Cathalogue

Jailed Semi-Inflated Balloon Technique (JSBT) for Preserving Side Branch Viability During Chronic Total Occlusion (CTO) Intervention

Bilal Ahmed — 2024-06-01

Background: Chronic total occlusion (CTO) of the coronary arteries poses significant challenges in managing coronary artery disease. Successful intervention is essential for improving patient outcomes, particularly in cases with prior history of coronary interventions. The Jailed Semi-Inflated Balloon Technique (JSBT) has emerged as a valuable strategy to enhance side branch patency during CTO procedures, thereby preserving viable vessels and reducing the risk of ischemia.

Case Presentation: A 58-year-old male with a significant medical history, including diabetes, hypertension, and ischemic heart disease, presented to the outpatient department with persistent retrosternal chest discomfort lasting for six months, despite optimal medical therapy.

Results: The intervention involved a provisional bifurcation stenting strategy, utilizing JSBT in the right ventricular marginal branch to preserve flow in this viable vessel during the CTO recanalization. The procedure was successful, leading to good stent expansion and maintaining patency without complications.

Conclusion: This case underscores the critical importance of preserving as many viable vessels as possible during CTO interventions. The implementation of JSBT not only facilitated successful revascularization but also enhanced overall outcomes, reducing the risk of future ischemic events.

Successful Management of NSTEMI in a 66-Year-Old Male Using DK Crush Technique for Complex Bifurcation Lesions

Hafsa Shahid Malik — 2024-06-01

Background: The management of non-ST elevation myocardial infarction (NSTEMI) in patients with complex coronary lesions poses significant challenges. The DK crush technique has emerged as a valuable option for addressing bifurcation lesions, ensuring optimal outcomes.

Case Presentation: A 66-year-old male with a history of hypertension presented with typical chest pain. ECG revealed dynamic ST-T changes, and cardiac biomarkers were positive, leading to a diagnosis of NSTEMI. Baseline echocardiography indicated hypokinetic anterior territory with an ejection fraction (EF) of 45% and no significant valvular pathology.

Results: Following the DK crush procedure, optimal stent placement was achieved with successful revascularization. The final angiographic assessment demonstrated improved coronary flow and resolution of the lesion.

Conclusion: The DK crush technique, when performed by experienced operators, provides an effective strategy for managing complex bifurcation lesions in NSTEMI patients. This case underscores the importance of meticulous procedural steps and intracoronary imaging for optimal results.

Simple Solutions to Common Cath Lab Challenges: Overcoming Damping, Stent Movement, Support Issues, and Distal Stent Delivery

Imran Khan — 2024-06-01

Background: Cardiac catheterization for percutaneous coronary intervention (PCI) can present various technical challenges that require innovative solutions to ensure successful outcomes. This report highlights four unique cases that demonstrate distinct problems encountered during PCI and the strategies employed to navigate them.

Case Presentation: This report examines four distinct cases encountered during percutaneous coronary interventions (PCIs), each highlighting unique technical challenges and innovative solutions. In the first case, a 60-year-old man undergoing RCA intervention experienced pressure damping due to selective guide engagement. The team addressed this by wiring the acute marginal branch, which allowed for coaxial support while maintaining hemodynamic stability. The second case involved a 30-year-old man with a tight ostial LAD lesion, where stent movement posed a challenge. High-rate pacing was utilized to stabilize the stent during deployment, similar to a washing machine's spin cycle. In the third case, a 65-year-old man with critical proximal left circumflex stenosis struggled with stent delivery due to inadequate guide support. The anchor balloon technique provided the necessary stability for successful stent advancement. Finally, a 55-year-old man with a mid-left circumflex lesion faced difficulties in distal stent delivery. The team employed the Buddy-in-Jail technique, which involved jailing a buddy wire to facilitate the positioning of the distal stent.

Results: Each case illustrates the successful application of innovative problem-solving strategies that not only resolved specific technical challenges but also contributed to improved procedural outcomes. The techniques employed ranging from coaxial support and high-rate pacing to the anchor balloon and Buddy-in-Jail methods demonstrated their effectiveness in navigating complex anatomical scenarios, ultimately leading to successful interventions and enhanced patient safety.

Conclusion: These case studies highlight the critical need for tailored, adaptive approaches in addressing the diverse technical challenges faced during percutaneous coronary interventions (PCI).

