia , Litotricia/efectos adversos , Infarto del Miocardio con Elevación del ST/etiología , Stents/efectos adversos , Anciano de 80 o más Años , Angiografía Coronaria , Estenosis Coronaria/diagnóstico , Vasos Coronarios/diagnóstico por imagen , Electrocardiografía , Humanos , Masculino , Falla de Prótesis , Infarto del Miocardio con Elevación del ST/diagnóstico , Ultrasonografía IntervencionalRESUMEN
Anomalies of the coronary arteries represent rare congenital disorders, which are characterized by a wide spectrum of clinical manifestations. Usually, they are asymptomatic, but sometimes they cause myocardial ischemia or sudden cardiac death. Here, we describe the case of a patient who suffered from angina. Coronary angiography revealed an ectopic origin of the left anterior descending coronary artery from the proximal trait of the right coronary artery and the left circumflex artery, originating from the left sinus; the whole coronary tree was free of atherosclerosis. To better define the coronary anatomy, we performed computed tomography angiography with a three-dimensional reconstruction. The patient was discharged from the clinic after 48 h under optimal medical treatment.
Asunto(s)
Angina de Pecho/etiología , Anomalías de los Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/diagnóstico por imagen , Anciano , Cateterismo Cardíaco , Angiografía por Tomografía Computarizada , Angiografía Coronaria , Anomalías de los Vasos Coronarios/fisiopatología , Electrocardiografía , Femenino , Humanos , Imagenología Tridimensional , Tomografía Computarizada por Rayos XRESUMEN
PURPOSE: The Shockwave Lithoplasty System represents a novel technology combining a balloon angioplasty catheter with the use of sound waves. Evidences suggest that it is a reliable tool to overcome calcified stenosis in both peripheral and coronary arteries. Here, we describe the case of a patient with calcified innominate artery stenosis successfully treated with the Shockwave Lithoplasty System. CASE REPORT: A 78-year-old woman with hypertension, and dyslipidemia, came to our observation for dizziness. Instrumental examinations showed critical calcified stenosis of the innominate artery. The lesion was successfully treated with the Shockwave Lithoplasty System and subsequent stent apposition. Final angiography demonstrated excellent position of the stent, good wall apposition, and confirmed patency of the right common and right vertebral artery origins. CONCLUSION: Our clinical experience demonstrates that Lithoplasty is safe and effective also for the treatment of supra-aortic vessels.
RESUMEN
Kounis syndrome refers to an acute coronary syndrome, consequent to an allergic reaction. It results from mast cell degranulation with subsequent release of numerous inflammatory mediators, leading to coronary vasospasm, atheromatous plaque rupture, or stent thrombosis. Here, we describe the case of a 47-year-old Caucasian man with acute stent thrombosis, as a consequence of allergic reaction to contrast media.
RESUMEN
Heavily calcified lesions may limit optimal stent deployment resulting in stent underexpansion, thus increasing the risk of restenosis and thrombosis. We describe the case of overlapping stents underexpansion treated with a shockwave intravasuclar lithoplasty system (Shockwave Medical Inc., Santa Clara, CA, USA). A 65-year-old man with angina, underwent coronary angiography and intravascular ultrasound showing restenosis, in a site of overlapping stents, due to calcified tissue. Shockwave lithoplasty balloon was able to break calcified tissue in a site of overlapping stents, allowing subsequent vessel dilation and repeat stent implantation with optimal final stent expansion.
Asunto(s)
Angioplastia , Cateterismo Periférico/métodos , Arteria Radial , Síndrome del Robo de la Subclavia/terapia , Angiografía por Tomografía Computarizada , Humanos , Masculino , Persona de Mediana Edad , Punciones , Arteria Radial/diagnóstico por imagen , Síndrome del Robo de la Subclavia/diagnóstico por imagen , Síndrome del Robo de la Subclavia/fisiopatología , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
We report the case of a stent under-expansion due to heavily calcified plaque treated with the shockwave lithoplasty system. A 77-year-old woman underwent coronary angiography, and intravascular ultrasound revealed stent under-expansion due to calcified plaque. Shockwave lithoplasty balloon was used to disrupt calcium deposits around the stent, thereby allowing a correct stent expansion with an excellent angiographic and intravascular ultrasound result.
Asunto(s)
Enfermedad de la Arteria Coronaria/terapia , Litotricia/métodos , Placa Aterosclerótica/terapia , Stents , Anciano , Angiografía Coronaria , Vasos Coronarios/diagnóstico por imagen , Femenino , Humanos , Ultrasonografía IntervencionalRESUMEN
Coronary calcification is a hard challenge for the interventional cardiologist, as it is associated with incomplete stent expansion and frequently stent failure. In recent years, innovative techniques, such as rotational atherectomy, have been developed to treat coronary calcification. However, these are burdened with an increased procedural risk. We report the case of a 60-year-old Caucasian man treated 1 month before at another center with primary coronary angioplasty and stenting of the ramus intermedius for coronary syndrome. Coronary angiography showed a critical stenosis of the left main coronary artery as well as critical calcified stenosis of the left anterior descending artery and the diagonal branch. Coronary calcification was treated with rotational atherectomy that preceded the angioplasty and stenting. Because of persistence of the symptomatology, coronary angiography was repeated 1 month later and showed a critical calcified restenosis of the ramus intermedius at the site of the previous stenting. Considering the high risk of traditional atherectomy, we performed lithotripsy-enhanced disruption of calcium beyond the stents with the Shockwave Coronary Lithoplasty System. The Shockwave Coronary Lithoplasty System has been introduced recently in order to treat calcified coronary lesions with greater safety. The procedure allows most calcified coronary lesions to be treated with simplicity and safety. This system employs sound waves, similar to those used for treating kidney stones, to crush the calcified lesions. We present the first case described to date in whom this technique was successfully used to treat calcified restenosis in a previous stent.
