Intramural hematoma extending from a dissection within an implanted stent: a case report treated with fenestration using a cutting balloon

Background

Dissection after balloon dilation or stent implantation is a common complication of percutaneous coronary intervention. In general, coronary stent implantation for coronary artery dissection is safe when the dissection is completely covered by the stent, particularly when dissection occurs during pre-dilation. However, here, we report a case of severe restenosis caused by a pre-dilation hematoma that extended after stent implantation.

Case summary

A 76-year-old man was diagnosed with angina on exertion and underwent percutaneous coronary intervention in the right coronary artery. After pre-dilation with a cutting balloon, non-flow-limiting dissection occurred. An everolimus-eluting stent was implanted, completely sealing the dissection, and intravascular ultrasound revealed adequate stent expansion without stent edge dissection. Two weeks after the procedure, confirmatory coronary angiography revealed severe restenosis extending from the distal stent edge to the distal right coronary artery. Intravascular ultrasound revealed a hematoma extending from the middle of the stent to the distal segment.

Discussion

The patient had been on steroids for a long time. The cutting balloon used for pre-dilation may have created a deep dissection reaching the tunica media, already rendered vulnerable by steroids, potentially leading to injury to the vasa vasorum. The intramural hematoma from the bleeding vasa vasorum might have been the underlying cause of this phenomenon, as evidenced by its increase in size despite the entry of the dissection being completely sealed. Cardiologists should be aware of this possibility.

Plaque modification in calcified chronic total occlusions: the PLACCTON study

INTRODUCTION AND OBJECTIVES

Severe calcification is present in> 50% of coronary chronic total occlusions (CTOs) undergoing percutaneous intervention. We aimed to describe the contemporary use and outcomes of plaque modification devices (PMDs) in this context.

METHODS

Patients were included in the prospective, consecutive Iberian CTO registry (32 centers in Spain and Portugal), from 2015 to 2020. Comparison was performed according to the use of PMDs.

RESULTS

Among 2235 patients, wire crossing was achieved in 1900 patients and PMDs were used in 134 patients (7%), requiring more than 1 PMD in 24 patients (1%). The selected PMDs were rotational atherectomy (35.1%), lithotripsy (5.2%), laser (11.2%), cutting/scoring balloons (27.6%), OPN balloons (2.9%), or a combination of PMDs (18%). PMDs were used in older patients, with greater cardiovascular burden, and higher Syntax and J-CTO scores. This greater complexity was associated with longer procedural time but similar total stent length (52 vs 57mm; P=.105). If the wire crossed, the procedural success rate was 87.2% but increased to 96.3% when PMDs were used (P=.001). Conversely, PMDs were not associated with a higher rate of procedural complications (3.7 vs 3.2%; P=.615). Despite the worse baseline profile, at 2 years of follow-up there were no differences in the survival rate (PMDs: 94.3% vs no-PMDs: 94.3%, respectively; P=.967).

CONCLUSIONS

Following successful wire crossing in CTOs, PMDs were used in 7% of the lesions with an increased success rate. Mid-term outcomes were comparable despite their worse baseline profile, suggesting that broader use of PMDs in this setting might have potential technical and prognostic benefits.

Left atrial unloading with an 8 mm septal cutting balloon to treat postcapillary pulmonary hypertension: a case report

We report the case of a 58‐year‐old female with severe postcapillary pulmonary hypertension (averaged mean pulmonary arterial pressure was 49 mmHg, pulmonary arterial wedge pressure 29 mmHg, and right atrial pressure 8 mmHg) due to heart failure with preserved ejection fraction. A left‐to‐right atrial shunt was created using an 8 mm cutting balloon, under transesophageal echocardiography guidance. Both pulmonary arterial and wedge pressure dramatically decreased after the procedure. Symptoms immediately improved and benefits were sustained at 6 months of follow‐up. This case suggests that iatrogenic septal defect using a cutting balloon could be an option to treat symptomatic postcapillary pulmonary hypertension.

