Mid Right Coronary Artery Research Articles

Recurrent intraventricular thrombus six months after ST-elevation myocardial infarction in a diabetic man: a case report

BackgroundPercutaneous coronary intervention with placement of a drug-eluting stent in a diabetic patient with ST-elevation myocardial infarction is a relatively common procedure, and always requires subsequent treatment with dual antiplatelet therapy. It is sometimes necessary to add oral anticoagulation therapy because of individual clinical circumstances, which further increases the risk of bleeding.Case presentationA 66-year-old hypertensive diabetic man with a history of gastrointestinal bleeding was admitted with an ST-elevation inferior myocardial infarction that had been evolving over 72 h. Electrocardiography showed ST segment elevation in the inferior leads and Q waves in the inferior and anterior leads. He reported a similar episode of chest pain 1 month previously, for which he had not sought medical treatment. Coronary angiography showed chronic occlusion of the mid-left anterior descending coronary artery, and acute occlusion of the mid-right coronary artery. He was treated by percutaneous coronary intervention, with placement of a drug-eluting stent in the right coronary artery. Soon after admission, transthoracic echocardiography showed abnormal left ventricular contractility and a large left intraventricular thrombus. Three weeks after admission, the patient was discharged on dual antiplatelet therapy (clopidogrel and aspirin) and oral anticoagulation therapy (acenocoumarol). Four months after discharge, transthoracic echocardiography showed absence of left ventricular thrombus and resolution of the abnormal contractility in the area supplied by the revascularized right coronary artery. Given the high risk of bleeding, oral anticoagulation therapy was stopped. Six months later, transthoracic echocardiography showed recurrent left ventricular apical thrombus, and an underlying hypercoagulable state was ruled out. Oral anticoagulation therapy was restarted on an indefinite basis, and dual antiplatelet therapy was continued.ConclusionsThe present case illustrates the need for repeat transthoracic echocardiography following the withdrawal of oral anticoagulation therapy in patients with ST-elevation myocardial infarction, both to monitor thrombus status and to assess left ventricular segmental contraction. In patients who require anticoagulation, avoidance of a drug-eluting stent is strongly preferred and second-generation stents are recommended. The alternative regimen of oral anticoagulation and clopidogrel may be considered in this scenario. In patients with recurrent intraventricular thrombus an underlying hypercoagulable state should be ruled out.

Coregistered Intravascular Ultrasound and Optical Coherence Tomography Imaging During Implantation of a Bioresorbable Vascular Scaffold

A 50-year-old man presented with exertional angina and a positive treadmill test. Coronary angiography demonstrated a significant lesion in the mid-right coronary artery, and he proceeded to percutaneous coronary intervention. Because implantation of a bioresorbable vascular scaffold (BVS) (Abbott

Knuckle Wire and Stingray Balloon for Recrossing a Coronary Dissection After Loss of Guidewire Position

A 73-year-old man presented with a non-ST-segment elevation myocardial infarction. Coronary angiography revealed severe lesions in the mid and proximal right coronary artery (RCA) ([Fig. 1][1]A). After pre-dilation, a dissection was noted at the mid RCA lesion ([Fig. 1][1]B). During attempts to

Single coronary artery from the right coronary sinus with proximal origin of the left anterior descending coronary artery and left circumflex as distal continuation of the right coronary artery : a rare variant : case report - online article

A single coronary artery is a rare coronary anomaly. A 68-year-old male underwent coronary angiography for recent inferior wall myocardial infarction. It revealed a common coronary trunk arising from the right sinus of Valsalva and bifurcated into the right coronary artery (RCA) and anterior descending coronary arteries. The RCA, after its usual distribution in the right atrioventricular groove, continued as the left circumflex artery in the left atrioventricular groove. There were significant stenoses in the mid and distal RCA, which were treated percutaneously.

