Direct Angioplasty Research Articles

Direct Cervical Carotid Angioplasty with Flow Reversal: A Single-Center Report from the Roadster Trial

Carotid stent and/or angioplasty (CAS) via the transfemoral route with distal protection carries twice the risk of stroke and/or death when compared with carotid endarterectomy (CEA) in multiple randomized trials. Potential causes for this include disadvantaged aortic arch anatomy and the need to traverse the lesion to place a distal protection device. This report describes the technique and our experience with direct CAS using flow reversal for embolic protection. University of California at Los Angeles (UCLA) division of Vascular and Endovascular surgery was a participant in the multi-institutional Roadster Trial of high-risk patients. We are reporting on our experience with 8 patients who met high-risk criteria. Using a small supraclavicular cutdown, the Michi sheath from Silk Road Medical was inserted into the common carotid artery. This provides a working channel for internal CAS as well as a side port to reverse and divert blood flow to the femoral vein, for embolic protection. All patients qualified as medically high risk because of a combination of factors including advanced age, smoking history, hypertension, diabetes, coronary artery disease, or hostile neck anatomy. All 8 patients had 3 or more risk factors including age >75 years (6 of 8), smoking (6 of 8), hypertension (7 of 8), overt coronary artery disease (4 of 8), diabetes (2 of 8), and chronic obstructive pulmonary disease (1 of 8). All stenoses were in the 80-99% category, and all were asymptomatic. All patients tolerated temporary clamping with flow reversal with no electroencephalogram changes. There were no deaths, strokes, transient ischemic attacks, or myocardial infarctions. All patients were discharged on the first postoperative day. Follow-up ranged from 7 to 21months. One patient developed in-stent restenosis (asymptomatic). Direct CAS with flow reversal appears to be a safe, less invasive alternative to CEA.

Percutaneous Transluminal Angioplasty in Patients with Peripheral Arterial Disease Does Not Affect Circulating Monocyte Subpopulations.

Monocytes are mononuclear cells characterized by distinct morphology and expression of CD14 and CD16 surface receptors. Classical, quiescent monocytes are positive for CD14 (lipopolysaccharide receptor) but do not express Fc gamma receptor III (CD16). Intermediate monocytes coexpress CD16 and CD14. Nonclassical monocytes with low expression of CD14 represent mature macrophage-like monocytes. Monocyte behavior in peripheral arterial disease (PAD) and during vessel wall directed treatment is not well defined. This observation study aimed at monitoring of acute changes in monocyte subpopulations during percutaneous transluminal angioplasty (PTA) in PAD patients. Patients with Rutherford 3 and 4 PAD with no signs of inflammatory process underwent PTA of iliac, femoral, or popliteal segments. Flow cytometry for CD14, CD16, HLA-DR, CD11b, CD11c, and CD45RA antigens allowed characterization of monocyte subpopulations in blood sampled before and after PTA (direct angioplasty catheter sampling). Patients were clinically followed up for 12 months. All 61 enrolled patients completed 12-month follow-up. Target vessel failure occurred in 12 patients. While absolute counts of monocyte were significantly lower after PTA, only subtle monocyte activation after PTA (CD45RA and β-integrins) occurred. None of the monocyte parameters correlated with long-term adverse clinical outcome. Changes in absolute monocyte counts and subtle changes towards an activation phenotype after PTA may reflect local cell adhesion phenomenon in patients with Rutherford 3 or 4 peripheral arterial disease.

Combined Infra-popliteal Angioplasty has No Advantage over Direct Angiosomal Revascularisation.

