Severe Spasm Research Articles

A retrospective study on real world, 2-stent left main bifurcation PCI using DK crush technique with IVUS guidance - a single center experience

Abstract Objectives The aim of this study is to investigate clinical outcome of the IVUS guided 2-stent bifurcation strategy using DK crush technique performed in a complex Left Main (LM) bifurcation lesions defined according to DEFINITION study in our local setting. We seek to assess the composite endpoint of target vessel failure (TVF) at 9-12 months. Methods All patients underwent IVUS guided 2-stent Bifurcation PCI with DK crush technique for complex LM bifurcation lesions defined by the DEFINITION criteria performed in a heart institute from 1.1.2019 to 31.7.2023 were included..Patient baseline characteristics, post-procedural and 12-months follow-up outcomes including cardiac death,myocardial infarction (MI),rate of target vessel failure (TVF),rate of stent thrombosis (ST) and major adverse coronary event (MACE) were analysed.Exclusion criteria are patients age <18 years and previous stenting in the target vessel Results A total of 50 patients were included in this analysis. Mean age was 64.3±9.1 years with predominant males (n= 38, 76%).Majority were hypertensive (n=37, 74%) and diabetes mellitus accounted for 32 (64%) cases.Patients with pre-existing coronary artery disease were 39 (78%) cases. 40% presented with history of recent myocardial infarction (MI), 12% had new onset angina and 6% had heart failure. Pre-existing chronic renal failure (18%) and history of CVA (2%). Among chronic renal failure cases, 50% had eGFR <50 during index procedure.Additionally, previous PCI was performed in 22 cases (44%) and 2 previous CABG cases included (4%).Majority of the cases were performed as staged elective procedure ( n=45, 90%) and others were indicated for ACS ( n=5, 10%). Radial approach was predominantly preferred with 25 cases (50%), where additional 5 cases (10%) were converted to femoral approach due to severe radial spasm. Among these 50 cases, 1 case required additional PCI to CTO LAD and mid LCX, while 7 cases (14%) had calcified lesions requiring scoring / cutting balloons and atherectomy device utilization for adequate lesion preparation prior to bifurcation stenting.All 50 patients received combination of both aspirin and a P2Y12 inhibitors for 12 months. Follow up done at at 30-day, 60-days and 1 year after the index procedure.Clinical follow-up were available in 46 (92%) patients only.4 cases were lost to follow up due to logistic reasons. At 1 year follow-up, cardiac death occurred in 5 (10.9%) patients, out of which 3 (6.5%) cases were cardiac related and 2 (4.4%) are non-cardiac. Major adverse cardiac events (MACE) and target vessel failure (TVF) occurred in total 4 (8.7%) cases, where 3 (6.5%) cases resulted in cardiac death and 1 (2.2%) case had MI and clinically driven target lesion revascularization. Conclusion Our experience demonstrates that IVUS guided, upfront 2-stent Bifurcation PCI using DK crush technique for complex bifurcation lesions is effective and safe with a low MACE and TLR rate at 1 year follow-up.

Preventing Sheep Carotid Artery Spasm for Vascular Graft Surgery and Computed Tomography Angiography.

The development of small-diameter vascular grafts requires testing in large animal models before advancing to clinical trials. Vascular graft interposition implantation in sheep carotid arteries (CAs) is the most widely used model, but ovine CAs are prone to severe spasm following surgical manipulation, potentially impairing graft performance assessment. There is paucity in the literature on reducing sheep CA spasm using effective vasodilator therapeutic protocols. In this study, four healthy Merino cross White Suffolk wethers (1-2 years, 52.1 ± 0.8 kg) underwent CT angiography and CA graft surgery. CT angiography using iodinated contrast agent was performed with innominate artery access through the CA or ascending aortic arch access through the femoral artery. Sheep then underwent right CA sham surgery or left CA vascular graft implantation. A variety of vasodilators, including papaverine, sodium nitroprusside, verapamil, and their combination, were tested for preventing or treating CA spasms intraoperatively. Blood flow was reassessed immediately after CA surgery using CT angiography. The results showed that innominate artery access through the CA for CT angiography in sheep induced presurgical CA spasm with reduced arterial flow. Conversely, ascending aortic arch access through the femoral artery for CT angiography did not cause CA spasm and maintained arterial flow. During CA graft surgery, surgical trauma induced CA spasm, which was prevented by localized intra-arterial administration of vasodilators papaverine hydrochloride and verapamil before significant surgical manipulation.