A case of percutaneous coronary intervention procedure successfully bailed out from multiple complications in hemodialysis patient

A 73year-old male who underwent coronary artery bypass surgery (CABG) 8years ago had PCI performed on him for a diffuse calcified stenotic lesion in the right coronary artery (RCA). Following 2.5mm non-compliant balloon dilatation supported with a child catheter (Dio from Goodman), we implanted a stent to the distal RCA through this catheter. However, because the tip of Dio was trapped by the implanted stent, it was stretched and almost ruptured by pulling it. Next, we tried to implant a stent for mid RCA with buddy wire technique, but we could not deploy it because of calcification. When we tried to withdraw this stent system, the stent was accidentally dislodged from the balloon. We could withdraw the stent with twisting two wires. However, because one of these wires had crossed a small artery in the distal RCA at twisting, a tip of this wire was fractured when the stent was removed. We could remove this wire with gooseneck snare. Finally, we successfully implanted stents in the mid RCA with balloon anchor technique and to the proximal RCA.

A successful treatment for a lesion of chronic total occlusion using a virtual 3 Fr guiding catheter

A 43year-old man was admitted due to effort related chest squeezing for 3months. Coronary angiogram showed a total occlusion of the proximal right coronary artery (RCA) with collateral vessels from left anterior descending artery. The 5F sheathless guiding catheter was engaged into the RCA and the 3F JL3.5 catheter was inserted into left coronary artery via left radial artery for simultaneous contra lateral angiography. We advanced the wire through the lesion with 2 wire technique. Three XIENCE stents (2.5mm×28mm) was inserted from distal to mid RCA, and a 3.0mm×15mm XIENCE stent was inserted to proximal RCA. The final angiographic result showed well expanded stent. The treatment of chronic total occlusion could be possible even slender device by getting hold of the characteristics of the device and evaluating an objective assessment of lesion characteristics.

A giant coronary aneurysm associated with a fractured cobalt-chromium stent

Figure 1: Critical stenosis with massive calcifications of the proximal and mid-right coronary artery in angiography (A). Angiogram after initial balloon angioplasty in the mid-right coronary artery (after an unsuccessful attempt to place a stent) and stent implantation in the proximal RCA (Multilink Vision 3.5 mm/12 mm, 24 atm) (B). Three months later coronary angiography revealed a giant aneurysm (31 × 23 mm) in the proximal segment of the RCA (C). There was also a complete transverse fracture of the stent (arrows) with displacement of the two fragments (D, arrowheads showing calcifications), which was confirmed by computed tomography (E and F, arrowheads showing an aneurysm). Intraoperatively, a large, round aneurysm (arrowhead) was found located close to the RCA orifice (G).

Percutaneous Coronary Intervention for Intra-stent Chronic Total Occlusion Assisted by Stent Visualization Enhancement Technology

A 50-year-old female patient with a history of prior acute inferior myocardial infarction successfully treated 2 years earlier by primary percutaneous coronary intervention (PCI) with thrombus aspiration and implantation of a 3x30 mm bare-metal stent in the proximal right coronary artery (RCA) was submitted to coronary angiography after reappearance of effort angina. An initial coronary angiogram showed a chronic total occlusion (CTO) intra-stent with Rentrop III collateral filling of the RCA originating from distal left anterior descending (LAD). A mid LAD 60% stenosis and a 60% mid circumflex stenosis were considered non-significant since fractional flow reserve (FFR) was measured at 0.84 and 0.90 respectively. After demonstrating inferior wall viability by cardiac magnetic resonance imaging (MRI), a PCI was programmed two months after the initial coronary angiogram. The intra-stent CTO was ≥ 30 mm long, with no blunt stump and at least 2 small branches originating at its proximal cap level. Mid and distal RCA antegrade filling existed due to bridging collaterals. The crossing technique by guidewire exchange and use of a microcatheter is described. After balloon predilatation the RCA was recanalized. The use of a stent visualization enhancement technology (StentViz) helped understand the most probable procedure-related restenosis mechanisms (stent undersizing and underexpansion) and guided the subsequent successful implantation of two drug-eluting stents. The use of this technology is described step by step for this intervention.

