Ostial Stenosis Research Articles

Coronary Anatomy in the Newborn: What Do We Need to Know and When?

Coronary Anatomy in the Newborn: What Do We Need to Know and When?

What Is the Best Proximal Anastomosis for the Free Right Internal Thoracic Artery during Bilateral Internal Thoracic Artery Revascularization? A Prospective, Randomized Study

Objective. Bilateral internal thoracic artery (BITA) grafting provides improved graft patency and potential survival advantage in selected patients as compared to single left internal thoracic artery (LITA) revascularization. The ideal functional BITA configuration remains controversial. Methods. Patients undergoing planned BITA revascularization with greater than 75% stenosis in both the left anterior descending artery (LAD) and in a circumflex branch were prospectively randomized to one of two proximal free right internal thoracic artery (RITA) connections directly off the aorta (Ao) (n = 12) or as a “t” graft off the LITA (t) (n = 12). The LITA was placed to the LAD in all cases, and the RITA was placed to a single lateral wall vessel. Intraoperative transit time flow measurements of all arterial grafts were performed, and RITA fractional flow parameters were compared between the 2 groups. Results. There were no differences in preoperative patient variables between the two groups. Cross-clamp times (91.5 + 15.3 versus 68.0 + 12.5 minutes, P < 0.01) and total cardiopulmonary bypass times (109.0 + 16.2 versus 85.0 + 15.1 minutes, P < 0.01) were shorter in the t group. The Ao group demonstrated significantly higher mean RITA flow (38.3 ± 13.5 versus 22.1 ± 9.5, P < 0.01), mean RITA conductance (flow/mean arterial pressure) (0.45 ± 0.16 versus 0.28 ± 0.11, P < 0.01), RITA fractional flow (0.52 ± 0.15 versus 0.36 ± 0.11, P < 0.01), and RITA fractional conductance (0.51 ± 0.15 versus 0.36 ± 0.11, P < 0.01) than the “t” grafted patients. Thirty-day mortality and wound infection were 0% for each group. Over an average of 42.8 + 6.6 months of followup there were no mortalities in either group. Repeat angiography were performed in 4 patients (33%) in the Ao group and 2 patients in the t group (16%). One occluded RITA graft and one ostial RITA stenosis were detected in the Ao group. Conclusions. Acute flow measurements indicate that the free RITA anastomosed to the aorta provides more acute fractional RITA flow than composite “t” grafting to the LITA. Longer-term angiographic and clinical followup are necessary to determine the consequences of these acute hemodynamic findings.

Long-term results of two cases of patch angioplasty for isolated left main coronary ostial stenosis

Long-term results of two cases of patch angioplasty for isolated left main coronary ostial stenosis

Primary angioplasty for infarction due to isolated right ventricular artery occlusion

We report an unusual case of an isolated right ventricular infarction with haemodynamic compromise caused by spontaneous isolated proximal occlusion of the right ventricular branch of the right coronary artery (RCA), successfully treated by balloon angioplasty. A 58-year-old gentleman presented with epigastric pain radiating into both arms. Electrocardiograph with right ventricular leads confirmed ST elevation in V4R and a diagnosis of isolated right ventricular infarction was made. Urgent primary percutaneous intervention was performed which revealed occlusion of the right ventricular branch of the RCA. During the procedure, the patient's blood pressure dropped to 80/40 mmHg, and echocardiography showed impaired right ventricular systolic function. Despite aggressive fluid resuscitation, the patient remained hypotensive, continued to have chest pain and persistent electrocardiograph changes, and hence balloon angioplasty was performed on the proximal right ventricular branch which restored flow to the vessel and revealed a severe ostial stenosis. This was treated with further balloon angioplasty which restored TIMI 3 flow with resolution of patient's symptoms. Repeat echocardiography showed complete resolution of the ST-elevation in leads V4R and V5R and partial resolution in V1. Subsequent dobutamine-stress echocardiography at 4 wk showed good left and right ventricular contractions. The patient was discharged after a 3-d in-patient stay without any complications.

