Percutaneous Transluminal Coronary Angioplasty Balloon Research Articles

Usefulness of percutaneous transluminal coronary balloon angioplasty for coronary artery stenosis after surgery for CHD.

Coronary artery involvements occur rarely both during cardiac repair and in the late period after surgery, and it may result in myocardial ischaemia and infarction. We present six cases who underwent percutaneous transluminal coronary balloon angioplasty for coronary artery stenosis in the late period after surgery. The patients included four boys and two girls. Post-operative states involving anomalous origin of the left coronary artery from the pulmonary artery and d-transposition of the great arteries were observed in two patients each. Two patients with univentricular heart had coronary artery injuries during surgery. The age at the angioplasty ranged from 1 month to 14 years, with a median of 3 years. The interval from the operation to angioplasty ranged from 37 days to 14 years (median 8 months). The interval from the angioplasty to follow-up coronary angiography ranged from 2 months to 14 years (median 11 months). The follow-up period ranged from 2 months to 20 years (median 8 years). One patient underwent a stent implantation because of post-procedure recoil. Coronary artery stenosis improved immediately after procedure in the six patients without complication, and restenosis occurred post-procedure in one patient. Five patients had no cardiac events. Although the angioplasty's initial effect may not be dramatic, it can improve late after the procedure. It was considered that the optimal balloon-reference vessel ratio to obtain a minimal effective lumen diameter was about 1.0. Angioplasty post-surgery for CHD in children was feasible and without complications.

Development of a patient-specific model of the human coronary system for percutaneous transluminal coronary angioplasty balloon catheter training and testing

BackgroundTo treat stenosed coronary arteries, percutaneous transluminal coronary angioplasty (PTCA) balloon catheters must combine pushability, trackability, crossability, and rewrap behavior. The existing anatomic track model (ASTM F2394) for catheter testing lacks 3D morphology, vessel tortuosity, and compliance, making evaluating performance characteristics difficult. This study aimed to develop a three-dimensional patient-specific phantom (3DPSP) for device testing and safe training for interventional cardiologists.MethodsA range of silicone materials with different shore hardnesses (00–30–45 A) and wall thicknesses (0.5 mm, 1 mm, 2 mm) were tested to determine compliance for creating coronary vessel phantoms. Compliance was assessed using optical coherence tomography (OCT) and compared to values in the literature. Stenosis was induced using multilayer casting and brushing methods, with gypsum added for calcification. The radial tensile properties of the samples were investigated, and the relationship between Young’s modulus and compliance was determined. Various methods have been introduced to approximate the friction between silicone and real coronary vessel walls. Computerized tomography (CT) scans were used to obtain patient-specific anatomy from the femoral artery to the coronary arteries. Artery lumens were segmented from the CT scans to create dissolvable 3D-printed core models.ResultsA 15A shore hardness silicone yielded an experimental compliance of 12.3–22.4 mm2mmHg·103\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\frac{m{m}^{2}}{mmHg}\\cdot {10}^{3}$$\\end{document} for stenosed tubes and 14.7–57.9 mm2mmHg·103\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\frac{m{m}^{2}}{mmHg}\\cdot {10}^{3}$$\\end{document} for uniform tubes, aligning closely with the literature data (6.28–40.88 mm2mmHg·103\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\frac{m{m}^{2}}{mmHg}\\cdot {10}^{3}$$\\end{document}). The Young’s modulus ranged from 43.2 to 75.5 kPa and 56.6–67.9 kPa for the uniform and calcified materials, respectively. The dependency of the compliance on the wall thickness, Young’s modulus, and inner diameter could be shown. Introducing a lubricant reduced the silicone friction coefficient from 0.52 to 0.13. The 3DPSP was successfully fabricated, and comparative analyses were conducted among eight commercially available catheters.ConclusionThis study presents a novel method for crafting 3DPSPs with realistic mechanical and frictional properties. The proposed approach enables the creation of comprehensive and anatomically precise setups spanning the right femoral artery to the coronary arteries, highlighting the importance of such realistic environments for advancing medical device development and fostering safe training conditions.