Delamination of Abluminal Polymer of Biolimus-Eluting Stent

A 76-year-old man with 80% and 90% stenosis with severe calcification in the proximal and mid-right coronary artery (RCA), respectively ([Figs. 1][1]A and [1][1]B), was referred for coronary angioplasty. After rotational atherectomy and balloon inflation, a 23-mm everolimus-eluting stent was

Imaging-Guided Selection of Patients With Ischemic Heart Failure for High-Risk Revascularization Improves Identification of Those With the Highest Clinical Benefit

A 65-year-old man presented to his local emergency department with rapid atrial fibrillation and acute pulmonary edema. This patient had a history of hypertension, and 2 months before this presentation, he developed progressive exertional dyspnea. The patient deteriorated in the emergency department and went into cardiogenic shock. Emergent coronary angiography revealed diffuse 3-vessel disease: a 99% proximal left anterior descending coronary artery lesion, 90% mid-right coronary artery lesion, occluded large first marginal branch, and diffuse severe disease of the left circumflex coronary artery. The initial ejection fraction (EF) on echocardiography was 15%, with mild mitral regurgitation and an estimated pulmonary artery pressure of 55 mm Hg. The patient stabilized with an intraaortic balloon pump and intensive care unit management; however, because of the diffuse nature of the disease, he was not believed to be a surgical candidate. He was transferred to another tertiary-care facility for consideration of cardiac transplantation. As part of this evaluation, a PET viability study was done that demonstrated a significant area of perfusion-metabolism mismatch in the entire anteriolateral wall. Less than 1% of the myocardium was scar, and 28% was defined as hibernating (Figure 1). Figure 1. A rest rubidium 82 and 18F-fluorodeoxyglucose (FDG) PET viability imaging study in corresponding short-axis, horizontal long-axis, and vertical long-axis slices. Perfusion images demonstrate a moderate to severe reduction in perfusion defect in the entire anterior wall, anterolateral wall, and apex. The lateral wall also has a moderate to severe perfusion defect. The FDG images (second row) demonstrate FDG uptake in the anterior wall extending to the apex and lateral wall, corresponding to a total scar score of 0.54% and a mismatch score of 26% of the ventricular myocardium. Response by Velazquez on p 270 The results of the viability test were pivotal in the decision to perform coronary artery …

Inferior acute myocardial infarction due to acute cardiac herniation after right pneumonectomy

A 69-year-old man underwent right intrapericardial pneumonectomy for lung cancer. After 24 h, he went into shock with inferior acute myocardial infarction. We performed urgent coronary angiography, which revealed total occlusion of the mid-right coronary artery. Intravascular ultrasound showed that the artery seemed to be compressed from the pericardial side. We implanted a coronary stent because the lesion was refractory to balloon dilatation. After the procedure, we performed computed tomography and cardiac herniation was diagnosed. Emergency thoracotomy was performed to return the herniated heart to its normal position. This patient was discharged 38 days after initial surgery.

A patient came back with retrograde coronary flow in the distal right coronary artery 2years after coronary intervention: clinical significance of retrograde coronary flow to detect coronary artery occlusion.

A 69-year-old male patient, who had a history of coronary stent implantation to the proximal right coronary artery (RCA), presented with exertional chest pain. Transthoracic Doppler echocardiography revealed retrograde coronary flow in the distal RCA, and treadmill stress echocardiography revealed inducible myocardial ischemia in the inferior and posterior segments. Coronary angiography demonstrated a severe stenotic lesion with flow delay in the mid RCA and collateral circulation to the distal RCA from the left coronary artery. Detection of retrograde coronary flow in the distal RCA using transthoracic Doppler echocardiography is a useful method to diagnose subtotal occlusion of the RCA.