Perioperative multivessel coronary artery spasm and cardiac arrest after cardiac surgery.

Postoperative coronary artery spasm, a rare but potentially fatal complication following cardiac surgery, warrants significant attention. This report discusses a 64-year-old male who suffered a severe coronary artery spasm leading to cardiac arrest following surgery. Initially stable, the patient rapidly developed critical ventricular arrhythmias and hypotension, resulting in cardiac arrest 4 h post-surgery. Emergency coronary angiography revealed extensive spasms, successfully managed with intracoronary nitroglycerine. This case stresses prompt recognition and management of coronary artery spasm after non-coronary cardiac procedures, underscoring coronary angiography's vital role in diagnosis and treatment.

Value and Limitations of Urethrotech Catheterisation Device to Manage Difficult Urethral Catheterisation in Male Spinal Cord Injury Patients.

We used a Urethrotech catheterisation device in 57 male patients with spinal cord injury, in whom urethral catheterisation was unsuccessful or previous catheterisation was difficult. Urethrotech catheter could be inserted in 51 patients. No patient developed urinary tract infection. In one patient, the guidewire could not be introduced into the bladder, and a coude Foley catheter was inserted. In two patients, the guidewire was inserted into the bladder, but a 16 CH catheter could not be advanced over the guidewire. Emergency suprapubic cystostomy was performed in one case; in the other, urethral stricture was dilated; a size 12 CH catheter was inserted. In three patients, the guidewire curled back into the urethra because of severe spasm of the urethral sphincter. Catheterisation with a Tiemann catheter was successful after administration of diazepam and/or stretching of the anal sphincter by another health professional, which caused reflex relaxation of the urethral sphincter. Complications of Urethrotech catheterisation included urethral bleeding, haematuria, pain, doubling back of the guidewire due to spasm of the urethral sphincter or from an empty bladder.We adopted variations in technique, eg filling the bladder with saline prior to catheterisation when feasible, insertion of the guidewire by the side of the old catheter, use of Tiemann tip catheters, administration of antibiotics, diazepam to control spasms, nifedipine to control autonomic dysreflexia, analgesics, stretching of the anal sphincter to induce reflex relaxation of the urethral sphincter, urgent imaging studies to confirm correct positioning of the catheter, omitting anticoagulants and monitoring patients, who developed bleeding. Use of Urethrotech in spinal injury patients warranted adaptations to the technique, which required expertise, experience, and backup facilities. To ensure patient safety, Urethrotech catheter should be used in a hospital setting, and by medical personnel with experience in the management of spinal cord injury patients.

SEVERE POSTURE AND GAIT DISTURBANCE IN LUMBAR SPINAL STENOSIS: A CASE REPORT

One of the causes of low back pain is lumbar spinal stenosis (LSS). LSS is defined as a disorder resulting from degenerative processes leading to narrowing of the spinal canal. The nature of pain in LSS—the neurogenic claudication—was aggravated by upright or extended trunk positions, such as during walking, descending stairs, or simply standing. Patient self-adjustments in response to pain can induce further muscle disturbance and worsen the condition. A 56-year-old male suffering from poor posture with antalgic and Trendelenburg gait. The MRI showed multiple spinal canal stenosis with compression of the L4-S1 nerve roots affected the gait and worsened posture. Physical medicine rehabilitation (PMR) program—including the use of ultrasound diathermy for severe muscle spasm followed by muscle stretching, Transcutaneous Electrical Stimulation (TENS) for pain relief, Neuromuscular Electrical Stimulation (NMES) for muscle strength improvement and several therapeutic exercises—has proven beneficial in reducing patient’s symptoms thus correcting the posture and gait. At this point spinal canal narrowing is not only causing pain with neurological deficit but may lead to posture and gait disturbance that increasing the patient's disability. The use of physical modalities combined with exercise has been shown to benefit patients similarly to surgery but without invasive approach.