Use of Trapping Techniques and a GooseNeck Snare to Retrieve a Fractured Balloon Catheter.

Percutaneous transluminal coronary angioplasty balloon fracture, retention, and embolization are rare complications of percutaneous coronary intervention. The incidence has historically been estimated at <0.8%, which is likely an underestimate given the increasing quantity and complexity of percutaneous procedures. We demonstrate how to avoid emergency surgery by using basic balloon trapping techniques and a snare in the more distal arterial bed.

Design of percutaneous transluminal coronary angioplasty balloon catheters

BackgroundEight commercially available percutaneous transluminal coronary angioplasty (PTCA), including semi-compliant and non-compliant balloons, have been assessed in detail on their tip, balloon, shaft, RX-Port, and hypotube design. Important performance characteristics such as tip deformation, balloon elongation, and deflation rate have been quantified.MethodsFive catheters of each model were evaluated during various tests. The robustness of the tips was evaluated through compression, measuring any occurrence of damage. The longitudinal growth of the balloons was recorded during inflation up to Rated Burst Pressure (RBP). The forces required to move the catheter forward and retract it into the guide catheter were measured in a simulated use test setup. The deflation behavior was studied by measuring extracted contrast media over time. Furthermore, balloon compliance and catheter dimensions were investigated.ResultsThe outer dimensions of the catheter were found to be smallest at the hypotube (0.59–0.69 mm) and highest at the balloon, respectively, the crossing profile (0.9–1.2 mm). The tip diameter increased after compression by 1.7–22%. Cross-sections of the folded balloons revealed a tri- and two-fold, respectively. The measured balloon elongation ranged from 0.6 to 2.0 mm. After the inflation of the balloon, an increase in friction between the guide wire and the catheter was observed on four catheters. A maximum increase of 0.12 N to 1.07 N was found. Cross-sections of the RX-Port revealed a semicircular-shaped inflation lumen and a circular guide wire lumen. The measured deflation rate ranged from 0.004 to 0.013 µL/s, resulting in an estimated balloon deflation time of 10.2–28.1 s.ConclusionThis study provides valuable insights into the design characteristics of RX PTCA balloon catheters, which can contribute to facilitating the development of improved catheter designs and enhancing clinical outcomes. Distinctions between SC and NC catheters, such as balloon performance and dimensions, are evident. It is important to note that no single catheter excels in all aspects, as each possesses unique strengths. Therefore, it is essential to consider individual intervention requirements when selecting a catheter.The research also identifies specific catheter weaknesses, such as reduced wall thickness, fringes at the tip, and reduced performance characteristics.

Numerical Methodology to Evaluate Trackability and Pushability of PTCA Balloon Catheter.

During percutaneous coronary intervention (PCI), the ability to navigate a catheter without causing injury to the vessel and damage to the device is crucial outcome of the procedure. This study aimed to develop a numerical model to analyse the percutaneous transluminal coronary angioplasty (PTCA) catheter navigation in coronary vessels. Trackability and pushability are two major parameters used to characterize the navigation of PTCA balloon catheters, and they are influenced by vessel tortuosity, contact interactions and catheter design. In the current study, finite element analysis model is presented to evaluate trackability and pushability considering two different vessel geometries. Impact of contact interactions among catheter, guidewire, and vessel were studied to validate the numerical model with in vitro test data. Further, a parametric study was conducted to understand the influence of distal shaft, and proximal shaft outer diameter. Obtained results suggest that contact interaction and co-efficient of friction between guidewire and catheter are critical parameters to obtain numerical results comparable to experimental data. Results from the parametric study predicted strong positive correlation of distal shaft diameter on pushability, and weak correlation on trackability force. Furthermore, parametric variation in proximal shaft diameter has strong positive correlation on trackability force and strong negative correlation on pushability. Numerical methodology presented in this study is a preliminary attempt to simulate the behavior of PTCA balloon catheter navigation. This methodology will be helpful in the design and optimization of PTCA balloon catheter and similar devices with improved deliverability.

