yoshinaga masataka

We present a novel, simple, and low-cost "side-hole" technique for a patient with ST-segment elevation myocardial infarction (STEMI) caused by an occlusion of an anomalous origin of the culprit coronary artery (AOCCA). In a case where standard guiding catheters failed to engage the anomalous left coronary artery (LCA), we created an approximately 3 mm side-hole near the tip of a 5 Fr diagnostic catheter and then introduced a guidewire and microcatheter directly into the anomalous left main trunk (LMT). Subsequently, we withdrew this diagnostic catheter and exchanged it for a guiding catheter over the guide wire, enabling rapid primary PCI. This approach facilitated rapid wire passage, minimized additional device use, and helped reduce overall reperfusion time. It may be especially useful in urgent STEMI cases where a suitable guiding catheter for AOCCA lesions cannot be readily identified.

OBJECTIVE: This study highlights a case in which we performed a complex percutaneous coronary intervention on a 60-mm chronic total occlusion lesion with a remarkably low radiation dose by using the SPOT region of interest (SPOT ROI) function available on the Alphenix Evolve Edition X-ray system (Canon Medical Systems). KEY STEPS: Fluoroscopy was conducted exclusively using SPOT ROI from the start of guiding catheter engagement. The wire successfully traversed the chronic total occlusion lesion with SPOT ROI. Despite a fluoroscopy time of 71 min, the total radiation dose was kept at 990 mGy, remaining <1 Gy. POTENTIAL PITFALLS: The SPOT ROI function is only available on the Alphenix Evolve Edition X-ray system and cannot be used with other X-ray equipment. TAKE-HOME MESSAGE: This case suggests that SPOT ROI can be leveraged to safely reduce radiation during complex percutaneous coronary intervention.

We report two cases of successful percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) lesion with an anomalous origin of the right coronary artery (AORCA) and challenging guiding catheter engagement using a new 3D virtual reality (VR) guiding catheter simulation system. Appropriate guiding catheter selection is critical for a successful complex PCI. A more suitable guiding catheter size, shape, and position with a robust backup force often leads to the successful completion of more accessible and safer procedures. The present case report highlights that VR simulation provides a greater possibility than usual of pre-procedural planning when selecting appropriate guiding catheters and vascular access. The present VR simulation system is based on three-dimensional volume rendering reconstructions of the computed tomography (CT) imaging data; thus, another strength of this technology is that it does not require radiation or radiocontrast exposure to patients. Therefore, transcatheter interventionalists who usually perform complex PCI should be familiar with this innovative system.

Slow-flow or no-reflow phenomenon is a common procedural complication during percutaneous coronary intervention (PCI). Given the presence of fragile plaque or thrombotic materials, we hypothesized that long-time predilatation using a perfusion balloon in conjunction with intracoronary nicorandil administration reduces the risk of slow-flow or no-reflow in patients presenting with acute coronary syndrome (ACS). Subjects were patients presenting with ACS who underwent PCI between April 2020 and April 2022. We retrospectively investigated the incidence of slow-flow or no-reflow during the procedure as well as in-hospital outcomes in comparison between the cases undergoing 3-min predilatation using a perfusion balloon in conjunction with intracoronary nicorandil administration followed by DES implantation (PB group) and those with direct stenting (DS group). Among 439 ACS patients, 36 patients in the PB group and 51 patients in the DS group were examined. Mean age was 70 years and 78.2% was male. Distal protection devices were more frequently used in the DS group than in the PB group (31.3% vs. 11.1%, p = 0.02). The incidence rate of slow-flow or no-reflow was significantly lower in the PB group than in the DS group (2.8% vs. 23.5%; p < 0.01). Six cases (11.7%) in the DS group required intra-aortic balloon pumping (IABP), while none in the PB group required (p < 0.01). In-hospital clinical outcomes did not differ between the two groups. Prolonged perfusion balloon predilatation in conjunction with intracoronary nicorandil administration was safe and feasible. This novel strategy could be an attractive alternative to conventional direct stenting for ACS patients.

We report two case series in which we encountered the difficulties to retrieve disrupted devices during percutaneous coronary intervention and endovascular treatment. The broken devices were successfully and safely retrieved by the "flower technique" that creates multiple cut and slit in the tip of the guiding catheter. This technique can be easily and safely applied in situations where a balloon catheter or stent has been disrupted and device entrapment has occurred, as the technique simply involves manually placing multiple cuts or slits in the tip of the guiding catheter. Transcatheter interventionists should be familiar with this technique because it can be bailout from device entrapment without additional cost or clinical experience.