Balloon Dacryoplasty in Internal Ostium Stenosis After Endoscopic Dacryocystorhinostomy

To determine the effectiveness of balloon dacryoplasty in the treatment of internal ostium stenosis after endoscopic dacryocystorhinostomy (EnDCR). A retrospective, noncomparative interventional case series of patients who underwent balloon dacryoplasty for post-EnDCR internal ostium stenosis were included. A balloon catheter was used in all procedures, with bicanalicular silicone intubation. Patient records were reviewed and data analyzed. Anatomical success was defined by functional endoscopic dye test, and functional success was defined as a subjective improvement in symptoms at last follow up. Nineteen lacrimal systems of 18 consecutive patients were studied between July 2007 and September 2012. At a mean follow up of 20 months (range, 3-53 months), anatomical success rate was 84% (16/19 systems), whereas functional success was 74% (14/19 systems). No major complication was observed. Balloon dacryoplasty is a minimally invasive procedure in the treatment of post-EnDCR internal ostium stenosis. It is a simple, safe procedure and can provide symptomatic relief to some of these patients. It can be considered as a treatment option for patients demonstrated with internal ostium stenosis after EnDCR.

Abstract 18549: Cardiac MR and CT Virtual Angioscopy Demonstrate Normal Coronary Ostial Morphology in Children With Anomalous Left Coronary Artery With Intraseptal Course

Background: Anomalous left coronary artery from the right sinus of Valsalva (ALCA) with intraseptal course is generally considered benign but is often confused on imaging studies with the potentially lethal interarterial, intramural ALCA with associated slit-like orifice. The clinical significance differs between the two subtypes and it is important to differentiate them in order to avoid unnecessary surgical exploration. Limited data exist on intraseptal ALCA in the pediatric population. Methods: Medical records were retrospectively reviewed on fifteen pediatric patients diagnosed with ALCA between 11/2009 and 3/2013. We also evaluated their coronary artery origins and courses using cardiac magnetic resonance or computed tomography imaging on each patient and virtual angioscopy for three-dimensional assessment of coronary ostial morphology. Results: Patients were 5-18 years at diagnosis; seven (67%) were male. The right and left coronary origins arose from the right sinus of Valsalva as a common origin (N=9) or as a single coronary artery (N=6). Thirteen had an anomalous intraseptal left main coronary; two had anomalous left anterior descending with retroaortic circumflex coronary artery. Anomalous coronary ostia were round without evidence of stenosis on all studies (Figure). Echocardiography identified the anomalous vessel but was neither able to describe the intraseptal ALCA course nor directly visualize or confirm a normal ostium in any patient. Conclusions: Using cardiac magnetic resonance or computed tomography imaging, we demonstrate the anomalous coronary course and confirm round coronary ostia without ostial stenosis in our pediatric cohort with intraseptal ALCA. These data provide the basis for understanding the benign clinical course of intraseptal ALCA, differentiating it from the potentially lethal interarterial, intramural ALCA, and avoiding unnecessary surgical exploration.

Abstract 18309: Outcomes of Single Versus Kissing Stenting Technique in Lateralized Complex Aortoiliac Bifurcation Lesion

Backgrounds: Kissing stenting technique has been frequently performed even in the cases of unilateral aortoiliac diseases in order to protect contralateral common iliac artery (CIA) with intermediate plaque burden. However, kissing stenting is associated with loss of access from contralateral side for future revascularization. We compared the outcomes of single versus kissing stenting technique in lateralized complex aortoiliac occlusive disease. Methods: From Jan. 2006 to Dec. 2012, we retrospectively enrolled 86 consecutive patients (73 males, 67±9 years) treated with a single stenting technique and 33 patients (29 males, 68±8 years) treated with a kissing stenting technique for lateralized complex aortoiliac bifurcation lesions. A lateralized complex aortoiliac bifurcation lesion was defined as a significant unilateral CIA ostial stenosis (&gt;70%) combined with an intermediate (30~50%) stenosis of contralateral CIA. Results: Single stenting and kissing stenting was successfully performed in all patients without procedure-related major complications. However, in the single stenting group, bailout stenting in contralateral CIA was required in two (2.3%) cases due to unfavorable plaque shift. Median follow up duration of the single and the kissing stenting group was 24 (3~88) and 14 (3~82) months, respectively. The primary patency of the ipsilateral CIA in the single stenting group was 93.9% comparable with 94.9% in the kissing stent group (OR 0.823, 95% CI 0.157-4.298). Target lesion revascularization occurred in 5 (6%) cases of the single stenting group and in 2 (6.1%) cases of the kissing stenting group. Progression of the contralateral un-stented CIA requiring additional revascularization was observed in only 2 (2.4%) cases of the single stenting group during follow up. Conclusions: Single stenting technique in lateralized complex aortoiliac bifurcation lesion was relatively safe and showed comparable outcomes as the kissing stenting technique.