Endo- and epicardial mapping of spontaneous ventricular fibrillation during acute myocardial infarction in a porcine model

Abstract Introduction Ventricular fibrillation (VF) during the first minutes of acute myocardial infarction (AMI) is among the most frequent causes of sudden cardiac death. Albeit mechanisms for arrhythmogenesis during ischemia are well understood on a cellular level, little is known in an in-vivo setting. Aim Aim of this study was the development and characterization of a porcine model of AMI and spontaneous VF with continuous electrical mapping using a non-contact mapping system (EnSite Array) in the left ventricle (LV) and an electrode sock covering the whole heart. Activation-recovery intervals (ARI), beat-to-beat variation in repolarization (BVR), and ectopic activation were measured. Methods Nineteen Danish Landrace pigs (56±4 kg, heart weight 251±20 g) were anaesthetized, equipped with electrophysiological (EP) catheters in the coronary sinus, right and LV as well as a multi electrode array (St. Jude, EnSite Array) catheter in the LV. Thoracotomy was performed and the sock electrode was placed on the pericardium covering the anterior and the posterior surface of the heart. Finally, the mid-left anterior descendent artery was occluded with a percutaneous transluminal coronary angioplasty balloon to induce AMI and kept in place for 45 minutes followed by 20 minutes of reperfusion. Data from both systems were analyzed offline using a custom-made software. Results All pigs had stable hemodynamic parameters during the procedure. Spontaneous VF occurred in 8/19 pigs during the occlusion period. Epi- and endocardial mapping showed similar shortening of ARI in the infarcted area (Figure 1A). AMI shortened ARI in the ischemic area to a greater extend in pigs that developed VF (Figure 1B) and caused beat-to-beat variation in repolarization (BVR) in later phases (Figure 1C). Ectopic beats proceeding spontaneous VF varied in activation site and subsequent repolarization (Figure 1D, left). Multiple short-coupled ectopic beats destabilized the electrical substrate further and led to progressive ARI shortening (Figure 1D, last 4 beats). Conclusion We present the first whole heart mapping experiments of spontaneous VF during AMI with endo- and epicardial mapping. Pigs with VF had shorter ARI, greater dispersion but similar BVR during AMI compared to those without VF. These findings provide a deeper understanding of arrhythmogenesis during AMI and can help to develop new antiarrhythmic drugs or to assess risk factors of VF. Funding Acknowledgement Type of funding sources: None.

Novel dry pericardiocentesis: Transvenous puncture of the right ventricle with the back end of a 0.014-inch PTCA guidewire and a 1.8 Fr microcatheter.

BackgroundDry transthoracic pericardiocentesis is challenging and carries the risk of right ventricle (RV) or coronary artery injury. The RV can usually control bleeding automatically. For example, most perforations of the RV caused by pacemaker leads are treated without open surgery. Thus, we performed a transvenous puncture of the RV for dry pericardiocentesis with the back end of a 0.014-inch percutaneous transluminal coronary angioplasty (PTCA) guidewire and a 1.8 Fr microcatheter.MethodsThe back end of a 0.014-inch PTCA guidewire within a 1.8 Fr microcatheter was used to transvenously punctured through the middle of the acute margin of the RV into the pericardial space in 12 Yorkshire swine and 5 beagles. PTCA balloons of different diameters were used to dilate the puncture holes for 15 min under anticoagulation in all the animals to assess the ability of the RV to control the bleeding. Then, for 3 days, the puncture hole was dilated by a 6 Fr catheter in 9 swine and 5 dogs.ResultsThe puncture was successful in all the animals. After withdrawal of the 2.5-mm balloon or the 6 Fr catheter, none of the animals exhibited pericardial effusion, as observed by echocardiography. There was no sustained ventricular arrhythmia or other complications. All the animals survived.ConclusionTransvenous puncture of the right ventricle with the back end of a 0.014-inch PTCA guidewire and 1.8 Fr microcatheter may be feasible and have a good safety margin.