Nitroglycerin to Ameliorate Coronary Artery Spasm During Focal Pulsed-Field Ablation for Atrial Fibrillation

BackgroundIn treating atrial fibrillation, pulsed-field ablation (PFA) has comparable efficacy to conventional thermal ablation, but with important safety advantages: no esophageal injury or pulmonary vein stenosis, and rare phrenic nerve injury. However, when PFA is delivered in proximity to coronary arteries using a pentaspline catheter, which generates a broad electrical field, severe vasospasm can be provoked. ObjectivesThe authors sought to study the vasospastic potential of a focal PFA catheter with a narrower electrical field and develop a preventive strategy with nitroglycerin. MethodsDuring atrial fibrillation ablation, a focal PFA catheter was used for cavotricuspid isthmus ablation. Angiography of the right coronary artery (some with fractional flow reserve measurement) was performed before, during, and after PFA. Beyond no nitroglycerin (n = 5), and a few testing strategies (n = 8), 2 primary nitroglycerin administration strategies were studied: 1) multiple boluses (3-2 mg every 2 min) into the right atrium (n = 10), and 2) a bolus (3 mg) into the right atrium with continuous peripheral intravenous infusion (1 mg/min; n = 10). ResultsWithout nitroglycerin, cavotricuspid isthmus ablation provoked moderate-severe vasospasm in 4 of 5 (80%) patients (fractional flow reserve 0.71 ± 0.08). With repetitive nitroglycerin boluses, severe spasm did not occur, and mild-moderate vasospasm occurred in only 2 of 10 (20%). Using the bolus + infusion strategy, severe and mild-moderate spasm occurred in 1 and 3 of 10 patients (aggregate 40%). No patient had ST-segment changes. ConclusionsAblation of the cavotricuspid isthmus using a focal PFA catheter routinely provokes right coronary vasospasm. Pretreatment with high doses of parenteral nitroglycerin prevents severe spasm.

Gastropericardial fistula complicated by severe multi-vessel coronary spasm.

Gastropericardial fistula complicated by severe multi-vessel coronary spasm.

Ruptured sinus of valsalva aneurysm - a rare cause of heart failure, challenges in transcatheter closure and mid-term outcomes

Abstract Introduction The ruptured sinus of valsalva aneurysm (RSOV) portends an important cause for acute heart failure. Closure of the defect either percutaneously or surgically is of paramount importance. We report 38 cases of RSOV who presented with cardiac failure, among which 22 cases were selected and amenable for transcatheter closure.Transcatheter closure of RSOV has favorable outcomes in the short-term and mid-term follow-up. Purpose of the study To assess the short-term and midterm outcomes of transcatheter closure of RSOV. Methods All patients who presented with cardiac failure and diagnosed as RSOV by transthoracic echo, from June 2012 to Dec 2022 were included in the study.Age group was between 12 to 73 years.All the 38subjects (Males -24, Females -14) of RSOV, underwent trans esophageal echo (TEE). 22 casesere selected for device closure..The subjects were classified according to New York Heart Association (NYHA) class III - 82%, class IV- 18 %. Size of the defect was measured at the aortic end by TEE and aortogram, and upsized by 2-4 mm from the aortic end. In 21 subjects, the RSOV was entered from the aorta, and an arterio-venous loop was created, and various devices, duct occluders and atrial septal occluder and muscular ventricular septal occluder were used to close the defects. In one patient the RSOV was acquired following surgical closure of perimembranous ventricular septal defect, which was small measuring 3mm at aortic end and hence closed using 4/6 ADO II without forming the arterio-venous loop. Patients were followed up post discharge 1 week, 1 month, 3 months, 6 months, 1 year and every year till 10 years by clinical examination, ECG, and transthoracic echo. Results All 22 patients who underwent successful RSOV device closure improved to NYHA functional class II within 48 hours post procedure and to functional class I at 3 months of follow-up. 3 female patients underwent successful pregnancy and labor after RSOV device closure without any intrapartum or postpartum complications. Two patients had trivial aortic regurgitation pre-procedure remained the same status on follow up post-procedure. One patient developed) severe right coronary artery spasm, due to inadvertent RCA cannulation while crossing the defect, which cleared with nasal oxygen and intracoronary nitroglycerine. A minimal residual shunt was found in 2 patients which gradually disappeared at 6 months. One patient with a large defect (15mm), an atrial septal occluder - 20mm was deployed, developed hemolysis, and hence referred for surgery. Transient global LV systolic dysfunction was present in two patients due to afterload mismatch, whose LV function recovered after 72 hours. Conclusion Percutaneous device closure of RSOV is a feasible and an enticing alternative to surgery in selected patients, as inferred by the short and mid-term outcomes. The age group 12 to 73 years encompasses the youngest and oldest age group yet reported.PROFILE OF RSOV DEVICE CLOSURE CASESRSOV CASE SELECTION AND OUTCOMES