Introduction: Meta-analysis has shown direct (the artery leading directly to the tissue loss) angiosomal re-perfusion to be superior to indirect reperfusion. Some units perform combined (direct and indirect i.e. open up as many tibial vessels as possible) reperfusion of the tibial vessels. There was inadequate data published on combined tibial angioplasty to perform meta-analysis in 2014. Our unit performs combined infra-popliteal angioplasty routinely, where possible, so the aim was to assess any advantage over traditional direct or indirect tibial angioplasty and to examine the effect of diabetes on the angiosome model. Methods: Analysis of consecutive infra-popliteal angioplasties over a 5 year period. Kaplan Meier survival curves were used to examine differences between groups; p-values were corrected. Combined angioplasty was performed routinely wherever possible. Results: Two hundred and sixteen tibial angioplasties were performed. 24.5% underwent combined revascularisation, 52.3% direct and 23.1% indirect. There was a significant improvement in amputation free survival (Hazard Ratio HR = 1.652, p = 0.019) in the direct and combined groups over indirect revascularisation. However, there was no improvement in wound healing (HR = 1.163, p = 0.117.) The direct vs. combined comparisons showed no difference for any outcome (wound healing HR = 0.947, p = 0.849 and amputation HR = 0.971, p = 0.906). All trends were lost in diabetic patients alone (n = 149, 69% of group). Conclusion: In this the largest series of combined angioplasty in the literature there was no advantage in opening up all the tibial vessels with angioplasty if the angiosome directly supplying the ischaemic tissue could be opened. The angiosome model does not appear valid, however, in diabetic patients.

Prognostic Significance of Different Strategies of Angiosome Targeted Lower Limb Revascularization

Prognostic Significance of Different Strategies of Angiosome Targeted Lower Limb Revascularization

Direct Cervical Carotid Angioplasty with Flow Reversal

Direct Cervical Carotid Angioplasty with Flow Reversal

May-Thurner Syndrome, the Role of Endovascular Intervention with Review of Published Treatment and Follow up Strategies

May-Thurner syndrome is a unique condition that strikes mainly young people. Its prevalence is likely underestimated and perhaps ranges from 22 to 32%. May-Thurner is under reported and often miss-diagnosed in accident and emergency, which can result in long term complication (post thrombotic syndrome) with its detrimental effect in this young age group. We describe a case of May-Thurner syndrome, a near miss, with review of published treatment and follow up strategies. This includes direct catheter thrombolysis, angioplasty, stenting, and IVC filter placement. Our patient has made a good recovery on follow up.

臨床 急性心筋梗塞に対するPTCA後no-reflow現象を呈した例の左室壁運動異常に関する検討

臨床 急性心筋梗塞に対するPTCA後no-reflow現象を呈した例の左室壁運動異常に関する検討

Evaluation of Cardiac Mitochondrial Function by a Nuclear Imaging Technique using Technetium-99m-MIBI Uptake Kinetics.

Mitochondria play an important role in energy production for the cell. The proper function of a myocardial cell largely depends on the functional capacity of the mitochondria. Therefore it is necessary to establish a novel and reliable method for a non-invasive assessment of mitochondrial function and metabolism in humans. Although originally designed for evaluating myocardial perfusion, 99mTc-MIBI can be also used to evaluate cardiac mitochondrial function. In a clinical study on ischemic heart disease, reverse redistribution of 99mTc-MIBI was evident after direct percutaneous transluminal coronary angioplasty. The presence of increased washout of 99mTc-MIBI was associated with the infarct-related artery and preserved left ventricular function. In non-ischemic cardiomyopathy, an increased washout rate of 99mTc-MIBI, which correlated inversely with left ventricular ejection fraction, was observed in patients with congestive heart failure. Increased 99mTc-MIBI washout was also observed in mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS) and in doxorubicin-induced cardiomyopathy. Noninvasive assessment of cardiac mitochondrial function could be greatly beneficial in monitoring possible cardiotoxic drug use and in the evaluation of cardiac damage in clinical medicine.