Functional and morphological assessment of side branch after left main coronary artery bifurcation stenting with cross‐over technique

In left main coronary artery (LMCA) bifurcation lesions, hemodynamic and geometrical change in left circumflex artery (LCX) ostium after main branch (MB) stenting has not been known. This study evaluated how accurately intravascular ultrasound (IVUS) predicts the functional compromise of the sidebranch. A single-stent cross-over technique was used to treat LMCA bifurcation lesions in 43 patients with LCX ostial diameter stenosis (DS) of <50%. The fractional flow reserve (FFR) in the LCX was measured after MB stenting, MB and sidebranch pullback IVUS was performed prestenting and poststenting. After MB stenting, angiographic DS >50% at the LCX ostium was observed in 18 (42%) patients, while only 3 (7%) showed FFR <0.80. A pre-procedural minimal lumen area (MLA) of <3.7 mm(2) within the LCX ostium was predictive of a poststenting FFR <0.80, with a sensitivity of 100%, specificity of 71%, a positive predictive value (PPV) of 16%, and a negative predictive value (NPV) of 100% (area under curve 0.80, P < 0.001). Moreover, pre-procedural plaque burden of >56% at the LCX ostium predicted FFR <0.80, with a sensitivity of 100%, specificity of 65%, a PPV of 14%, and a NPV of 100% (area under curve 0.80, P < 0.001). A poststenting LCX ostial DS >57% predicted FFR <0.80 with a sensitivity of 100%, specificity of 88%, a PPV of 38% and a NPV of 100% (area under curve 0.962, P < 0.001). However, the poststenting MLA within the LCX ostium showed no significant correlation with FFR (r = 0.197, P = 0.391). In LMCA bifurcation lesions with mild LCX ostial disease, the use of single-stent technique rarely resulted in the functional LCX compromise. Because the functional LCX stenosis is poorly predicted by a small MLA, sidebranch treatment should be based on the poststenting FFR.

When stenting in renal artery stenosis? Update on pathophysiology of ischemic nephropathy and management strategies

In recent years, decisions taken on the optimal management of patients with renal artery stenosis have triggered off controversy and debate among clinicians dealing with renovascular disease. The main reason underlying this ongoing controversy may be the heterogeneity of the clinical entities that are normally associated with the umbrella definition of renal artery stenosis . Indeed a causal link between the stenosis and its clinical consequences ( i.e. hypertension, renal failure) can often demonstrated in some entities, such as fibromuscular dysplasia, truncal stenosis or arterial stenosis in the transplanted kidney, which can be defined as pure renal artery stenosis. On the contrary, the entity generally called ostial stenosis is a disease of the abdominal aorta where it encroaches the ostium of the renal artery at the end of a long process involving the entire vascular tree. Patients affected by ostial stenosis also suffer from generalized atherosclerosis, and kidney damage is often caused by the atherosclerotic environment with the stenosis acting as an innocent bystander. This may account for the low rate of renal function recovery in subjects with ostial stenosis. In our view, keeping the different entities separate along with a careful understanding of the mechanisms underpinning renal damage, particularly the intrarenal activation of the renin angiotensin system which in turn induces renal inflammation and oxidative stress, may enable clinicians to make the right decisions in regard to revascularization.

Takayasu Arteritis: Assessment of Coronary Arterial Abnormalities with 128-Section Dual-Source CT Angiography of the Coronary Arteries and Aorta