Intravascular ultrasound-guided treatment for simultaneous ostial left main intramural hematoma and anomalous right aortocoronary dissection

The prevalence of iatrogenic catheter-induced ostial coronary artery dissection is very low (0.09%) (1). The incidence of coronary anomalies (total) is 5.64% and ectopic right coronary artery (RCA) (left cuspid) is also rare (0.92%) (2). To the best of our knowledge, this is the first case report of a simultaneous iatrogenic catheter-induced ostial RCA dissection and propagation to the ostial left main (LM) coronary artery by intramural hematoma (IMH). We report a case of a 61-year-old male with underlying disease of type 2 diabetes mellitus and hypertension under regular medication control. He had experienced intermittent chest pain for more than 3 months. He came to our hospital after suffering acute RCA occlusion with cardiogenic shock without management while receiving diagnostic catheterization in another hospital. To perform the initial diagnostic, we used a 6 French Ikari Left 4 (Terumo, Japan) guiding catheter and changed to a 6 French SAL1 (Medtronic, U.S.A.) guiding catheter to determine the origin of the RCA anomaly in the left coronary cuspid. Initially, ostial dissection with intramural hemorrhage at the RCA without flow compromised with the acknowledgement of LM propagation (Panel A) (Video 1). Ostial RCA was managed directly with a Xience Sierra stent (3.5 × 23 mm; Abbott, U.S.A) to seal the entry of dissection, followed by NC emerge 3.5 × 15 mm balloon (Boston, U.S.A.) inflated up to 24 atmosphere (atm). Intravascular ultrasound (IVUS) confirmed that the stent fully covered the entry point of the ostial RCA (Panel B). The left main (Panel C) was then managed by IVUS-guided (Boston iLAB Opticross, U.S.A.) cutting balloon (Wolverine 4.0 × 6 mm; Boston, U.S.A.) inflated at up to 12 atm to fenestrate the IMH (Panel D; Video 2) at the LM level, followed by the implantation of a bailout stenting Xience Sierra (4.0 × 18 mm; Abbott, U.S.A) and by NC emerge 5.0 × 15 mm balloon (Boston, U.S.A.) inflated up to 18 atm. Post procedure angiogram and IVUS confirmed the effectiveness of the intervention. (Panel E, F). In this case, due to the origin of the RCA anomaly, the dissection and IMH immediately propagated to the LM. Fortunately, the patient was hemodynamically stable. We chose to use the cutting balloon and IVUS-guided intervention strategy, which resulted in the remission of the patient's condition.

Wolverine cutting balloon in the treatment of stent underexpansion in heavy coronary calcification: bench test using a three-dimensional printer and computer simulation with the finite-element method

Heavy coronary calcification hinders successful stent implantation, and cutting balloons can be used for post-dilation after stent deployment. However, evidence regarding its use is limited to case reports. Therefore, this study aimed to investigate in-stent dilation in circumferential coronary calcifications using Wolverine cutting balloons, compared with conventional non-compliance (NC) balloons. Circumferential coronary calcification models were designed based on the patient's intravascular ultrasound images. Three-dimensional printed models were subjected to bench tests and software analysis was performed using the finite-element method (FEM). As a result, the bench test showed that higher balloon pressure was needed to dilate the models with stent implantation, either using Wolverine (17.1 ± 2.7 atm) or NC Emerge (18.9 ± 1.8 atm), while lower pressure was needed in models without stents using Wolverine [11.7 ± 2.9 atm, analysis of variance (ANOVA) p < 0.001]. Furthermore, models without stents were all successfully cracked by Wolverine at the first dilation, while models with stent implantation needed more dilations (ANOVA p = 0.0132). The FEM showed similar results that the first principal stress was the highest in Wolverine-dilated models without stents. In conclusion, implanted stents significantly increase the difficulty of balloon dilation and adequate pretreatment is critical for successful coronary stenting.