Paclitaxel Drug-Coated Balloon for the Treatment of De Novo Small-Vessel and Restenotic Coronary Artery Lesions: 12-Month Results of the Prospective, Multicenter, Single-Arm PREVAIL Study.

The PREVAIL study evaluated the safety and effectiveness of a paclitaxel-coated percutaneous transluminal coronary angioplasty balloon catheter for the treatment of coronary de novo and in-stent restenosis (ISR) lesions in patients with symptomatic ischemic heart disease. PREVAIL was a prospective, multicenter, single-arm study that enrolled patients with clinical evidence of ischemia who had coronary lesions (de novo or first ISR) amenable to treatment with a drug-coated balloon (DCB). The study included 50 subjects (53 target lesions) who were treated with a Prevail DCB (Medtronic) during the index procedure and followed for 12 months. Mean lesion length was 14.5 ± 7.6 mm. The primary endpoint was in-stent (in-balloon) late lumen loss (LLL) by quantitative coronary angiography at 6 months post procedure. If the mean in-stent (in-balloon) LLL was less than the maximum acceptance rate of 0.50 mm at 6 months, then the study was considered successful. Mean in-stent (in-balloon) LLL was 0.05 ± 0.44 mm at 6 months post procedure. There were no deaths, myocardial infarctions, or stent (lesion) thrombosis events within 12 months. The incidence of clinically driven target-lesion revascularization was 6.0% at 12 months and clinically driven target-vessel revascularization was 10.0%. Paclitaxel DCB treatment of coronary de novo and first ISR lesions led to low LLL at 6 months and low rates of revascularization and safety events through 12 months.

Temperature-dependent tensile properties of polyamide 12 for the use in percutaneous transluminal coronary angioplasty balloon catheters

BackgroundPercutaneous transluminal coronary angioplasty (PTCA) balloon catheters must withstand high pressures required for the lesion treatment, pushing loads during insertion, and pulling loads during withdrawal. These loads pose a challenge especially for polymeric tubular shafts with small cross sections. In order to enable new design innovations and to better understand the mechanics of current catheter technologies, the tensile properties of polyamide (PA) 12 were investigated. PA 12 dog bone specimens and medical PA 12 tubes were either stored at ambient temperature and humidity or conditioned in water, and subjected to tensile loads at different temperatures. In addition, the effect on the tensile properties of the necking process, a forming process to reduce the wall thickness of the tubes, was determined.ResultsThe tested tubes showed a reduction in both Young’s Modulus (− 41.5%) and yield stress (− 29.2%) compared to standardized specimens. Furthermore, an increase in temperature and water absorption softens the material and reduces the mechanical properties like the Young’s Modulus and the yield stress. It was found that the material strengthens during the necking process. Likely due to the orientation of the polymers chain molecules in load direction (Rösler et al., 2007), the Young’s Modulus of the material could be increased by 43.5%. Furthermore, the absence of a yield point after necking allows for a greater loading capacity of the material without unstable neck growth. Besides the strengthening, the ultimate strain is reduced by 50%. This indicates that the necking process induces plastic deformation.ConclusionThe investigation showed that the environmental conditions like temperature and humidity can influence mechanical properties. It could also be shown that pre-forming processes such as necking can enhance the mechanical properties, such as the Young’s Modulus, while reducing the wall thickness. These findings suggest possible further development of catheters with a small cross section and higher mechanical strength and highlight the importance to account for the targeted operating temperature during the design process.

Long-term results of percutaneous transluminal coronary balloon angioplasty in Kawasaki disease.