Asunto(s)
Enfermedad de la Arteria Coronaria/terapia , Vasos Coronarios/diagnóstico por imagen , Litotricia/métodos , Calcificación Vascular/terapia , Angioplastia Coronaria con Balón/efectos adversos , Aterectomía Coronaria , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Vasos Coronarios/patología , Humanos , Masculino , Persona de Mediana Edad , Stents/efectos adversos , Resultado del Tratamiento , Ultrasonografía Intervencional , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/etiologíaRESUMEN
BACKGROUND: Age, estimated glomerular renal function (eGFR), and ejection fraction are preprocedural predictors of contrast-induced acute kidney injury (CI-AKI) after primary percutaneous coronary intervention. The effect of renal function-adjusted contrast volume (CV) remains not totally explored, and a threshold has not yet been established. METHODS AND RESULTS: Logistic regression and receiver-operating characteristic curve analyses were used to assess whether CV/eGFR was an independent predictor of CI-AKI. The increased discriminative value of CV/eGFR over the preprocedural model based on age, eGFR, and ejection fraction was examined using the net reclassification improvement analysis. Of 470 patients enrolled, we observed 25 (5.3%) cases of CI-AKI. Patients with CI-AKI had received a higher renal function-adjusted CV (CV/eGFR 3.62 versus 1.96; P<0.001), and CI-AKI incidence was higher (15%; P<0.001) in patients in the highest quartile of CV/eGFR, corresponding to the cutoff indicated by the receiver-operating characteristic curve (>2.5; area under the curve, 0.77). At multivariable analysis, CV/eGFR above the cutoff (odds ratio, 5.57; P=0.002) remained an independent predictor of CI-AKI. The model with CV/eGFR demonstrated a statistically significantly net reclassification improvement of 0.23 (P=0.021) over the baseline preprocedural model, largely driven by a correct decrease in risk estimates for patients not experiencing CI-AKI, with a likelihood ratio χ(2) of 5.973 (P=0.029). CONCLUSIONS: CV remains a key risk factor for CI-AKI after primary percutaneous coronary intervention and our study supports the need for minimizing CV, independently from baseline preprocedural risk. A CV restricted to no more than twice and a half the baseline eGFR might be valuable in reducing the risk of CI-AKI.
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Lesión Renal Aguda/prevención & control , Medios de Contraste/efectos adversos , Riñón/efectos de los fármacos , Intervención Coronaria Percutánea , Complicaciones Posoperatorias/prevención & control , Lesión Renal Aguda/inducido químicamente , Adulto , Anciano , Anciano de 80 o más Años , Medios de Contraste/administración & dosificación , Femenino , Tasa de Filtración Glomerular , Humanos , Riñón/metabolismo , Riñón/patología , Masculino , Persona de Mediana Edad , Análisis Multivariante , RiesgoRESUMEN
BACKGROUND: In patients undergoing primary percutaneous coronary interventions (PCI) for ST-segment elevation myocardial infarction (STEMI), the occurrence of Contrast-Induced Nephropathy (CIN) has a pronounced impact both on morbidity and mortality. We investigated the variables associated with CIN development in 481 consecutive patients with STEMI undergoing primary PCI and evaluated the predictive value of a 3-variable clinical risk score (the AGEF score) based on age, left ventricular ejection fraction (EF), and estimated glomerular filtration rate (eGFR). METHODS: CIN was defined as an absolute increase in serum creatinine ≥0.5 mg/dL or an increase ≥25% from baseline within 72 hr. AGEF score was calculated by adding 1 point to the Age/EF(%) ratio if the eGFR was <60 mL/min per 1.73 m(2) . RESULTS: Overall, the incidence of CIN was 5.2%. In-hospital mortality was higher in patients with CIN than in those without (16% Vs 1.3%, P = 0.001). At multivariate analysis age (OR 1.06, P = 0.042), eGFR (OR 0.95, P = 0.001), EF (OR 0.94, P = 0.007) and post-procedural TIMI flow grade (OR 0.43, P = 0.045) were independent predictors of CIN. AGEF score was an accurate (OR 5.19, P < 0.001, AUC 0.88) and calibrated (Hosmer-Lemeshow χ(2) = 10.25, P = 0.25) predictor of CIN. CONCLUSIONS: Advanced age, depressed EF, and reduced eGFR are independent predictors of CIN development after primary PCI for STEMI. The preprocedural individual patient risk can be clinically assessed with the calculation of the AGEF score, which is based on such readily available parameters.