Geoffrey O. Hartzler, MD

On Saturday, March 10, 2012, cardiology sadly lost one of its brightest stars. Geoffrey O. Hartzler died suddenly at his home at the Lake of the Ozarks; he was 65 years old. Geoff was a very special individual, intellectually brilliant, intense, energetic, and controversial. He was born in 1946 in Goshen, IN, the second of 3 brothers, the youngest of whom died tragically of a berry aneurysm as a teenager. His father was a Mennonite minister who in a later career was instrumental in establishing the first outpatient community mental health center in the United States. His mother contracted polio when Geoff was 4 years old and survived in an iron lung. She remained the focus of the family's energy for nearly 4 decades. Pictured from left to right, Dr Andreas Gruentzig (AG), Dr Geoffrey O. Hartzler (GOH), and Dr Barry D. Rutherford (BDR) at Saint Luke's Mid America Heart Institute catheterization laboratory in 1984. He entered medical school at Indiana University. While a freshman, he worked 10-hour shifts watching a telemetry monitor and responding to cardiac arrests. At that time, he developed a keen interest in acute care medicine. He won an essay contest sponsored by the Mayo Clinic and spent a 3-month summer externship at Mayo. During that externship, he met and worked with another student clerk, David R. Holmes, Jr. Both went on to complete internal medicine and cardiology training at the Mayo Clinic and became Mayo faculty members in 1977. I (B.D.R.) first encountered Geoff Hartzler in the early 1970s when he was a cardiology fellow at the Mayo Clinic. At that time, I was a young consultant working in the Coronary Care Unit at St. Mary's Hospital. We were floating polyethylene catheters at the bedside to the pulmonary artery in patients with acute myocardial infarction. …

Abstract 3070: Assessment of Manual Aspiration Therapy for the Treatment of Sinus Thrombosis

Objective: While hydration and anticoagulation is typically the standard of care for cerebral venous sinus thrombosis, some patients remain refractory to medical management and continue to deteriorate. In these instances a number of more aggressive endovascular techniques have been reported to remove clots and restore blood flow in the venous sinuses. These techniques include direct thrombolysis, angioplasty, and various methods to disrupt and aspirate clot. Here we present the technique of endovascular transvenous manual aspiration thrombectomy (MAT) in five patients. Methods: We reviewed the records of five patients with medically refractory cerebral venous sinus thrombosis who received transvenous MAT. Presentation, technique, and outcome were evaluated. Results: Out of the five cases reviewed presentation included vomiting, dehydration, mental status changes, headaches, and acute motor deficits. On imaging three of the five patients had hemorrhage, edema, and mass effect present before treatment, while two had edema only. All of the patients reviewed were treated with anticoagulation therapy, intravenous heparin or subcutaneous lovenox, for a minimum of 24 hours. However, all of the patients continued to deteriorate despite early and aggressive medical anticoagulation therapy. All of the patients demonstrated rapid and progressive worsening of their neurological exam pre-operatively, including lack of arousal, pathological posturing, and expansion of secondary hemorrhages. This rapid deterioration warranted aggressive intervention, making the patients candidates for endovascular therapy. Direct thrombolysis with tPA was utilized with MAT via a distal access catheter(DAC) in all but one patient in which tPA was not used due to concern for hemorrhage. Aspiration of the superior sagittal sinus, transverse sinuses, straight sinus, and internal jugular were all included in this series. Catheters included the 0.070, 0.057, and 0.044 DAC and the 0.054 Penumbra microcatheter. Revascularization was achieved in all instances. One patient presented and remained neurologically devastated. She died 5 days after treatment. All other patients experienced improvement in their neurological examinations and were eventually discharged from the hospital in stable condition. Conclusions: Endovascular transvenous MAT is a feasible and effective revascularization technique to treat patients with cerebral venous sinus thrombosis.

Direct percutaneous transluminal angioplasty for acute embolic middle cerebral artery occlusion: Report of two cases

Two patients with cardioembolic middle cerebral artery (MCA) trunk occlusion were treated by direct percutaneous transluminal angioplasty (PTA).