Spasm of Near Synkinetic Reflex: Outcomes of a Comprehensive Management Protocol

Objective: To find out the frequency of spasm of near reflex presenting to our clinic and outline the management outcomes. Study Design: Quasi-experimental study. Place and Duration of Study: Armed Forces Institute of Ophthalmology, Rawalpindi Pakistan, from May to Dec 2022. Methodology: A patient who was suspected to have spasm of near reflex underwent subjective and objective refraction and detailed orthoptic evaluation. Dry and cycloplegic retinoscopy was obtained along with post-mydriatic refraction achieved after 3 days of Cycloplegic. Spasm of near reflex was categorized as mild if it resolves on administration of a weaker cycloplegic drug like cyclopentolate, moderate if administration of stronger cycloplegic i.e., atropine/homatropine is required or severe if long term home therapy of atropine 0.5% once daily is required. Results: Our study included 236 patients with suspected spasm of near reflex, among which it was confirmed in 200 only. Of the 200 patients with confirmed spasm of near reflex, there were 74 mild cases (37%), with no spasm of near reflex during their post-cycloplegic visit. Eighty-eight patients (44%) had moderate spasm of near reflex that was relieved by the post atropine examination. Whereas, 38 patients (19%) had severe spasm of near reflex, requiring long-term atropine 0.5% management. Conclusion: Spasm of near reflex is often a diagnostic dilemma which is otherwise not very difficult to treat. Most of such cases were found to be mild to moderate having good visual outcomes to once or twice application of moderate (Cyclopentolate 1%) to stronger acting Cycloplegic eye drops (Atropine 1%).

AB-452675-4 CORONARY ARTERIAL SPASM DURING CAVO-TRICUSPID ISTHMUS ABLATION WITH A NOVEL FOCAL PULSED FIELD ABLATION CATHETER: FINDINGS FROM CORONARY ANGIOGRAPHY AND FRACTIONAL FLOW RESERVE MEASUREMENTS

Pulsed field ablation (PFA) has been shown to avoid esophageal damage, PV stenosis and permanent phrenic nerve paralysis. But not studied in these trials was ablation of the cavo-tricuspid isthmus (CTI), a not uncommon adjunct target for ablation during pulmonary vein isolation (PVI) procedures. Indeed, recent studies demonstrated that when PFA is performed adjacent to a coronary artery, there is a susceptibility for vasospasm: in a study of right coronary artery (RCA) angiography during PFA of the cavo-tricuspid isthmus (CTI), there was universally severe RCA spasm, albeit subclinical. However, these studies were performed with a pentaspline PFA catheter designed to create a broad electrical field, not with a focal spot ablation catheter. To evaluate the potential for PFA to cause coronary spasm during CTI ablation, but using a focal PFA catheter. As part of a clinical trial of persistent AF ablation (PersAFOne 3, NCT05272852), after PVI and posterior wall ablation using a 12F commercial pentaspline PFA catheter (Farawave, BSC Inc.), CTI ablation was performed using an investigational 8F deflectable focal catheter (Farapoint, BSC Inc.). PFA was performed at 2kV (2 x 2.5 sec applications per site) with fluoroscopy and ICE guidance. Coronary angiography of the RCA with FFR measurement (Abbott PressureWire X) was performed before, during and after PFA at each application site. Spasm was categorized as mild (<50%), moderate (50-90%) or severe (>90%). At a single center, PFA of the CTI was performed in 8 patients. Bidirectional CTI conduction block was achieved in all patients after a mean of 13.3 lesions/pt (range 8-18). One patient had a left dominant coronary arterial system, and a de minimis RCA; of the remaining, 6 of 7 patients developed moderate (n=5) to severe (n=1) spasm as determined by both angiography and FFR (mean pressure differential 0.60, range 0.31-0.78 among patients developing spasm). There were no EKG changes and no symptoms (albeit sedated patients). The mean time for spasm resolution was 13.8 min. In an additional patient, intracoronary NTG pretreatment (1 mg) was administered before PFA lesions were delivered to the CTI: no coronary spasm was provoked. Focal PFA to the CTI provokes subclinical coronary vasospasm when delivered adjacent to the RCA. Additional investigation is necessary to determine the optimal NTG dosing strategy to prevent this phenomenon.

Diagnostic Cerebral Angiography Through Distal Transradial Access: Early Experience with a Promising Access Route.

