Surgical Management for a Broken Delivery Shaft in <i>Vivo</i>during PCI Following Acute Myocardial Infarction in a Complex LAD Artery Lesion: A Case Report and Literature Review

Stuck up and fracture of coronary angioplasty hardware are unwonted complications of percutaneous coronary interventions (PCI) for which surgical retrieval and management is once in a while required. We present one case of a 59-year-old diabetic, a hypertensive gentleman who attended the emergency room (ER) with central chest pain for 2 hours. After evaluation of the patient by physical and noninvasive diagnostic tests, he was diagnosed as a case of acute myocardial infarction (AMI) with stable hemodynamic. For the aforementioned findings, the patient was treated first with a thrombolytic agent in ER and then shifted to Cardiology Department for monitoring and further coronary evaluation by coronary angiography (CAG). CAG revealed essentially single vessel disease (SVD) with complex left anterior descending (LAD) artery lesion, so PCI was attempted but failed with an unfortunate incidence of the broken delivery shaft and left in vivo. Immediate decision making and surgical management for retrieval of lost angioplasty device and correction coronary lesion with revascularization save the patient from grave complication. All the series of events and management approaches of this very complex coronary artery lesion are discussed in this article.

冠状动脉内支架在复杂冠脉病变中的应用

Objective To study the clinical value of coronary stenting in treatment of severe complex coronary artery lesions, to evaluate the short and long term outcome of the patients imployed coronary stents, and to well recognize the role of stenting in dealing with the complications of PTCA.Methods In this study, two hundrad sixty four patients with coronary artery disease were included, who were classified as PTCA group (138 cases)and coronary stented group(126 cases).They all received Exercise Test(ET)、Ultrasound Cardiogram(UCG)and Ambulatory Electrocardiography (AECG)at admission and before discharge, respectively. The coronary artery lesions were categorized into type A.B.C according to the methods reported by ACC/AHA . It was that the data between two groups including clinical information, cronary artery lesion characteristicis, procedural success rate, major complications, Minimum Lumen Diameter (MLD),residual stenosis, collateral circulation scores both before and after procedure had been compared. Following up were performed 6 months to 3 years after procedure. Results The study showed that there were no significant different in two groups including the clinical information, positive rate of ET, EF, results of AECG. But the rate of type B2/C lesions were higher in CS group than that in PTCA group( P <0.05). Both PTCA Group and CS Group had extremely success rate in type A and type B1, but CS had a higher success rate than that in PTCA in type B2 and type C (94.28%VS 89.2%, P <0.05). CS group had a lower rate of complication in procedure than that of PTCA group. There are no signifiance in MLD between the two groups (0.53± 0.22)mm vs (0.42±0.26)mm,( P >0.05) before procedure. But MLD was signifantly higher in CS group than that in PTCA group (2.51±0.66)mm vs (3.08±0.66)mm,( P <0.001) after procedure.The collateral circulation scrores were signifantly decreased after procedure (1.7±0.6) vs (0.8±0.4); (2.1±0.3) vs (0.3±0.4) in both PTCA Group and PTCA Group respectivesly,( P <0.001). Residual stenosis were higher in PTCA group(15±6%)than that in CS group (6±3%, P <0.001). The positive rate of ET, exercise capacity, ST depressions, EF and wall motion were all improved significantly both in PTCA group and CS group, CS group has a higher effect in exercise capacity, MLD, EF and ischemia duration.Seventy nine patients were followed up and the rate of cardiac events in the CS group were lower than in PTCA group.Conclusions 1.Coronary stenting had a high success rate and low complication in treatment of severe and complex coronary artery lesions.2.Coronary stentig reduced residual stenosis, improved blood supply, salvaged the hibernating and /or stunned myocardium, improved the left ventricular function. CS have offered a new, safe and effective metbods for treatment of left main trunk lesions; 3.Coronary stenting has broden the indication for invasive treatment of coronary artery diseases.