We report the long-term results of percutaneous transluminal coronary balloon angioplasty for early appearing localised stenosis of the left anterior descending artery caused by Kawasaki disease in two 2-year-olds. One patient had 50% restenosis and newly appearing aneurysm at 21-year-old, and the other had no restenosis at 16-year-old. They had no symptoms or cardiac events for 20 years. It is useful in the early localised stenosis without aneurysm.

Long-Term Angiographic Results of Recanalization of Small Diameter Coronary Arteries in Patients with Coronary Heart Disease

One of the most serious problems of modern times are cardiovascular diseases, and these are the leading cause of death worldwide. The main contribution to the structure thereof belongs to coronary heart disease (CHD) which has become the greatest threat to the health of the population all over the world.&#x0D; The aim. To study the results of endovascular procedures in revascularization of small diameter coronary arteries.&#x0D; Materials and methods. The study included 417 patients aged 59 to 78 years with a mean diameter of the true in-ternal lumen of the arteries of 2.75±0.016 mm who underwent revascularization of the myocardium through stenting or percutaneous transluminal balloon coronary angioplasty (PTCA).&#x0D; In patients undergoing stenting of coronary artery (N=269), the mean diameter of the true internal lumen of the arteries was 2.68±0.03 mm. In the group of patients who underwent PTCA (N=148), this indicator was found to be 2.61±0.09 mm. The average degree of stenosis was 81.3±4.07%. The length of the artery stenosis was 12.4±0.71 mm.&#x0D; All the patients had the history of Q wave myocardial infarction (MI) more than 3 months ago, which made it possible to diagnose postinfarction cardiosclerosis. Ischemic history of more than 5 years was noted in 46 patients of this group (11.03% of cases), up to one year in 221 patients (70.2% of cases), from 1 to 2 years in 41 patients (9.83% cases), and 3 to 4 years in 38 people (9.11% of cases).&#x0D; Results and discussion. As a result of the studies, it was found that in patients with eccentric type of stenosis who used balloon angioplasty, restenosis in the remote postoperative period was 21% more frequent compared to a similar contingent of patients with implanted stents. In addition, restenosis of the stenosed area of the coronary artery &gt; 1.5 mm in the distant period was 14.9% more common when PTCA was performed. And the frequency of remote restenosis (with complex morphology of initial damage of the arteries) in the stenting group was 14.2% lower than in the group of PTCA. Additionally, in the group of patients who underwent stenting, neoatherosclerosis in the treated segment was found in 92 patients (34.2 %). Patients with PTCA had a less progress of atherosclerosis (44 patients 29.72%)&#x0D; Conclusions. Restenosis in the remote postoperative period was 25.4 % less frequent in patients with eccentric ste-nosis who underwent stenting than in patients with balloon angioplasty. At the same time, restenosis of the stenosed area of CA &gt;15 mm in the distant period was 10.43% more frequent during PTCA. In the coronary angioplasty group, patients with complicated morphology of basal damage of arteries had a 21.67% higher incidence of restenosis than in the coro-nary stenting group. Thus, we plan to carry out further study and analysis of immediate and long-term results of X-ray and endovascular operations in patients with coronary artery disease and small coronary artery diameter.

The periprocedural myocardial infarction and probability of the developing of the contrast-induced acute kidneys injury in clinical practice. Case report

Nowadays, taking into account the number of elderly patients with sеveral associated diseases requiring percutaneous transluminal balloon coronary angioplasty (PTCA), the risk of the development of unwanted complications is also growing. In this article we present the clinical case, where the PTCA had complications with myocardial infarction of the 4a type without contrast-induced acute kidney injury (contrast-induced nephropathy).

The Use of Anterograde Percutaneous Transluminal Coronary Angioplasty Balloons in Congenital Nasolacrimal Duct Obstruction: A Cost-Effective Alternative to the Traditional Dacryoplasty Balloons.