Left Main Coronary Disease Treated by Direct Surgical Angioplasty: Long-Term Results

Left main coronary artery (LMCA) disease is currently treated by coronary artery bypass grafting or, more recently, by percutaneous coronary intervention. Occasionally, direct surgical patch angioplasty of the LMCA can be proposed as an alternative treatment. The aim of this study was to analyze, on a long-term basis, the safety and efficacy of this technique. This retrospective analysis was obtained from clinical data between April 1995 and December 2008: 91 consecutive patients (67 men, 24 women; mean age: 58+/-10 years) underwent surgical angioplasty of the LMCA with an autologous pericardial patch. Among them, 80 (87.9%) presented an isolated LMCA disease. Mean logistic European system for cardiac operative risk evaluation of this series was 3.9+/-2.9. Concomitant surgical procedures included coronary artery bypass grafting (n=11; 12%), valve procedure (n=5; 5.5%), and carotid endarterectomy (n=1; 1.1%). We analyzed the early and late mortality, major adverse cardiac or cerebral event rate, and repeat revascularization rate. The mean follow-up was 7.22+/-3.60 years (maximum 13.8 years, minimum 180 days). Perioperative mortality was 1.1%. Five and ten-year global survival was 95+/-4.5% and 80+/-8.3%, respectively. Major adverse cardiac or cerebral event rates at five and ten years were, respectively, 21+/-8.4% and 31+/-9.6%. First repeat postoperative revascularization rate was 12+/-6.8% at five and 17+/-7.8% at ten years (n=10 patients). Among them, repeat target lesion revascularization concerned four patients. Similar to other series, our study shows satisfactory long-term outcomes with the surgical patch-plasty of LMCA. This technique can be proposed as an efficient and safe alternative to selected patients, particularly in case of isolated LMCA disease without extended calcification.

Surgical angioplasty of the left main coronary artery

The conventional treatment for isolated stenosis of the left main coronary artery is bypass surgery (myocardial revascularization). However, the process of atherosclerosis is not arrested by myocardial revascularization and it will lead to the occlusion of the left main coronary artery. Revascularization will establish retrograde perfusion for 50-70% of the myocardium of the left ventricle. Direct surgical angioplasty of the left main coronary artery enables normal physiological perfusion of the whole myocardium and better myocardial function. The aim of our study is to point out a new surgical approach of treating left main coronary artery stenosis. Between October 2002 and October 2003, direct surgical angioplasty of the main left coronary artery was performed on three patients with isolated stenosis of the left main coronary artery using the anterior approach and the pericardium as a patch. The procedure was performed under total endotracheal anaesthesia and standard cardiopulmonary circulation, moderate hypothermia, anterograde St. Tomas cardioplegia and local cooling. Patients were followed clinically, echocardiographically and by load-tests. All three patients were without complications. In postoperative follow-up (54-68 months) neither angina pectoris nor electrocardiographically registered ischaemic changes were found. Load-tests performed every six months on all three patients were negative. Surgical angioplasty of isolated stenosis of the left main coronary artery is a preferred method for treating this type of coronary disease. Contraindications for this type of treatment are stenosis of the left main coronary artery with bifurcation and advanced calcification of the left main coronary artery.

The comparison of early and late outcome of direct and conventional stenting of patients with st elevation myocardial infarction