Over the last few years, there has been considerable interest in the neurointervention community to use transradial approach for diagnostic and therapeutic neurointerventions. Distal radial approach has been postulated as an effective technique with reduced risk of hand ischemia. Our objective was to assess the safety and feasibility of distal transradial access (DTRA) to perform diagnostic cerebral angiography. A retrospective evaluation of 25 patients who were taken for DTRA through the anatomical snuff box from December 2021 to March 2022 was done. Twenty-five diagnostic cerebral angiographies were attempted with DTRA in 25 patients (age, 23-70 years; mean age, 45.4 years; 10 (40%) females). The right distal radial artery mean diameter was 2.09 mm. The procedure was successful in 21 (84%) procedures. Failure was seen in four cases, with three being converted to the proximal transradial approach without any need for redraping and one was converted to the transfemoral approach. The reason for access conversion was a severe spasm in three cases and dissection in one case. Selective catheterization of the cranial vessels through a distal transradial approach was achieved in 92 (96.8%) of 95 vessels. No significant access site complications were seen in the study cohort. DTRA is a promising approach for diagnostic cerebral angiography. Interventionists should get accustomed to this approach by overcoming the initial learning curve.

MP-453081-7 A COMPARISON OF LEFT CIRCUMFLEX CORONARY VASOSPASM BETWEEN RADIOFREQUENCY ABLATION AND PULSED FIELD ABLATION AT THE MITRAL ISTHMUS

Pulsed field ablation (PFA) is a nonthermal energy modality that largely spares collateral structures like the esophagus and phrenic nerve. However, a recent study indicates that subclinical coronary artery vasospasm is common during PFA of the cavo-tricuspid isthmus. There is also a case report of left circumflex artery (LCx) vasospasm during PFA at the mitral isthmus (MI). To determine the frequency of LCx vasospasm during PFA on the lateral MI and compare to RFA. In a prospective, consecutively enrolled cohort of patients undergoing AF ablation under deep sedation, diagnostic coronary angiography was performed via right femoral arterial access before, during, and after endocardial ablation on the lateral MI with either a PFA catheter (Farawave, Boston Scientific Inc) or an irrigated RFA catheter (Thermocool, Biosense-Webster Inc). When vasospasm was identified on angiography, it was monitored for clinical remission and hemodynamic changes and intervention with nitroglycerin administered if refractory to upfront supportive care. A total of 19 patients received PFA on the lateral MI with acute bidirectional block: 11 along the superior MI (1-2 o’clock on the annulus) and 8 along the inferior MI (3-5 o’clock on the annulus). In total, 7 patients experienced LCx vasospasm (2 mild, 3 moderate, 1 severe). By site, 7 of 11 (64%) and 0 of 8 (0%) were at the superior or inferior MI, respectively. In comparison, 9 patients underwent RFA of the MI (all at the superior MI with coronary sinus lesions in 3 patients), during which there were no instances of LCx spasm. Of note, 5 of 9 patients also received MI PFA due to the absence of MI block after first pass RFA; 3 of these 5 patients did demonstrate LCx spasm during PFA. In none of the instances of MI spasm were there any symptoms or hemodynamic compromise. ECG changes were seen in 1 patient: ST elevations with severe LCx spasm. While PFA confers an important degree of tissue preferentiality and enhanced safety compared to thermal ablation for esophageal/phrenic damage and pulmonary vein stenosis, our data indicate that PFA can cause reversible (mostly) subclinical LCx spasm during MI ablation. Vasospasm occurred during superior MI ablation while inferior MI PFA did not cause spasm; this may be related to the proximity of the PFA catheter to the LCx along its superior-inferior course. Conversely, RFA of the MI does not appear to be associated with a significant risk for LCx spasm.

CE-454610-1 VENTRICULAR FIBRILLATION REQUIRING EXTRACORPOREAL RESUSCITATION DURING RADIOFREQUENCY ABLATION IN THE CORONARY SINUS