To assess the efficacy of commonly available coronary angioplasty balloon catheters as a low-cost alternative to the traditional dacryoplasty catheters in select patients of congenital nasolacrimal duct obstruction. A prospective, interventional study was performed between July 2018 and December 2018 in children with congenital nasolacrimal duct obstruction, who underwent balloon dacryoplasty using the coronary angioplasty balloon catheters (2.75 × 10 mm, SPALNO, Cardiomac, Haryana, India). The inclusion criteria were children ≥4 years of age, and/or previously failed probing and/or previous failed intubation. Parameters documented were demographics, techniques, costs, complications, and postoperative outcomes. Twenty-three eyes of 22 children underwent balloon dacryoplasty using coronary angioplasty balloon catheters. The mean age of the patients was 4.33 years (range 1.5-10 years). The procedure was performed in 8 patients (8 eyes, 35%) as the primary procedure. The remaining 14 patients (15 eyes, 65%) had a history of probing, of which 4 eyes had it twice earlier. All eyes underwent balloon dacryoplasty as per standard protocols. The insertion profile and trackability of the coronary catheters were good. At a mean follow up of 6.17 months (range 1.5-9 months), anatomical and functional success was obtained in 87% cases (n = 20/23). No lacrimal passage trauma or injuries were noted during the procedure. The cost of coronary balloon catheter was approximately $60. The present pilot study has shown that outcomes of balloon dacryoplasty in patients with congenital nasolacrimal duct obstruction with coronary balloon catheters is comparable to that of traditional balloons and offers significant economic advantage for developing nations.

Allergic Acute Coronary Artery Stent Thrombosis After the Administration of Sugammadex in a Patient Undergoing General Anesthesia: A Case Report

In addition to cutaneous, gastrointestinal, hemodynamic, and respiratory symptoms, allergic reactions can induce an acute coronary syndrome in normal or atheromatous coronary arteries and can cause coronary stent thrombosis. Here, we report a case of coronary stent thrombosis due to allergic acute coronary syndrome during anaphylaxis induced by sugammadex in a female patient undergoing general anesthesia. She was emergently treated with percutaneous transluminal coronary balloon angioplasty with catecholamine, vasodilator, and intraaortic balloon support. Knowledge of perioperative allergy-triggered acute coronary syndrome is crucial for prompt and appropriate treatment.

Assessing the feasibility of GIS multimethod approach to ascertain territorial accessibility to hemodynamics rooms in Spain mainland

Between 1981 and 2001 health competencies in Spain passed from the Central Government to the Autonomous Communities (AC). Those issues conducted to a not heterogeneous health services in continental Spain. This is undoubtedly aggravated high-tech health equipment provision, as in the case of hemodynamics rooms that perform primary balloon percutaneous transluminal coronary angioplasty (PTCA), used to deal with acute myocardial infarction. In this regard, the present study aims to assess the territorial accessibility to these rooms of the potential population that may suffer an acute myocardial infarction, in each Spanish municipality, on continental Spain.The study has used a large amount of methodologies and research tools, related to accessibility based on Geographic information Systems (GIS). Among the used methods, should be highlighted the spatial interaction model. This particular method has been based on the three-step floating catchment area (method-3SFCA). Nevertheless, the authors have developed a specific methodology, increasing the mentioned method, with the goal to assess, in a more accurate way, the spatial distribution of the hemodynamics rooms, and the impacts this distribution might have on people's life quality.The results obtained by means of thematic maps allowed us to identify the municipalities with greater and less health equipment provision, the differences in health coverage between Autonomous Communities, and the municipalities where this health coverage is going to increase, if patients could be moved to other Autonomous Communities. The developed analysis enabled us to present a detailed view of the problem identifying the regions where it must be improved in order to achieve a more equitable access to the high-tech health (HTH) services, presenting a framework which indicator how these dispersions may be overcome.

Nationwide survey of coronary aneurysms with diameter >6 mm in Kawasaki disease in Korea.