Spontaneous Coronary Artery Dissection in Patients With Fibromuscular Dysplasia

Young women with acute coronary syndrome (ACS) frequently have nonatherosclerotic coronary artery disease (NACAD) and may be misdiagnosed. Coronary fibromuscular dysplasia (CFMD) commonly is overlooked, as the angiographic appearance is often subtle. Our group previously described CFMD as a diffuse obliterative disease starting abruptly at the mid-distal vessel, involving long segments.1 Spontaneous coronary dissection (SCAD) is another common form of NACAD and may be superimposed on CFMD, causing ACS. We report the first case series of SCAD and concomitant fibromuscular dysplasia (FMD). ### Case 1 (Figure 1) Figure 1. Case 1. A Coronary angiogram of the right coronary artery (RCA) showing diffuse stenosis from the mid-segment to the posterior descending artery. B Optical coherence tomography (OCT) image of the normal proximal RCA (* corresponding to A ). C OCT image showing intramural hematoma in the distal RCA (+ corresponding to A ). D Carotid angiogram showing shelf-like fibromuscular dysplasia (FMD) lesion at the ostium of the left internal carotid artery (*), followed by mild irregularities in the proximal left carotid artery. E Iliac angiogram showing diffuse mild FMD in the left external iliac artery (*). A 35-year-old African female with no cardiovascular (CV) risk factors presented on April 18, 2011 with persistent chest pain for 2 days while doing aerobic exercises. ECG showed T-inversion anteriorly and inferiorly, and troponin I (Tn-I) peaked at 4.2μmol/L. Coronary angiogram showed diffuse severe stenosis from mid-right coronary artery (RCA) to the distal posterior descending artery with TIMI3 flow. A subsequent optical coherence tomography (OCT) showed coronary dissection with extensive intramural hematoma, and she was treated with stents. She had incidental bilateral external iliac artery FMD, and her carotid computer tomography angiography (CTA) showed a flap at the origin of the left carotid artery, prompting catheterization that confirmed FMD of both carotid …

A patient with significant slow-flow phenomenon during percutaneous coronary intervention for ST elevation myocardial infarction associated with scattered necrotic core by virtual histology intravascular ultrasound

A 68-year-old man with acute ST elevation myocardial infarction (STEMI) underwent emergent coronary angiography which showed total occlusion in the proximal right coronary artery (RCA). Gray-scale intravascular ultrasound (IVUS) revealed the culprit lesion was expansively remodeled and contained ruptured and echolucent plaques with spotty calcification, whereas thin-capped fibroatheroma and a large amount of scattered necrotic core were observed by virtual histology (VH)-IVUS. After stent implantation in the proximal RCA under a filter protection, filter-no-reflow phenomenon occurred and thrombus-like defect was observed in the mid RCA. Under these conditions, VH-IVUS detected a large amount of scattered necrotic core in the mid RCA. We suggest scattered necrotic core detected by VH-IVUS may be associated with slow-flow phenomenon during percutaneous coronary intervention in our patient with STEMI.

Quantitative coronary angiography findings of patients who received previous breast radiotherapy

PurposeTo compare the coronary angiographic findings between patients who had previous left sided versus right sided breast cancer radiotherapy (RT). Materials and methodsBetween 1995 and 2009, 12,696 patients who underwent curative RT for breast cancer at Princess Margaret Hospital were screened to assess if they had been investigated with a post-RT coronary angiogram. Two cardiologists, blinded to the laterality of radiation treatment, assessed all angiograms and measured the percentage of stenotic lesions, the mean diameters of each segment of the left anterior descending artery (LAD) and the right coronary artery (RCA) using quantitative coronary angiography (QCA). ResultsNinety-one patients were included, 49 patients with left sided RT and 42 with right sided RT. The median time from RT to coronary angiogram was 4.2years (range: 22days–16.9years). Seventeen patients (35%) in the left sided RT group and 17 (40%) in the right sided RT group needed coronary revascularization (percutaneous coronary intervention or by-pass surgery). The LAD territory was revascularized in 12 (24%) and 11 (26%) patients, respectively. The proportion of clinically significant stenoses, degree of stenoses and mean vessel diameter were not significantly different between the two groups. In 33 patients who had coronary angiograms >5years after breast RT (17 left-sided and 16 right-sided), the only statistically significant finding was marginally narrower mid RCA segments among those who had right sided RT: 2.52mm versus 2.92mm (P=0.039). ConclusionsIn our patients, left sided breast cancer RT did not increase the risk of coronary artery disease within the first few years, when compared to right sided RT. However, with the limitation of short duration between radiotherapy and coronary angiogram, late development of coronary artery stenoses 10–15years after left sided RT could not be excluded.