Coronary vasospasm is a rarely reported but potentially catastrophic complication of radiofrequency ablation (RFA). The mechanism is not fully understood but may be related to thermal energy transfer, inflammatory markers released during ablation, and/or alterations in autonomic tone from stimulation of epicardial ganglionated plexi. While most vasospasm occurrences appear subclinical and self-limited, there are exceptions. To highlight an exceptional, life-threatening case of RFA-induced coronary vasospasm. N/A A 62-year-old man with persistent AF and five prior ablations (including one at our institution) presented for ablation of atypical atrial flutter. Termination of the flutter occurred with RFA (7 lesions) at the left atrial roof. There was also a breakthrough of conduction through a prior posterior mitral isthmus line, so coronary sinus (CS) lesions were placed to re-attain mitral block. Two irrigated RF lesions (#1 - 59 seconds, max 26 Watts; #2 - 40 seconds, max 33 Watts) were placed, but 7 seconds into the 3rd lesion (max 27 Watts), ventricular fibrillation (VF) occurred, initially refractory to multiple external shocks. ACLS/CPR commenced. Arterial access was rapidly achieved, and initial coronary angiography simply revealed diffusely slow/no flow related to ongoing VF. Emergent veno-arterial extracorporeal membrane oxygenation (VA ECMO) cannulation was initiated, following which the VF was successfully defibrillated, converting to sinus rhythm. Repeat coronary angiography revealed (known) minimal non-obstructive coronary disease as well as a focal, severe spasm of a dominant left circumflex artery adjacent to the location of CS ablation. Intracoronary nitroglycerin resulted in minimal initial angiographic improvement, so balloon angioplasty and deployment of a drug eluting stent was performed (post: TIMI III flow). The patient made a full recovery and was discharged home on post-procedure day 6 without long-term sequelae. This case underscores a life-threatening complication of RFA within the CS leading to coronary vasospasm and refractory VF. Expedient intervention with extracorporeal resuscitation and support can stabilize patients to allow time to manage arrhythmias and resolve spasm either pharmacologically or procedurally.

PO-04-005 LEFT CIRCUMFLEX ARTERY VASOSPASM DURING PULSED FIELD ABLATION AT THE MITRAL ISTHMUS: CHARACTERIZATION OF TIME-TO-RESOLUTION

While pulsed field ablation (PFA) has emerged as a novel energy modality for ablation of atrial arrhythmias and is accompanied by a theoretically safer profile given its tissue selectivity and sparing of collateral structures, a recent study has highlighted the occurrence of subtotal coronary vasospasm during atrial fibrillation (AF) ablation on the cavo-tricuspid isthmus with PFA. While these observations were subclinical, there is at least one case report of left circumflex (LCx) coronary artery vasospasm during PFA at the mitral isthmus (MI) during AF ablation. To evaluate the natural history time-to-resolution of coronary vasospasm of the LCx artery during PFA at the MI. In a prospective, consecutively enrolled cohort of patients receiving AF ablation under deep sedation, diagnostic coronary angiography was performed via right femoral arterial access before, during, and after ablation on the MI with a multi-spline PFA catheter (Farawave, Boston Scientific Inc). LCx spasm was identified, characterized by severity, and monitored for progression and time-to-resolution. A total of 19 patients underwent PFA on the lateral MI with successful bidirectional block. Notably, 7 patients (37%) developed LCx vasospasm during ablation, of which 3 cases were mild (<50% decrease in luminal diameter), 2 were moderate (50 to 90% decrease), and 2 were severe (>90% decrease). All of the mild and moderate spasm occurrences self-resolved, with mild spasm taking on average 5.7 minutes to be relieved, and moderate spasm requiring 5 minutes. Relief of severe spasm required an average of 15 minutes, with both necessitating administration of intracoronary or intravenous nitroglycerin. Electrocardiographic ST changes were only present in one case of severe spasm (which resolved with relief of spasm), and there were no hemodynamic changes during spasm. As PFA becomes an alternative to radiofrequency and cryothermal ablation, it behooves operators to be vigilant for vasospastic effects on adjacent coronary vessels during ablation. Further investigation with larger populations is required to more fully elucidate the injurious potential of PFA-induced coronary vasospasm. This study is one of the first to elaborate on the features of LCx vasospasm during PFA on the MI.Tabled 1Patient CharacteristicsAge, mean±SD, y65.6±10.1Male, n (%)14 (74)Body mass index, mean±SD30.3±4.9Medical HistoryType of atrial fibrillationParoxysmal, n (%)4 (21)Persistent, n (%)15 (79)Duration of atrial fibrillation, mean±SD, months48.2±66.4CHA2DS2-VASc Score, mean±SD2.1±1.4Hypertension, n (%)13 (68)Diabetes, n (%)4 (21)Dyslipidemia, n (%)11 (58)Sleep apnea, n (%)1 (5)Prior stroke or transient ischemic attack, n (%)2 (11)Coronary artery disease, (%)4 (21)Congestive heart failure, n (%)1 (5)Left ventricular ejection fraction, mean±SD, %62.3±3.4Left atrium dimension, mean±SD, mm45.8±9.2MedicationsWarfarin, n (%)12 (63)Non-Warfarin oral anticoagulant, n (%)7 (37)Antiarrhythmic drugs, n (%)Class I7 (37)Class II11 (58)Class III5 (26)Class IV0 (0) Open table in a new tab

Transradial Carotid Artery Stenting Using Walrus Balloon Guide Catheter: Technical Aspects and Clinical Outcome.