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Medios de Contraste/efectos adversos , Tasa de Filtración Glomerular/efectos de los fármacos , Enfermedades Renales/inducido químicamente , Riñón/efectos de los fármacos , Infarto del Miocardio/terapia , Intervención Coronaria Percutánea/efectos adversos , Volumen Sistólico , Función Ventricular Izquierda , Factores de Edad , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Distribución de Chi-Cuadrado , Creatinina/sangre , Técnicas de Apoyo para la Decisión , Femenino , Mortalidad Hospitalaria , Humanos , Riñón/fisiopatología , Enfermedades Renales/sangre , Enfermedades Renales/diagnóstico , Enfermedades Renales/mortalidad , Enfermedades Renales/fisiopatología , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/mortalidad , Infarto del Miocardio/fisiopatología , Oportunidad Relativa , Intervención Coronaria Percutánea/mortalidad , Valor Predictivo de las Pruebas , Radiografía , Medición de Riesgo , Factores de Riesgo , Resultado del Tratamiento , Regulación hacia ArribaRESUMEN
The prevalence of isolated right ventricular infarction is 0.4-2.4% in autopsy series and may occur by at least three different mechanisms, of which occlusion of a nondominant right coronary artery is reviewed here. Although rare, as oxygen demand/supply of the right is lower than that of the left ventricle, due to the smaller muscular mass, and it has a good prognosis, sudden death and cardiac rupture have been reported. Differential diagnosis with anterior infarction is needed. ECG may help but specific criteria should be adopted: dome-like and decreasing ST segment elevation from V1 to V3 leads; rapid ST segment normalization and no Q wave evolution from V1 to V3 leads, either accompanied or not by modest ST segment elevation in DIII (but not aVF) evolving in no Q wave; ST segment elevation in right-sided leads which should be explored; absence of ST segment depression in aVL; absent concomitant ST segment elevation in all inferior leads (DII, DIII, aVF). Applying these criteria may prevent erroneous management of right ventricular infarction if it is confused with left ventricular infarction. Right ventricular function evaluation should always be performed by echocardiography. Magnetic resonance imaging should be useful. An illustrative case and an ECG flow-chart are presented.
Asunto(s)
Anomalías de los Vasos Coronarios/complicaciones , Electrocardiografía , Ventrículos Cardíacos/fisiopatología , Infarto de la Pared Inferior del Miocardio/diagnóstico , Función Ventricular Derecha , Angioplastia Coronaria con Balón/instrumentación , Infarto de la Pared Anterior del Miocardio/diagnóstico , Angiografía Coronaria , Anomalías de los Vasos Coronarios/diagnóstico , Anomalías de los Vasos Coronarios/fisiopatología , Diagnóstico Diferencial , Errores Diagnósticos/prevención & control , Humanos , Infarto de la Pared Inferior del Miocardio/etiología , Infarto de la Pared Inferior del Miocardio/fisiopatología , Infarto de la Pared Inferior del Miocardio/terapia , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Stents , Resultado del TratamientoRESUMEN
Dilated forms of cardiomyopathy are characterized by ventricular chamber enlargement and systolic dysfunction with normal LV wall thickness. Among other causes, chronic excessive consumption of alcohol has a very important presence. We present a case of a dilated alcoholic cardiomyopathy in a 65-year-old man. Also this case focuses attention on dilated alcoholic cardiomyopathy.
Asunto(s)
Alcoholismo/complicaciones , Cardiomiopatía Dilatada/complicaciones , Anciano , Cardiomiopatía Dilatada/diagnóstico por imagen , Angiografía Coronaria , Ecocardiografía , Humanos , MasculinoRESUMEN
Signs of plaque inflammation in carotid arteries may serve as a window to the entire cardiovascular system, to identify "vulnerable" patients. Moreover, flow-mediated vasodilation in the brachial artery and intima media thickness (IMT) in the carotid artery could represent a surrogate diagnostic method for assessment of coronary artery disease (CAD) severity. Renal function is an important predictor of the presence and severity of angiographic CAD in patients without severe renal impairment with incremental value over traditional risk factors for CAD and IMT. It has also been reported ,that renal dysfunction may exert differential effects on the development of coronary and peripheral atherosclerosis. An accumulating burden of hypertension, diabetes, and smoking is important in the progression of atherosclerosis from the coronary to the carotid circulation. We present an unusual case of lack of correlation of carotid atherosclerosis and coronary atherosclerosis.
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Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Índice de Severidad de la Enfermedad , Anciano , Enfermedades de las Arterias Carótidas/epidemiología , Angiografía Cerebral , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/epidemiología , Humanos , Masculino , Factores de RiesgoRESUMEN
Controlled hyperventilation leading to respiratory alkalosis may induce coronary artery spasm. This manoeuvre is currently used in the diagnosis of Prinzmetal's angina. We describe the case of a comatose patient with tracheostomy in whom hyperventilation, caused by excessive bronchial secretion resulting in partial obstruction of the tracheal cannula, was followed by ST segment elevation mimicking acute myocardial infarction.