We investigated the course of coronary aneurysm with diameter > 6 mm in Kawasaki disease (KD), as well as related therapeutic trends and prognosis in Korea. A nationwide questionnaire survey was carried out in 77 hospitals, to investigate, retrospectively, patients with KD who had coronary aneurysms with a diameter > 6 mm between 1990 and 2011. The median age of onset was 3 years (range, 2 months-16 years) in a total of 239 patients. During the acute stage of KD, most patients received i.v. immunoglobulins and aspirin. In addition, 27 patients received steroid therapy. In the current study, the mean coronary aneurysm size was 8.7 ± 3.2 mm (range, 6-21 mm). Twenty-two patients underwent interventional catheterization. Procedures included percutaneous transluminal coronary balloon angioplasty (n = 10), stent placement (n = 9), and percutaneous transluminal coronary rotational ablation (n = 3). Fourteen patients underwent coronary artery bypass graft surgery. Of the 239 patients who had coronary aneurysms with diameter > 6 mm, 13 (5.4%) presented with findings suggestive of myocardial infarction. Five patients died during the follow-up period. Severe stenosis or occlusion of the coronary artery may occur in some patients who develop coronary aneurysms with diameter > 6 mm; early management such as coronary interventions or surgery should be considered in such cases.

Pseudo-ballooning of Radial Artery-An Artifact.

Transradial approach (TRA) for coronary intervention is rapidly increasing worldwide and therefore novel difficulties and complications are frequently observed. Most of these difficulties and complications can be dealt with new techniques and the procedure can be completed through the same artery and seldom needs change to femoral artery approach [1]. Among the various difficulties encountered through TRA, radial artery spasm either focal or diffuse is common and is observed in 14.7% of the cases [2]. Mostly the spasm is relieved completely by spasmolytic cocktails. Here, we describe a very unusual behavior of the radial artery where diffuse spasm was relieved only in the focal segment in spite of repeated spasmolytic cocktail. A 64-year-old hypertensive female presented with chest pain of 6 hours duration. She had significant past history of ischemic heart disease and underwent percutaneous coronary intervention (PCI) from right radial approach in left anterior descending coronary artery (LAD). A 12-lead electrocardiogram revealed no significant ST-T changes. Transthoracic echocardiography revealed mild left ventricular systolic dysfunction (LVEF ~ 40%). After informed consent, coronary angiography was planned through left radial approach as right radial artery was occluded because of the previous procedure. Left radial artery was punctured successfully but 0.025″ hydrophilic wire as well as floppy-tipped 0.014″ percutaneous transluminal coronary angioplasty (PTCA) wire could not be negotiated. Injection with diluted contrast through the cannula revealed diffuse spasm of the left radial artery [Table/Fig-1]. As a part of our protocol, 200 mcg of nitroglycerine and 5 mg of diltiazem was administered through the cannula but the radial spasm was not relieved, therefore the spasmolytic cocktail was repeated after 3 minutes. Contrast injection after second spasmolytic cocktail showed focal relief of diffuse spasm presenting an interesting image of ‘pseudoballooning’ of radial artery mimicking inflated PTCA balloon catheter [Table/Fig-2]. Despite administration of spasmolytic cocktail for third time, the diffuse spasm was not relieved and the coronary angiography was completed through femoral approach [Video-1]. [Table/Fig-1]: Diluted contrast injection through the intra-arterial cannula showing diffuse spasm of left radial artery [Table/Fig-2]: Repeat contrast injection after spasmolytic cocktail showing focal relief (Arrow) of diffuse spasm mimicking “pseudo-ballooning of radial artery”

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Drug-eluting balloons: where are we and what are the problems?