Severe Aortic Regurgitation After Transradial Percutaneous Coronary Intervention

A 60-year-old man presented to a community hospital with new-onset shortness of breath after a 2-hour episode of typical chest pain. The ECG showed anteroseptal and inferior wall Q-waves. Serum troponin T levels were negative. An echocardiogram revealed anterior wall hypokinesia with left ventricular ejection fraction of 40% and no signs of valvular disease. The patient was transferred to our center for coronary angiography. Arterial access was obtained from the right radial artery. The angiogram showed mild disease of the left coronary artery and a right coronary artery (RCA) arising from the left coronary sinus. The RCA was extremely difficult to cannulate; nonselective injections revealed a long and severe stenosis of the mid segment (Figure 1 and Movie 1). After many unsuccessful attempts to cannulate the RCA with different guiding catheters, the operator decided to engage first the left coronary artery with an Amplatz 2 guiding catheter. A BMW Universal II guide wire was advanced into the left anterior descending artery (LAD) for better stability. This approach …

Abstract P4-11-07: Quantitative Coronary Angiography Findings of Patients Who Received Previous Breast Radiotherapy

Abstract Purpose: To compare the coronary angiographic findings, between patients who had previous left sided breast radiotherapy (RT) and those who had right sided RT. Methods: Between 1995 and 2009, 12696 patients who underwent curative RT for breast cancer in Princess Margaret Hospital were screened to check if they had a post-RT coronary angiogram. Two cardiologists, blinded to treatment, assessed all angiograms and measured the percentage of stenotic lesions and the mean diameter of each segment of the left anterior descending artery (LAD) and the right coronary artery (RCA) using Quantitative Coronary Angiography (QCA). Results: Ninety-one patients were included, 49 and 42 patients had left sided RT and right sided RT respectively. The median time from RT to coronary angiogram was 4.4 years (range: 22 days - 16.9 years). Nineteen patients (39%) in the left sided RT group and 17 (40%) in the right sided RT group needed coronary revascularization (percutaneous coronary intervention or by-pass surgery). The LAD territory was revascularized in 14 (29%) and 11 (26%) patients respectively. The degree of stenoses and mean vessel diameter were not significantly different between the two groups. Table 1: Quantitative The proportion of patients who developed clinically significant stenoses of coronary arteries were not statistically different between the two groups. Table 2: Patiens In 32 patient who had coronary angiograms >5 years after breast RT (16 left-sided and 16 right-sided), the only statistically significant finding (P<0.05) was marginally narrower mid RCA segments among those who had right sided RT: 2.52 mm versus 2.92 mm (P = 0.039). Conclusions: Left sided breast RT did not increase the risk of premature coronary artery disease as compared with right sided RT. However, with the limitation of short duration between radiotherapy and coronary angiogram, late development of coronary artery stenoses 10-15 years after left sided RT can not be excluded. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-11-07.