The aim of this study was to compare direct and conventional stenting procedure in the subacute stable phase on short- and long-term results in patients with ST elevation myocardial infarction. Eighty-eight clinically stable ST-segment elevation myocardial infarction (STEMI) patients were enrolled into the study. The patients were classified as group I (direct stenting) and group II (conventional stenting - stenting after balloon dilatation). Baseline characteristics of patients were scanned from hospital records. Coronary angiograms before and after the revascularization procedure were evaluated with the quantitative coronary angiogram technique. Patients were followed for 5 years for clinical outcomes. The study population consisted of 58 patients (65%) in group I and 30 patients (35%) in group II. Mean ages were 55.8 +/- 10.8 and 57.3 +/- 9.8, respectively. There were no significant differences between the two groups regarding clinical characteristics (hypertension, diabetes mellitus, family history of cardiovascular disease, smoking and dyslipidemia). The thrombus score was similar in both groups. Diameter stenosis was lower in group I (54.8 +/- 12.7 versus 61.4 +/- 12.6; p = 0.023) and TFC (Thrombolysis in Myocardial Infarction frame count) was higher in group II (30.7 +/- 14.5 versus 40.8 +/- 26.7; p = 0.02) before the percutaneous coronary intervention (PCI). Other quantitative angiographic parameters were not different. For all angiographic criteria, the difference between pre- and post-PCI parameters was significantly different in both groups. However, the change in TFC was higher within the group II compared to pre-PCI TFC rates. This difference was statistically significant (p = 0.002). Procedural success was statistically different between groups (69% in group I, 43% in group II; p50.01). Immediate clinical and angiographic results were similar. At 5-year follow-up the incidence of major adverse cardiac events including death, angina pectoris and myocardial infarction were similar for direct stenting versus conventional angioplasty. Direct stenting is safe and feasible for the treatment in patients with STEMI at the subacute phase. Immediate clinic, angiographic and late clinical results are similar for direct stenting and conventional stenting following balloon angioplasty. Although conventional stenting improved TFC better than direct stenting, this did not translate to better clinical outcomes.

Duration of Symptoms Is Not Always the Key Modulator of the Choice of Reperfusion for ST-Elevation Myocardial Infarction

Fibrinolytic therapy (FT) and primary percutaneous coronary intervention (PCI) are both well-accepted reperfusion therapies in ST-segment elevation myocardial infarction (STEMI). The evidence of randomized clinical trials indicates a relatively modest difference in 30-day mortality (≈1%) in favor of primary PCI over fibrin-specific FT and was based on very timely primary PCI (ie, a primary PCI–related delay of 40 minutes [door-to-balloon less door-to-needle time]).1 Longer delays to primary PCI, which are far more frequent in clinical practice,2 are associated with attenuated benefit or no benefit at all, particularly when compared with fibrin-specific FT.3,4 The benefit of timely primary PCI over FT is likely to especially apply to higher-risk patients.5,6 Irrespective of the method of reperfusion, the potential for myocardial salvage and better clinical outcome is inversely proportional to ischemic time or its only available clinical surrogate, symptom duration.7–12 These considerations underpin the notion expressed in the American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the treatment of STEMI that timely reperfusion therapy is likely more important in determining outcome than whether FT or primary PCI is the chosen reperfusion method.13 Response by Armstrong et al p 1310 The ACC/AHA STEMI guidelines highlight the time point of 3 hours of symptom duration in guiding the choice of reperfusion therapy. They state that if symptom duration is <3 hours, no preference exists between FT and primary PCI provided that treatment is timely (for FT, door-to-needle time <30 minutes; for primary PCI, door-to-balloon time <90 minutes and ≤60 minutes between estimated needle time and estimated balloon time). However, if symptom duration exceeds 3 hours, these guidelines favor primary PCI over FT, again provided that primary PCI can be performed in a timely fashion.13 This article reexamines the evidence that may or may not be the basis …

Prognostic value of heart rate variability after acute myocardial infarction in the era of immediate reperfusion