Purpose To evaluate coronary arterial lesions and to assess their correlation with clinical findings in patients with Takayasu arteritis (TA) by using coronary computed tomographic (CT) angiography. Materials and Methods This retrospective study was approved by the hospital internal review board, and informed consent was waived. A total of 111 consecutive patients with TA (97 female, 14 male; mean age, 44 years ± 13.8 [standard deviation]; age range, 14–74 years) underwent CT angiography of the coronary arteries and aorta with 128-section dual-source CT. CT angiographic, clinical, and laboratory findings of each patient were retrospectively reviewed. Statistical differences between coronary CT angiographic findings and clinical parameters were examined with univariate analysis. Results Of 111 patients, 32 (28.8%) had cardiac symptoms and the remaining 79 (71.2%) had no cardiac symptoms. Fifty-nine patients (53.2%) had coronary arterial lesions at coronary CT angiography. Three main radiologic features were detected: coronary ostial stenosis (n = 31, 28.0%), nonostial coronary arterial stenosis (n = 41, 36.9%), and coronary aneurysm (n = 9, 8.1%). Coronary artery ostial or luminal stenosis of 50% or more or coronary aneurysms were observed in 26 (23.4%) patients with TA. Patients with coronary arterial abnormalities at coronary CT angiography had higher incidences of hypertension (P = .02), were older at the time of CT (P = .01), and had longer duration of TA (P = .02) than those without coronary artery abnormalities. The presence of cardiac symptoms, disease activity, and other comorbidities was not associated with differences in coronary artery involvement. Conclusion In patients with TA, there is a high prevalence of coronary arterial abnormalities at coronary CT angiography, regardless of disease activity or symptoms. Thus, coronary CT angiography may add information on coronary artery lesions in patients with TA. © RSNA, 2013

Takayasu Arteritis: Assessment of Coronary Arterial Abnormalities with 128-Section Dual-Source CT Angiography of the Coronary Arteries and Aorta

To evaluate coronary arterial lesions and to assess their correlation with clinical findings in patients with Takayasu arteritis (TA) by using coronary computed tomographic (CT) angiography. This retrospective study was approved by the hospital internal review board, and informed consent was waived. A total of 111 consecutive patients with TA (97 female, 14 male; mean age, 44 years ± 13.8 [standard deviation]; age range, 14-74 years) underwent CT angiography of the coronary arteries and aorta with 128-section dual-source CT. CT angiographic, clinical, and laboratory findings of each patient were retrospectively reviewed. Statistical differences between coronary CT angiographic findings and clinical parameters were examined with univariate analysis. Of 111 patients, 32 (28.8%) had cardiac symptoms and the remaining 79 (71.2%) had no cardiac symptoms. Fifty-nine patients (53.2%) had coronary arterial lesions at coronary CT angiography. Three main radiologic features were detected: coronary ostial stenosis (n = 31, 28.0%), nonostial coronary arterial stenosis (n = 41, 36.9%), and coronary aneurysm (n = 9, 8.1%). Coronary artery ostial or luminal stenosis of 50% or more or coronary aneurysms were observed in 26 (23.4%) patients with TA. Patients with coronary arterial abnormalities at coronary CT angiography had higher incidences of hypertension (P = .02), were older at the time of CT (P = .01), and had longer duration of TA (P = .02) than those without coronary artery abnormalities. The presence of cardiac symptoms, disease activity, and other comorbidities was not associated with differences in coronary artery involvement. In patients with TA, there is a high prevalence of coronary arterial abnormalities at coronary CT angiography, regardless of disease activity or symptoms. Thus, coronary CT angiography may add information on coronary artery lesions in patients with TA.

Drug‐eluting stents for ostial coronary stenoses: Perspectives on the horizon

Catheterization and Cardiovascular InterventionsVolume 82, Issue 5 p. 735-736 Coronary Artery Disease Drug-eluting stents for ostial coronary stenoses: Perspectives on the horizon Massoud A. Leesar MD, FSCAI, Corresponding Author Massoud A. Leesar MD, FSCAI Professor of Medicine, Section Head, Interventional Cardiology, Baker-Dean Endowed Professor in Interventional Cardiology, University of Alabama, Birmingham, AlabamaCorrespondence to: Massoud A. Leesar, md; Professor of Medicine, Section Head, Interventional Cardiology, Baker-Dean Endowed Professor in Interventional Cardiology, University of Alabama, Birmingham, AL. E-mail: mleesar@uab.eduSearch for more papers by this author Massoud A. Leesar MD, FSCAI, Corresponding Author Massoud A. Leesar MD, FSCAI Professor of Medicine, Section Head, Interventional Cardiology, Baker-Dean Endowed Professor in Interventional Cardiology, University of Alabama, Birmingham, AlabamaCorrespondence to: Massoud A. Leesar, md; Professor of Medicine, Section Head, Interventional Cardiology, Baker-Dean Endowed Professor in Interventional Cardiology, University of Alabama, Birmingham, AL. E-mail: mleesar@uab.eduSearch for more papers by this author First published: 26 October 2013 https://doi.org/10.1002/ccd.25192 Conflict of interest: Nothing to report. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume82, Issue51 November 2013Pages 735-736 SCAI Member Sign in RelatedInformation