Unraveling Uncontrolled Hypertension in a Young Female with Atypical Aortic Coarctation: A Case Review.

Mohammad Imran Hanif — 2024-06-01

Background: Atypical aortic coarctation can lead to significant complications such as uncontrolled hypertension, particularly in young patients. This case highlights the importance of thorough evaluation and timely intervention.

Case Presentation: A 25-year-old female, non-diabetic, presented with uncontrolled hypertension despite a regimen of multiple antihypertensive medications. On examination, she had a blood pressure of 160/90 mmHg in both upper limbs, feeble bilateral femoral pulses, and absent distal pulses. Baseline investigations, including echocardiography, showed an ejection fraction (EF) of 62% with a tri-leaflet aortic valve. Notably, imaging revealed narrowing of the distal descending thoracic aorta with a pressure gradient of 49 mmHg, severe concentric left ventricular hypertrophy (LVH), and grade II diastolic dysfunction.

Results: The patient successfully underwent percutaneous endovascular stenting with a covered stent (Aortic Be Graft, 14x49 mm) for aortic coarctation. Post-procedural hemostasis was achieved after addressing significant oozing. A follow-up aortogram indicated total occlusion of the common and superficial femoral arteries, which was treated with percutaneous transluminal angioplasty (PTA). Discharged on the fourth postoperative day, the patient was prescribed dual antiplatelet therapy (aspirin and clopidogrel, 75 mg each). At one-week follow-up, she reported no complications and maintained stable blood pressure (100/60 mmHg to 120/80 mmHg) without antihypertensive medications. A repeat echocardiogram confirmed a zero-pressure gradient across the descending aorta, demonstrating the intervention's success. The patient expressed satisfaction with her treatment and recognized the importance of medication adherence for long-term health.

Conclusion: This case highlights the importance of early diagnosis and appropriate intervention in young patients with uncontrolled hypertension. Atypical coarctation of the aorta should be considered a potential etiology, and percutaneous endovascular stenting is a safe and effective treatment option.

Management of Severe Angina Following Myocardial Infarction in a Patient with Comorbid Hypertension and Diabetes: A Case Report

Habib ur Razaq — 2024-06-01

Background: Managing severe angina in patients with comorbid conditions following a myocardial infarction poses significant clinical challenges. Optimal medical therapy often proves insufficient, necessitating advanced interventional strategies to address persistent symptoms and improve patient outcomes.

Case Presentation: A 50-year-old female with a history of hypertension and type 2 diabetes mellitus presented with severe angina classified as Canadian Cardiovascular Society (CCS) class II-III despite receiving optimal medical therapy after an inferior wall myocardial infarction treated with thrombolysis. Initial evaluations, including electrocardiogram (ECG) and echocardiography, indicated residual myocardial ischemia.

Results: Coronary angiography revealed moderate disease in the mid-left circumflex artery and severe tubular lesions in the mid-right coronary artery (RCA). Percutaneous coronary intervention (PCI) was performed on the RCA, involving the deployment of multiple drug-eluting stents. The procedure was complicated by a distal edge dissection and the breakage of a guide wire, both of which were successfully managed. Final angiographic results demonstrated TIMI III flow with no residual stenosis.

Conclusion: This case highlights the challenges and complexities of managing severe angina in post-myocardial infarction patients with comorbid conditions. It emphasizes the necessity of timely and precise interventional strategies to achieve optimal patient outcomes.

Out of the Frying Pan into the Fire: A Case Study of NSTEMI Complicated by Complex Bifurcation Lesions

Hafsa Liaqat — 2024-06-01

Background: Acute coronary syndrome (ACS) encompasses a spectrum of conditions, including unstable angina and myocardial infarction, necessitating swift diagnosis and intervention to prevent morbidity and mortality. Timely management is especially critical for patients presenting with complex coronary anatomies, which can complicate standard treatment protocols. In cases involving bifurcating lesions, the choice of intervention whether single or dual stenting requires careful consideration of anatomical factors to optimize outcomes.

Case Presentation: A 42-year-old female patient with a history of hypertension and diabetes presented initially with NSTEMI but left the hospital against medical advice. Two weeks later, she returned with ST elevation in anterior leads. Cardiac markers were elevated, and echocardiography indicated impaired left ventricular function with a 36% ejection fraction.