Despite an overall surge in transradial access (TRA) for neurointerventional procedures, the feasibility and safety of TRA carotid artery angioplasty and stenting using balloon guide catheters (BGCs) through a short 8-Fr sheath have not been studied. In this study, we present our experience of using Walrus BGC through TRA for carotid artery stent placement. To define the safety and efficacy of using a balloon guide catheter for carotid stenting by a transradial approach. Our prospectively maintained retrospective database was reviewed, and consecutive patients were identified who underwent elective carotid artery stenting through TRA using Walrus BGC between January 2021 and June 2022. Demographics, procedural details including access site complications, the rate of radial to groin conversion, and procedure-related transient ischemic attack or stroke were reviewed. Twenty patients were identified who underwent carotid artery angioplasty and stenting through TRA Walrus BGC use; the mean age was 66 years (range 42-89), and 67% were male. A short 8-Fr sheath was used in all patients without any complications. Two of 20 patients required TRA conversion to transfemoral access, both secondary to severe spasm of the radial artery after initial access inhibiting further advancement of the Walrus BGC. Use of Walrus BGC by TRA through an 8-Fr sheath for carotid artery stenting is safe and feasible with a low rate of conversion to transfemoral access and no access site complications.

Severe near Reflex Spasm in a Healthy Teenager. A Case Report

Spasm of the near reflex usually includes accommodative spasm, esophoria/tropia, and different degrees of miosis. Patients usually refer to distance blurred and fluctuating vision, ocular discomfort, and headaches. The diagnosis is established with refraction with and without cycloplegia; most of the cases have a functional etiology. However, some cases require neurological conditions to be ruled out; cycloplegics have an important diagnostic and therapeutic role. To describe a case of bilateral severe accommodative spasm in a healthy 14-year-old teenager. A 14-year-old boy with progressive diminished visual acuity attended for YSP consultation. The diagnosis of bilateral spasm of the near reflex was made, based on a gap refraction of 9.75 D between retinoscopy with and without cycloplegia and esophoria with normal keratometry and axial length. The spasm was eliminated with 2 drops of cycloplegic in each eye separated by 15 days; no clear etiology was found other than the start of school. Clinicians should be aware of pseudomyopia, especially in children with acute changes in visual acuity, who are usually exposed to myopigenic environmental factors that induce overstimulation of the parasympathetic third cranial nerve's innervation.

Resuscitated sudden cardiac arrest related to intraplaque haemorrhage and coronary artery spasm.

A 72-year-old man with a history of chronic kidney disease, dyslipidaemia, and hypertension felt chest tightness after walking uphill and sat down to rest. Shortly thereafter, he suddenly collapsed, and cardiopulmonary resuscitation was started by a nearby family member. The initial electrocardiogram waveform was ventricular fibrillation, which was restored to sinus rhythm with an automated external defibrillator. He was transported to our hospital. No significant electrocardiographic changes, but positive serum troponin was observed on arrival. Emergency coronary angiography was performed, revealing a moderate stenosis in the proximal left anterior descending coronary artery (Panel A) which was functionally significant (Panel B). Optical coherence tomography showed a large eccentric plaque with a confined low-intensity plaque with strong signal attenuation (Panel C) and some areas of low intensity and low attenuation (Panel D), highly suggestive of intraplaque haemorrhage (IPH) (see Supplementary data online, Video S1).1 A stent implantation was subsequently performed (Panel E). On the ninth day of hospitalization, an acetylcholine provocation test was performed for the right coronary artery and severe diffuse coronary spasm was induced (Panels F and G) accompanied by chest tightness and ST elevation on electrocardiogram, leading to a diagnosis of coronary spastic angina.

Denosumab-induced hypocalcemia post bariatric surgery—a severe and protracted course: a case report