Complex coronary lesions and rotational atherectomy:one hospital's experience

Objective:To evaluate the safety and effectiveness of rotational atherectomy followed by drug eluting stent (DES) implantation in patients with complex coronary lesions. Methods:From August 2006 to August 2012, 253 consecutive patients with 289 lesions and who underwent rotational atherectomy in our center were enrolled in this study. Results:The overall procedure success rate was 98% with the cost of two (0.8%) coronary perforations, three (1.2%) dissections, five (2.0%) slow flows or no flows, three (1.2%) peri-procedure myocardial infarctions, and two (0.8%) in hospital deaths. During follow-up (mean three years), one (0.4%) patient died, two (0.8%) patients had acute myocardial infarction, 14 (5.5%) had restenosis, and target lesion revascularization occurred in eight patients (3.2%). Conclusions:Rotational atherectomy followed by DES implantation is a safe and effective technique for patients with complex coronary lesions, especially calcified and non-dilatable lesions.

Relationship between coronary artery remodeling and cumulative incidence of coronary angiographic lesions with vulnerable characteristics in patients with stable angina pectoris

ackground Development of vulnerable lesions is not limited to the target lesions, but a pan-coronary process. Such lesions are identified by positive remodeling （intravascular ultrasound （IVUS） and complex lesions （angiography））. The prevalence of lesions with vulnerable characteristics in patients with stable angina was not well known. The purpose of the present study was to evaluate the relationship between coronary artery remodeling and incidence of angiographic complex lesions and its calcification in stable angina patients.Methods One hundred and sixty-one stable angina patients （95 males, aged （68±11） years） with 161 de novo target lesions were studied using pre-interventional IVUS. Remodeling index was defined as the lesion divided by reference vessel area; positive remodeling was defined as remodeling index 〉1.05. Besides the 161 target lesions, there were 613 angiographic lesions with 〉30% diameter stenoses, classified as complex or smooth. Multiple complexes were defined as more than one complex lesion in one patient. Stenoses of at least 70% were described as tight. Calcium arc area was used as a new method to quantify coronary calcification.Results Fifty-six patients had positive remodeling target lesion, while 105 did not. The overall number of lesions with a diameter stenoses 〉30% was similar in patients with or without positive remodeling, and the frequency of angiographically complex lesions was higher in positive remodeling patients, especially at non-target site. Calcium arc area was smaller in patients with positive remodeling.Conclusions Positive remodeling on intravascular ultrasound was associated with more complex lesions angiographic findings, especially at non target site. Positive remodeling was found less calcified in patients with stable angina.

Impact of Side Branch Lesion Length on Clinical Outcome after Coronary Stenting Techniques in Patients with Coronary Artery Bifurcation Disease:A Meta-Analysis

Objective:The optimal percutaneous coronary intervention(PCI)technique for bifurcation lesions remains controversial,especially considering the variability of the side branch(SB).A provisional stenting technique is currently recommended in most cases.This meta-analysis aimed to compare outcomes of different bifurcation PCI strategies,clarifying their scope of application.Methods:Randomized controlled trials comparing PCI strategies for coronary bifurcation lesions were systematically retrieved from PubMed,Cochrane,Web of Science,and EBSCO literature databases without limitations on published date or language.Major adverse cardiovascular events(MACEs)were stipulated as main outcomes.Secondary outcomes of interest were all-cause mortality,cardiovascular mortality,target lesion revascularization(TLR),target vessel revascularization,myocardial infarction(MI),and stent thrombosis.Both pooled analysis and sub-group analysis were performed.Results:Twenty-three randomized controlled trials with 6380 participants were included.Eighteen studies compared the provisional strategy with 2-stent approaches.No significant difference in MACEs(relative risk(RR),1.16;95%confidence interval(CI),0.90-1.48;I2=62%)was found between 1-stent and 2-stent techniques.However,when SB lesion length was used as the separation condition,the 2-stent strategy was associated with fewer MACEs(RR,1.87;95%CI,1.46-2.41;I2=70%),TLRs(RR,2.13;95%CI,1.50-3.02;I2=59%),and MIs(RR,2.17;95%CI,1.19-3.95;I2=52%)than the provisional strategy in those where SB lesions measured>10 mm long.Conclusions:In the current work,there was no significant difference between 1-stent and 2-stent techniques in terms of MACEs or secondary outcomes.However,2-stent approaches have clinical advantages over the provisional strategy in bifurcation when the SB lesion length is>10 mm due to fewer cases of TLR and MI.