Stenting of symptomatic vertebral artery ostium stenosis with self-expanding stents

Symptomatic vertebral arterial stenosis carries a stroke risk of 30% at 5years. The efficacy of stenting with balloon-expandable stents remains questionable due to a high long-term restenosis rate. This study aimed to investigate the feasibility and efficacy of using self-expanding stents to treat symptomatic vertebral artery ostium (VAO) stenosis in selected patients. Clinical and angiographic results were retrospectively reviewed in patients with symptomatic VAO stenosis who underwent stenting with self-expanding stents between June 2008 and December 2011. In total, 32 patients were included. Self-expanding stents (25 tapered and seven non-tapered) were deployed with a modified technique of deploying the stents from the V1 segment to the proximal subclavian artery. The mean degree of stenosis before and after stenting declined from 76.4% to 11.4%. No peri-procedural complications occurred. During the mean clinical follow-up of 18.3months, no vertebrobasilar stroke, transient ischemic attack or death occurred. During the mean angiographic follow-up of 12.5months, asymptomatic restenosis occurred in one (3.1%) patient 6months after the procedure. No stent fracture occurred. The involved subclavian artery was patent and no clinically apparent events occurred in the dependent upper extremity. Stenting with self-expanding stents for symptomatic VAO stenosis is technically feasible and safe, with reduced restenosis and stent fracture rates in selected patients. Long-term investigations are warranted to validate its performance.

Comparison of intra-aortic computed tomography angiography to conventional angiography in the presurgical visualization of the Adamkiewicz artery: first results in patients with thoracoabdominal aortic aneurysms

The aim of this study was to compare the sensitivity of intra-aortic computed tomography angiography (IA-CTA) to that of regular spinal digital subtraction angiography for the presurgical location of the Adamkiewicz artery (AKA). Thirty patients (21 males, 9 females; mean age 64 years) had an IA-CTA for the location of the AKA before surgery of aneurysm (n = 24) or dissection (n = 6) of the thoracoabdominal aorta. After femoral artery puncture, a pigtail catheter was positioned at the origin of the descending aorta. CT acquisition was performed with an intra-aortic iodinated contrast media injection (15 mL/s, 120 mL). The visualization of the AKA and the location of the feeder(s) to the AKA were independently evaluated by two observers. Interrater agreement was calculated using a kappa test. Spinal angiogram by selective catheterization was systematically performed to confirm the results of the IA-CTA. The AKA was visualized by the IA-CTA in 27/30 cases (90 %); in 26/31 (84 %) cases, the continuity with the aorta was satisfactorily seen. Interrater agreement was good for the visualization of the AKA and its feeder(s): 0.625 and 0.87, respectively. In 75 % of the cases for which the AKA was visualized, the selective catheterization confirmed the results of the IA-CTA. In the remaining 25 % of the cases, the selective catheterization could not be performed due to marked vessels' tortuosity or ostium stenosis. IA-CTA is a feasible technique in a daily practice that presents a good sensitivity for the location of the AKA.

TCT-451 Impact of Stent Recoil and Fracture in RCA Ostium Restenosis Following Stainless Steel or Cobalt Chromium Drug-Eluting Stent Implantation: A Serial Angiographic and IVUS Study