BackgroundDenosumab is known to cause abnormalities in calcium homeostasis. Most of such cases have been described in patients with underlying chronic kidney disease or severe vitamin D deficiency. Previous bariatric surgery could also contribute to hypocalcemia and deterioration in bone health.Case presentationWe present a case of a 61-year-old Malay female with worsening bilateral limb weakness, paresthesia, and severe carpopedal spasm a week after receiving subcutaneous denosumab for osteoporosis. She had a history of gastric bypass surgery 20 years ago. Post gastric bypass surgery, she was advised and initiated on lifelong calcium, vitamin D, and iron supplementations that she unfortunately stopped taking 5 years after surgery. Her last serum blood tests, prior to initiation on denosumab, were conducted in a different center, and she was told that she had a low calcium level; hence, she was advised to restart her vitamin and mineral supplements. Laboratory workup revealed severe hypocalcemia (adjusted serum calcium of 1.33 mmol/L) and mild hypophosphatemia (0.65 mmol/L), with normal magnesium and renal function. Electrocardiogram showed a prolonged QTc interval. She required four bolus courses of intravenous calcium gluconate, and three courses of continuous infusions due to retractable severe hypocalcemia (total of 29 vials of 10 mL of 10% calcium gluconate intravenously). In view of her low vitamin D level of 33 nmol/L, she was initiated on a loading dose of cholecalciferol of 50,000 IU per week for 8 weeks. However, despite a loading dose of cholecalciferol, multiple bolus courses, and infusions of calcium gluconate, her serum calcium hovered around only 1.8 mmol/L. After 8 days of continuous intravenous infusions of calcium gluconate, high doses of calcitriol 1.5 μg twice daily, and 1 g calcium carbonate three times daily, her serum calcium stabilized at approximately 2.0 mmol/L. She remained on these high doses for over 2 months, before they were gradually titrated down to ensure sustainability of a safe calcium level.ConclusionThis case report highlights the importance of screening for risk factors for iatrogenic hypocalcemia and ensuring normal levels before initiating denosumab. The patient history of bariatric surgery could have worsened the hypocalcemia, resulting in a more severe presentation and protracted response to oral calcium and vitamin D supplementation.

Evaluation of Peripheral Vascular Function After Distal Radial Artery Access for Invasive Percutaneous Coronary Procedures

Abstract Objective: The aim of this study is to investigate the difference in impact between distal transradial access (dTRA) and classical transradial access (TRA) on vascular function using flow-mediated vasodilation (FMD) following coronary diagnostic and therapeutic catheterizations. Methods: The analysis involves a non-randomized inclusion of patients undergoing either diagnostic or elective percutaneous coronary intervention, using a dTRA access or a conventional standard TRA. Two hours after the procedure ended, the endothelium-dependent flow-mediated dilation of the brachial artery was measured by ultrasound. Results: A total number of 50 patients were included. There was no statistically significant difference between the two groups (7.20% vs 6.99%, p &lt; 0.09 for non-inferiority). Additionally, there were higher baseline values observed for BA diameters in the conventional approach group. Regarding the other secondary endpoints, there were no major access site complications, radial occlusion, in-hospital major bleeding or severe arterial spasm recorded in both groups. Conclusion: Compared to conventional TRA, accessing distal radial artery for diagnostic and therapeutic coronary interventions has the same impact on short-term vascular endothelial function and was safely performed without any major vascular complications.

Refractory Coronary Vasospasm After Spine Surgery; A Rare Case Report

Refractory vasospastic angina (RVSA) is a rare condition leading to several episodes of constriction of coronary arteries which eventually leads to myocardial ischemia. Calcium-channel blockers (CCBs) and nitrates are usually used, however, sometimes the vasospasm is refractory and recurrent leading to high morbidity and mortality. A 35-year-old man known case of hypertension underwent two times operation due to T9-T10 discopathy and decompressive laminectomy of three segments T8/T9/ T10 following a previous car accident 4 months before this admission. Three days postoperatively he developed chest pain, dyspnea and diaphoresis. Electrocardiography showed inverted T wave in leads I, II and ST elevation in pericardial leads of V1-V4. Left anterior descending (LAD) artery stenosis was present (99%) at mid part that resolved after Trinitroglycerin (TNG) injection during angiography. Totally, he underwent 3 times coronary angiography due to recurrent chest pain refractory to conventional management of Prinzmetal’s angina. Coronary stent could not be placed due to severe spasm. Finally, he developed refractory chest pain and dyspnea and cardiac arrest in the CCU despite receiving intravenous high dose TNG, Diltiazem, Nicorandil and Hydrocortisone. He expired after several times of cardiopulmonary resuscitation. Refractory VSA after spine surgery has not been reported in the literature yet. This patient was resistant to available medications. There is no consensus regarding the treatment unfortunately. Randomized clinical trials have to be done to find ways regarding unconventional treatment options such as alpha-2-agonists, Corticosteroids, rho-kinase-inhibitors, statins and magnesium. Despite the fact, some surgical interventions with sympathetic denervation like left-stellate-ganglion denervation must be assessed.