Results: Coronary angiography revealed total occlusion of the left anterior descending (LAD) artery, an 80% stenosis in the major diagonal branch, and diffuse 80% disease in the mid-segment of the right coronary artery (RCA). An upfront two-stent strategy using the culotte stenting technique was employed. Following predilation, a Promus stent was deployed in the major diagonal, and a XIENCE stent was placed in the LAD with kissing balloon inflation performed to ensure optimal stent apposition. Post-intervention, TIMI flow III was achieved, leading to improved hemodynamics. Follow-up echocardiography showed an increased ejection fraction of 60%, with the patient remaining pain-free.

Conclusion: This case highlights the importance of early and comprehensive management of ACS in patients with complex coronary lesions. An upfront two-stent strategy proved effective in restoring cardiac function and improving patient outcomes.

Managing Coronary Artery Perforation in a Calcified, Tortuous, and Angulated LAD

Hashim Khan — 2024-06-01

Background: Coronary artery disease remains a leading cause of morbidity and mortality worldwide. Non-ST elevation myocardial infarction (NSTEMI) often presents with complex anatomical challenges, particularly in patients with significant coronary artery disease. Understanding the risks associated with various intervention techniques is essential for improving patient outcomes.

Case Presentation: A 78-year-old male, ex-smoker, with no known comorbidities presented with shortness of breath on exertion and chest pain classified as Canadian Cardiovascular Society (CCS) Class III. Initial evaluation on May 6, 2024, included echocardiography, which revealed an ejection fraction of 40-45% with severe hypokinesis of the apex and anterior wall. The ECG demonstrated sinus rhythm with deep T wave inversions in leads V2-V5. Coronary angiography indicated a short left main artery, a single-vessel disease with a tortuous and critically diseased proximal left anterior descending (LAD) artery, and mild disease in the right coronary artery (RCA) and dominant left circumflex artery (LCX). The patient was planned for percutaneous coronary intervention (PCI) to the LAD.

Results: During the PCI, a hydrophilic wire induced a perforation in the LAD. The lesion was subsequently crossed with a workhorse wire, and pre-dilation was performed using a semi-compliant balloon. Two drug-eluting stents (DES) were successfully placed. A relook angiogram conducted 48 hours later showed no signs of perforation and achieved TIMI 3 flow following post-dilation.

Conclusion: Coronary perforation is a recognized complication of PCI, particularly in patients with tortuous and angulated coronary vessels. While hydrophilic wires are beneficial for navigating complex anatomy, they carry a risk of dissection and perforation due to their poor tactile feedback. Careful management and monitoring during procedures involving challenging coronary anatomies are crucial for optimizing patient outcomes.

Navigating the Uncrossable: Utilizing GuideLiner for Complex Coronary Lesions

Muhammad Usman — 2024-06-01

Background: Coronary calcification occurs when calcium accumulates in the plaque within the walls of the coronary arteries, serving as an early indicator of coronary artery disease. Managing calcified lesions is challenging, and various techniques can be employed, including cutting balloons, scoring balloons, high-pressure balloons, rotational atherectomy, orbital atherectomy, lithotripsy, and, notably, GuideLiner-assisted techniques.

Case Presentation: We present two cases involving calcified lesions that were successfully treated using the GuideLiner technique. The first case involves a 64-year-old male with a history of diabetes and hypertension who presented with non-ST elevation myocardial infarction (NSTEMI) and demonstrated normal left ventricular (LV) function. The second case features a 60-year-old male, also with a history of diabetes and hypertension, who presented with NSTEMI and moderate LV systolic dysfunction. In both instances, the GuideLiner technique played a crucial role in facilitating successful interventions for the complex calcified lesions.

Results: In both cases, while the lesions were easily crossed with semi-compliant and non-compliant balloons, stent delivery was initially unsuccessful. The use of the GuideLiner provided the necessary coaxial support to navigate the complex lesions, allowing for successful stent deployment. This approach not only facilitated the procedure but also enabled it to be performed via transradial access, avoiding the need for a shift to transfemoral access.

Conclusion: The GuideLiner technique proved to be an effective and safe method for the percutaneous treatment of complex coronary lesions when conventional angioplasty devices faced challenges. Its application, particularly in the transradial approach, enhances procedural success and minimizes fluoroscopy time, thereby reducing radiation exposure risks.