The incidence and significance of impaired heart rate variability (HRV) after acute myocardial infarction (AMI) have not yet been evaluated in cohorts of patients in whom early reperfusion was systematically attempted. Therefore, HRV was evaluated in 412 unselected patients with AMI (311 men, mean age: 60+/-12 years, anterior AMI in 172 patients) treated with direct coronary angioplasty (PTCA) within 12 hours of symptom onset (mean 3.5+/-2.0 h). Standard deviation of normal RR intervals (SDNN), square root of the mean of the sum of the squares of differences between adjacent RR intervals (RMSSD) and left ventricular ejection fraction (LVEF, mean: 55+/-15%) were measured 11+/-9 days after AMI before discharge. Angiotensin-converting enzyme (ACE) inhibitors and beta-blockers were prescribed at discharge in 81.1% and 70.1% of patients, respectively. Mean SDNN was 94+/-30 ms (range 14-155). SDNN was <50 ms in 7% of patients. Mean RMSSD was 34+/-32 ms (range 2-234). RMSSD was <15 ms in 21% of patients. Low SDNN (<50 ms) was unrelated to gender, age, infarct location or extension of CHD but was related to low LVEF (p<0.001, logistic regression analysis). During mean follow-up of 4.3+/-3 years, there were 31 deaths; 24 were cardiac. SDNN was higher in long-term survivors (102+/-39 ms) as compared to nonsurvivors (81+/-33 ms, p=0.02) but RMSSD was unrelated to the long-term vital status. Four-year survival of patients with a SDNN <50 ms vs >50 ms was 80% vs 92%, respectively (p<0.001, Kaplan Meier analysis). Low SDNN (odds ratio OR=2.0, p<0.05) but not RMSSD was an independent denominator for long-term mortality as were low LVEF (OR=1.0 decrease in LVEF, p<0.01, proportional hazards model) and age (OR=1.1, p<0.001). Only 3/31 fatalities and 1/24 cardiac deaths were predicted by a SDNN <50 ms and only 5/31 fatalities by a RMSSD <15 ms. The incidence of severely depressed HRV in patients after AMI is low (<10%) in the era of early reperfusion of the infarct vessel using direct PTCA. Mortality in patients with a very low HRV when assessed by SDNN is substantial but the positive predictive value of this parameter is low.

Efeitos da prostaglandina E1 (PGE1) na gênese de capilares sanguíneos em músculo esquelético isquêmico de ratos: estudo histológico

CONTEXTO: A angiogênese terapêutica é uma modalidade de tratamento para pacientes com insuficiência arterial crônica que não têm indicação para revascularização direta ou angioplastia e que não tiveram uma resposta satisfatória ao tratamento clínico. Entre as drogas utilizadas para essa finalidade está a prostaglandina E1 (PGE1). OBJETIVO: Estudar os aspectos morfológicos na gênese de capilares sanguíneos em músculo esquelético do membro caudal de ratos submetidos à isquemia sob a ação da PGE1, administrada por via intramuscular (IM) ou endovenosa (EV). MÉTODOS: Foram utilizados 48 ratos, linhagem Wistar-UEM, distribuídos aleatoriamente em três grupos de 16, redistribuídos igualmente em dois subgrupos, observados no 7º e 14º dias, sendo um grupo controle onde apenas foi provocada a isquemia no membro, outro com a isquemia e a injeção da PGE1 via IM e outro com a isquemia e a injeção da PGE1 EV. Para análise dos resultados, foram realizadas a coloração com hematoxilina e eosina (HE) e coloração imuno-histoquímica. RESULTADOS: Constatou-se um aumento estatisticamente significativo no número de capilares nos subgrupos com o uso da PGE1 IM e EV, através da contagem nos cortes corados com HE. A imunomarcação não foi eficiente para a quantificação dos capilares. CONCLUSÕES: A PGE1, administrada por via IM ou EV, promoveu, após 14 dias de observação, um aumento no número de capilares no músculo esquelético de ratos submetido à isquemia, identificáveis histologicamente com a coloração em HE. A imunocoloração não permitiu estabelecer uma correlação com o aumento de vasos encontrados na coloração com HE.