The starting point of percutaneous transluminal coronary angioplasty was defined by Andreas Gruntzig in 1977 [1]. He developed the novel technique of revascularization and established a new speciality – interventional cardiology. Since that time, interventionalists have been confronted with the problems of vessel recoil during the procedure and restenosis within the first 6 months of balloon angioplasty. In spite of progress in some indications, in others these challenges have lost nothing of their significance, motivating investigators to pursue their research efforts with a view to finding new strategies for overcoming these difficulties. Stents proved to be a significant advance in reducing the frequency of restenosis by eliminating elastic recoil and negative remodeling at the treatment site [2]. However, neointimal proliferation is not prevented by stenting, and thus in-stent restenosis became a ‘new’ disease, especially in some patient populations such as diabetics or in certain lesions such as bifurcation, long lesions, lesions in small vessels, total occlusions and diffuse disease [3]. The systemic administration of anti-inflammatory, antiproliferative, anticlotting or other agents before or after balloon dilatation was shown to effectively reduce neointimal hyperplasia in animal models. Clinical use in humans, however, failed to result in adequate restenosis prevention [4]. The advent of drug-eluting stents (DESs) marked a decisive advance, enabling direct transfer of drugs to the target site and prolonged exposure of the vessel wall. Sirolimus and paclitaxel were shown to be effective pharmacological inhibitors of neointimal hyperplasia in vitro and in vivo [5,6]. Stents coated with these agents were successfully used in both the coronary arteries [7] and below the knee [8]. By contrast, use of these stents were not found to be superior to bare-metal stents in femoral and popliteal arteries or in patients with severe diffuse disease and long, complicated lesions [9]. The occurrence of late stent thrombosis, caused by incomplete endothelization of the stent struts and an inflammatory response to the polymer matrix, considerably limited the use of DES [10,11]. Coating paclitaxel onto the surface of conventional percutaneous transluminal coronary angioplasty balloon catheters with a new coating technique that provides immediate drug release upon inflation was a new approach to preventing restenosis without having to implant a stent. The drug is transferred to the dilated segment when the balloon is inflated. An effective local drug concentration is achieved with very low systemic exposure. Paclitaxel admixed to a small amount of the hydrophilic x-ray contrast medium iopromide (Ultravist) emerged as a very effective coating matrix from numerous in vitro and in vivo experiments investigating different coating techniques, the adhesion of paclitaxel to the balloon surface while the catheter is advanced to the lesion, and the release of the active agent into the vessel wall during balloon expansion [12,13]. Balloon catheters coated in this way have a paclitaxel dose of 3 μg/mm of balloon surface and are marketed as Paccocath (Bayer Schering Pharma AG, Germany). 1Department of Radiology, Charite – Universitatsmedizin Berlin, Chariteplatz 1, 10117 Berlin, Germany 2Clinic for Internal Medicine III, Cardiology, Angiology and Intensive Care, University Hospital of Saarland, Homburg/Saar, Germany †Author for correspondence: Tel.: +49 304 5053 9076 Fax: +49 304 5052 7993 E-mail: beatrix.schnorr@charite.de

Multiple Fractures With Pseudoaneurysm Formation in a Subclavian Artery Stent

A 50-year-old right-handed man (ex-smoker) with a history of left upper limb claudication for the previous 6 years underwent successful left subclavian artery (LSA) angioplasty with stent implantation (8×59 Genesis Stent [Cordis, Warren, NJ]) for 99% ostial and proximal stenosis of the LSA with use of a combined anterograde and retrograde approach (Figure 1A through 1D). The erythrocyte sedimentation rate and the C-reactive protein were normal. No other vascular system was affected. After an asymptomatic period of 4 months, the patient presented with a history of high-grade fever for 7 days, pain and swelling of the left hand, bluish discoloration of finger tips and palms, and restriction of movements of the fingers of left hand (Figure 2A). All left upper limb pulses were well felt. A Doppler arterial study of the left upper limb was also normal. At the diagnostic angiogram, fluoroscopy revealed that the LSA stent had transected at multiple levels (4 levels) (Figure 3A and Movie I of the online-only Data Supplement). The angiogram revealed the presence of 2 pseudoaneurysms, one at the origin …