Optical coherence tomography follow-up of the subintimal tracking and re-entry technique for chronic total occlusion

A 44-year-old man, a smoker with dyslipidaemia, underwent successful percutaneous coronary intervention (PCI) of a chronic total occlusion in the right coronary artery (RCA). The site of occlusion was very proximal. An attempt to cross the lesion was performed using an antegrade approach, during which dissection of the ostium occurred and the guidewire entered the false lumen. The ostial dissection was treated with stent implantation of a Xience, 3.5 x 18 mm (Abbott Vascular, Redwood City, CA, USA). The STAR technique with proximal antegrade subintimal dissection and distal re-entry into true lumen of the posterolateral (PL) branch was then performed. The bifurcation lesion of PL/posterior descending branch, with significant disease, was treated using the mini-crush technique with implantation of Cypher (Cordis, Johnson & Johnson, Warren, NJ, USA) stents 2.75 x 23 mm and 3.0 x 28 mm, respectively. Three Cypher stents, 3.5 x 23 mm (1), 3.0 x 33 mm (2), and 3.0 x 33 mm (3), were implanted into the false lumen, from proximal to mid RCA with stent overlap, achieving full metal coverage of RCA (Figure 1, Panel A). Due to the complexity of the procedure, a follow-up was planned after eight months, at which the patient was asymptomatic. A coronary angiography showed a moderate restenosis at the site of overlapping stents 2 and 3 (Panel A, arrow) and an irregular profile of the outer border of the segment of overlapping stents 1 and 2, with evidence of saccular protrusions (Panel A, blue dotted line). Optical coherence tomography (OCT) was performed using a non-occlusive technique with 2 mm/sec pullback M2 machine (Image wire and Image system; LightLab Imaging Inc., Westford, MA, USA) and automated injection of isoosmolar Visipaque medium contrast. OCT documented the presence of moderate neointimal hyperplasia (minimal lumen cross-sectional area of 4.3 mm), along with abrupt disappearance of circumferential struts in cross sectional images and altered stent geometry (Panels B-E) suggestive of stent fracture, at the coronary segment corresponding to the angiographic restenosis. It also detected the presence of diffuse strut malapposition with digit like elongations of the vessel wall (Panels F-G) at the site of angiographic saccular protrusions. Most malapposed struts did not present visible tissue coverage (Panels F-G). The patient was discharged with the recommendation to continue aspirin and clopidogrel indefinitely unless serious bleeding occurred. He remained asymptomatic at the 18 month follow-up. Restenosis requiring repeat revascularisation occurs in approximately 50% of patients at angiographic follow-up after STAR technique. Stent fracture has been reported in cases of long stented segments, lesions at hinge points, and use of sirolimus-eluting stents, perhaps facilitated by the closed cell design and high strut thickness of such stent, and is associated with restenosis. Abnormal vessel remodelling is a pathological condition that may Image in cardiology

Cardiac lymphoma causing coronary compression, pericardial effusion, and atrioventricular block

A 75-year-old male patient underwent stenting of a mid-right coronary artery (RCA) lesion because of exertional chest pain. The procedure was complicated by acute stent-thrombosis 3 days later managed by thrombectomy and repeat stenting with favourable results. However, 3 weeks later, the patient was re-admitted with symptoms of progressive dyspnea. An echocardiographic examination showed an additional structure attached to the right ventricular wall and inhomogeneous thickening of the interatrial septum, together with a significant amount of pericardial fluid causing echocardiographic signs of tamponade ( Panel A ). These findings were confirmed by subsequent cardiac magnetic resonance (MR) ( Panel B ) and …

Stent thrombosis after complex multivessel stenting in an elderly patient

We report a challenging case in terms of procedural difficulty as well as long-term patency. Multivessel stenting procedures for long subtotal occlusions in the right coronary artery (RCA) and left anterior descending coronary artery (LAD) were successfully performed in an 84-year-old female who had complications of severe left ventricular dysfunction and a recent history of gastric ulcer bleeding. Two bare-metal stents were successfully deployed in the mid and distal RCA. A drug-eluting stent could only be deployed in the proximal RCA. Two drug-eluting stents were deployed in the proximal LAD and LMT. Late stent thrombosis in the proximal RCA occurred about 3 months later. We speculated that a lack of aspirin and bare metal stent restenosis were the reasons for the late stent thrombosis. This case was very challenging in terms of balancing the risk of ischemia and bleeding after coronary stent deployment.