Background: PCI procedure of RCA ostium stenosis is still a challenging issue due to high stent restenosis rate, possibly due to mechanical stress. However, mechanisms of restenosis following cobalt-chromium everolimus-eluting stent (EES) or stainless steel biolimus-eluting stent (BES) implantation have not been well clarified. Methods: Sixty-fourRCAostium restenosis cases after 2ndgenerationDES (40EESand 24 BES) were retrospectively analyzed. Serial (post initial stent and follow-up as revascularization) angiographic and IVUS evaluation were performed. In quantitative angiographic analysis (QCA), incidence of stent fracture (defined as complete separation of the stent segments and/or the absence of a stent strut on magnified fluoroscopic image), and partial (only one of the inner or outer struts was separated) and complete (both the inner and outer struts were disconnected) fracture type were evaluated. In IVUS, serial changes ofminimum lumen and stent area (SA), and degree of stent recoil atminimum lumen area, defined as (follow-up SA baseline SA / baseline SA*100), were also measured. Results: Average follow-up phase was 14 10-months. Angiographic and IVUS morphometric parameters were similar in both groups at baseline. Significant lumen narrowingwas observed from baseline to follow-up in both groups (10.2 4.6 to 2.5 2.0, 10.7 5.4 to 2.4 2.3 mm2 in minimum lumen area, EES vs. BES, p<0.01 from baseline to follow-up for all). Stent fracturewasmore frequently observed inBES than EES (85 vs. 8%, p<0.01). In addition, complete fracturewas highly observed inBES (29%) compared to EES (2%, p<0.05). In contrast, significant stent recoil was observed in EES only (11.8 5.7 to 9.0 5.4 mm2, p<0.01 from baseline to follow-up for EES, 11.6 4.8 to 11.3 3.4 mm2, p1⁄4ns for BES, and degree of stent recoil was significantly larger in EES than BES (23.8 vs. 2.6%, p<0.05). Additionally, there was only 1 BES and no EES case that both stent fracture and significant recoil, resulting in stent restenosis, was observed. Conclusions: Stent fracture appears to be the major cause of RCA ostium restenosis after stainless steel BES, whereas stent recoil seem to be associated with restenosis after cobalt-chromium EES.

Surgical repair for giant ascending aortic aneurysm to superior vena cava fistula with positive syphilitic test

Syphilitic aortitis is usually associated with thoracic aortic saccular aneurysm, aortic regurgitation and coronary ostial stenosis. However, syphilitic aneurysms have rarely been reported today. Here, we report a patient with ascending aortic aneurysm with aorta-superior vena cava (SVC) fistula with positive syphilitic test. A 52-year-old man was admitted to our institution with a giant ascending aortic aneurysm complicated with SVC syndrome. Computed tomography revealed a giant ascending aneurysm 79 mm in diameter. The result of serodiagnostic tests for syphilis had not been judged yet preoperatively. Total arch replacement concomitant with elephant trunk was performed. Intraoperatively, we detected the ascending aorta to SVC fistula. Postoperatively, we suspected the syphilitic aneurysm strongly, because preoperative serodiagnostic test was concluded to be positive. However, histological examination did not show typical syphilitic features. The patient remains asymptomatic 1 year later. Although extremely rarely today, syphilitic aneurysm should be still considered in the differential diagnosis of ascending aortic aneurysm.

Coronary angioplasty of left main coronary artery in patient with Takayasu's arteritis