The Transforming Growth Factor-β/Smad3 Pathway

Myocardial infarction (MI) is followed by a well-described sequence of events known as postinfarction ventricular remodeling, a process that involves both the infarct scar itself and the residual surviving myocardium.1 The net results of infarct remodeling are changes in chamber size, function, and geometry. Furthermore, the remodeled ventricle becomes a substrate for both heart failure and sudden cardiac death. The elements of post-MI remodeling include infarct expansion, neurohormonal activation, myocardial hypertrophy, myocardial fibrosis, and cellular apoptosis. Article p 2127 These are linked physiological responses that attempt to compensate for the sudden decrease in contractility resulting from acute myocardial cell death.2 Infarct expansion is the thinning of the infarcted segment from slippage and stretching of myocytes and cell rupture. It is highly influenced by hemodynamic loading conditions.3 The prototypic pathways that participate in post-MI remodeling include the autonomic nervous system and renin-angiotensin-aldosterone system, which may be an attempt to maintain blood pressure and cardiac output.4 Over time, however, elevated adrenergic activity may lead to further myocardial cell loss from apoptosis,5 and both adrenergic and renin-angiotensin-aldosterone system upregulation have an adverse impact on cardiac hemodynamics. Myocardial hypertrophy, fibrosis, and apoptosis are primarily seen in the noninfarcted regions of the heart, particularly within the peri-infarct zones.2,6–8 Hypertrophy occurs in response to the increased workload for the surviving myocardiocytes, especially under suboptimal hemodynamic conditions. Myocardial hypertrophy, fibrosis, and apoptosis in the noninfarcted regions are believed to result, in part, from the neurohormonal activation of the sympathetic nervous system, renin-angiotensin-aldosterone system and cytokine cascades. The effect of these processes is to further compound the myocardial damage sustained during the initial acute injury. The end result of these remodeling responses is global ventricular dilatation, which is a significant predictor of dysfunction and future mortality.9 Understanding the components of remodeling …

Comparison of angiographically guided direct stenting technique with direct stenting and optimal balloon angioplasty guided with intravascular ultrasound. The multicenter, randomized trial results

The primary objective of the trial was to test the hypothesis that intravascular ultrasound (IVUS) guidance for coronary angioplasty is superior to the quantitative coronary angiography approach both during stenting and plain balloon angioplasty. Two hundred fifty-nine patients (70 females, 189 males; mean age, 54 +/- 9) were enrolled into our study. They were randomized into 3 groups: group 1--direct stenting guided with quantitative coronary angiography; group 2--direct stenting guided with IVUS; group 3--optimal balloon angioplasty guided with IVUS. At 6-month follow-up, we recorded evidence of major adverse cardiac events (death, myocardial infarction, repeat coronary revascularization). Procedural success was achieved in 95% of cases. At 6-month follow-up, the evidence of composite end point (major adverse cardiac events) was 16.2%, 7.3%, and 21.8% in groups 1, 2, and 3, respectively (P < .05). Use of IVUS led to 55% reduction of the primary end point between group 1 and group 2. The same when compared to the balloon angioplasty group assumed 66% reduction. Ultrasound guidance for direct stenting is the most effective for long-term outcome in comparison with other strategies. It is very likely that bigger lumen gain due to appropriate device sizing is responsible for better outcome. Direct stenting guided with IVUS might be an alternative option for patients requiring coronary revascularization and have contraindications to prolonged antiplatlet therapy as is mandatory for drug-eluting stent implantation.

Tako-tsubo-like left ventricular dysfunction in a patient with chronic total occlusion of the left anterior descending artery

This report describes a case of tako-tsubo-like left ventricular dysfunction in a patient with chronically occluded left anterior descending artery. A 74-year-od female, experiencing severe pain due to osteoarthritis, presented with chest pain lasting for 6 h. Electrocardiography revealed ST-segment elevation in the anterior and lateral walls. Left ventriculography in the acute phase displayed an akinetic apex and hyperkinetic basal region. Emergent coronary angiography revealed total occlusion of the left anterior descending artery. Although direct coronary angioplasty to the totally occluded left anterior descending artery was unsuccessful, the left ventricular function returned to normal within three weeks after admission. Thallium scintigraphy showed no significant abnormality, and cardiac enzyme elevation showed only a slight increase. In this case, tako-tsubo-like left ventricular dysfunction was considered to occur in the presence of chronically occluded left anterior descending artery.