Dear Editor We are here with presenting our recent experience with left main coronary angioplasty in a young girl with Takayasu' arteritis. A 15-year-old female, without exposure to traditional risk factors for coronary artery disease, was hospitalized with recurrent chest pain at rest for the previous seven days. There was associated generalized weakness and malaise for the last three months. Physical examination was unremarkable except absence of right brachial and radial pulses. Electrocardiogram (ECG) showed 3 mm ST segment depression in the anterior precordial and inferior leads. The TropT test was positive and CPK-MB was raised. Routine biochemical and hematological investigations were normal except presence of mild normochromic normocytic anemia and raised ESR (40 mm in first hour). Serologic tests were negative for both C-reactive protein and syphilis. Indices of collagen disorders were negative. CT angiography revealed normal arch vessels, renal arteries and aorto-iiliac systems, but right axillary and brachial vessels showed diffuse narrowing. Coronary angiography revealed 90% stenosis of ostium of left main coronary artery (LMCA) and normal left anterior descending (LAD), left circumflex (LCx) and right coronary (RCA) arteries (Fig. 1). After discussing the option of CABG and coronary angioplasty (PTCA), the patient refused surgery and opted for PTCA. She underwent PTCA and stenting of LMCA (Fig. 2) with 3.5 × 12 Zotarolimus eluting stent (Endeavor® Drug-Eluting Coronary Stent, Medtronic). The procedure was uneventful and she was advised dual antiplatelet therapy (DAPT) with aspirin and clopidogrel along with oral corticosteroid. After one year of intervention she underwent CT-coronary angiography which showed patent stent in LMCA. The patient is asymptomatic in four year follow-up. Fig. 1 LAO and RAO caudal views showing stenosis of left main coronary ostium (selective engagement not done to avoid pressure damping). Fig. 2 Coronary stent placement (A) and final result (B). Takayasu's arteritis (TA), which predominantly involves the aorta and its major branches, can affect coronary artery in 9–12% of cases.1 Although rare, isolated coronary arterial involvement with normal aorta and its major branches has been reported.1 Axillary artery involvement, as present in our case, is uncommon but reported.2 Besides atherosclerosis, the commonest cause, isolated coronary ostial stenoses have also been reported due to congenital anomaly and also due to syphilis, Takayasu disease and radiation exposure.1 In our case, the patient, without any atherosclerotic risk factors, presented with both coronary ostial and axillary artery involvement. The indices of collagen vascular diseases and syphilis were negative. So TA was considered as the most probable etiology. Although CABG has been considered the “gold standard” for unprotected left main atherosclerotic disease revascularization, results of CABG have not been satisfactory in patients with TA. Though internal mammary artery (IMA) graft has excellent patency rate in atherosclerotic CAD, there is substantial risk of progressive subclavian artery stenosis in patients with TA.3,4 Besides a low patency rate, SVG graft has the added disadvantage of occlusion and aneurysm formation at the proximal anastomotic site since arterial inflammation is persistent in over 40% of cases even after treatment.5 Thickened aortic wall makes it difficult to create aortotomy incision.5 More recently PCI has emerged as a possible alternative mode of revascularization in carefully selected patients especially in those with left main ostium or trunk disease. It has been shown that the stenotic lesions of aorta and its major branches can be satisfactorily treated with angioplasty and stenting.6 There are few reports of PTCA with or without stenting in symptomatic coronary artery disease with TA (Table 1). However, data regarding long term results are limited because of paucity of cases. However, drug eluting stent (DES) can reduce the restenosis by inhibiting the proliferation of inflammatory and smooth muscle cells. Table 1 Coronary angioplasty data in patients with Takayasu's arteritis (TA). As in our case, isolated coronary ostial and axillary artery involvement is a rare presenting feature of TA.1,2 Acute success along with evident long term patency of stent in our case suggests that angioplasty and DES implantation will be an effective alternative method to CABG for coronary artery stenosis in Takayasu's arteritis.

Is Percutaneous Transluminal Coronary Angioplasty the Treatment of Choice for Iatrogenic Stenosis of the Left Main Coronary Artery following Aortic Valve Replacement?

Iatrogenic coronary ostial stenosis after aortic valve replacement (AVR) is a rare but life-threatening complication. This condition has been treated with urgent coronary bypass surgery, but such surgery is associated with high morbidity and mortality. The clinical symptoms are usually severe and may appear from 1 to 6 months postoperatively. Pains in the chest that are typical for coronary artery disease but occur in patients after the AVR operation suggest a significant threat. We report a case of left main coronary artery ostial stenosis in a patient who had normal preoperative coronary angiography results. The patient was successfully treated with implantation of a drug-eluting stent.

Vertebral artery in-stent restenosis incidence, risk factors and treatment methods in the prospective randomized STOVAST (STenting for Ostial Vertebral Artery STenosis) trial population

Vertebral artery in-stent restenosis incidence, risk factors and treatment methods in the prospective randomized STOVAST (STenting for Ostial Vertebral Artery STenosis) trial population

Death from pulmonary artery erosion complicating implantation of percutaneous left atrial appendage occlusion device

A 72-year-old woman with paroxysmal atrial fibrillation (CHA2DS2-VASc score = 6) underwent percutaneous left atrial appendage (LAA) occlusion. Comorbidity included diabetes mellitus, hypertension, coronary artery disease, and mild left ventricular dysfunction. A permanent pacemaker had been implanted previously for tachy-brady syndrome. A drug-eluting stent had been implanted to treat an ostial left circumflex coronary artery stenosis. The proximal end of the stent protruded into the distal left main coronary artery, and this was considered an indication for long-term dual antiplatelet agents. Percutaneous LAA occlusion was requested by the treating physician to avoid the need for warfarin and dual antiplatelet agents.