Efficacy of the Wolverine cutting balloon on a circumferential calcified coronary lesion: Bench test using a three-dimensional printer and computer simulation with the finite element method

Heavy calcification is one of the factors that hinder the success of coronary angioplasty, and a cutting balloon is used for such lesions. This study aimed to explore the optimal method of dilation of highly calcified lesions using a cutting balloon. Calcification models were developed from patient computed tomography and intravascular ultrasound data, and were constructed using three-dimensional printers. The lesions were dilated using a Wolverine™ cutting balloon and NC Emerge™ noncompliant balloon catheter, and the success rate of dilation and maximum dilation pressure were compared. The maximum first principal stresses in calcified lesions were also evaluated by computer simulation using the finite element method. In the bench test, the dilation success rate of the Wolverine™ cutting balloon was higher and the maximum dilation pressure required was lower (p < 0.01 in all analyses), compared with that of the NC Emerge™ balloon catheter. Finite element analysis showed that the cutting blade increased the maximum first principal stresses in calcified lesions, thus allowing for successful dilation at low pressures. The highest stress was obtained when the cutting blade was positioned at the thinnest part of the calcification. The cutting balloon allows for efficient calcification expansion by concentrating the stresses in the blade. When a cutting balloon is used, if the calcified lesion cannot be expanded in a single dilation, dilation success may be achieved after the balloon is rotated and the position of the blade is changed.

Network meta-analysis of trials comparing first line endovascular treatments for arteriovenous fistula stenosis

OBJECTIVE

We investigated the comparative effectiveness of different endovascular treatments for patients with failing autogenous arteriovenous fistulas (AVFs) with outflow vein stenosis.

METHODS

The Medline (via PubMed) and SCOPUS databases were searched. We performed a systematic review and network meta-analysis of randomized controlled trials that had investigated the effectiveness of plain balloon angioplasty (PBA), cutting balloon angioplasty, and drug-coated balloon angioplasty (DCBA) to treat vein stenoses in autogenous AVFs. Studies of central vein stenosis were excluded. The main outcome measures were the failure rates at 6 months and 1 year after treatment.

RESULTS

Eleven randomized controlled trials were included, with 814 patients, 395 of whom had undergone PBA. The network meta-analysis showed that DCBA at 6 months was significantly more effective than PBA (odds ratio, 0.39; 95% confidence interval, 0.18-0.81) and ranked as the best treatment option, although the difference was not statistically significant compared with cutting balloon angioplasty (odds ratio, 0.65; 95% confidence interval, 0.20-2.12). The differences among the three treatments at 1 year were not statistically significant. Additional conventional pairwise meta-analyses did not find significant differences at 1 year.

CONCLUSIONS

In failing AVFs with outflow stenosis, DCBA was significantly superior to PBA, with improved 6-month failure rates. However the effectiveness of DCBA in the long term deserves further investigation.

An update on vessel preparation in lower limb arterial intervention

Background

Plain balloon angioplasty has traditionally been used to treat lower limb arterial disease but can be limited by significant residual stenosis, vessel recoil, dissection, and by late restenosis. Appropriate vessel preparation may significantly improve short and long-term outcomes. We aim to give an overview of some of the devices currently available, or under investigation, for vessel preparation in the lower limb.

Main text

Vessel preparation devices include those that remove plaque (atherectomy devices) and those that modify plaque.

The four groups of plaque removing atherectomy devices are defined by their plaque removal method: Directional, rotational orbital and excimer laser are categories of devices investigated for plaque modification.

Intravascular lithotripsy devices generate sonic pulsatile pressure waves that pass into the vessel wall cracking calcified plaques whilst sparing soft tissue. This enables dilatation of calcified lesions at low pressure by conventional balloons and enables full stent expansion.

Other balloon based vessel preparation devices were designed to modify plaque and produce more controlled, lower pressure luminal expansion without major dissections and potentially with less recoil than conventional angioplasty balloons. Scoring balloons have a helical nitinol element attached to the balloon that scores plaque facilitating uniform luminal enlargement. Further specialty balloons have been developed in recent years, including the Chocolate, Phoenix and Serranator balloons. Finally, the temporary Spur self-expanding retrievable nitinol stent has a series of radially aligned spurs that are driven into the vessel wall by post-dilatation, potentially improving drug delivery.

Conclusion

Lesion specific vessel preparation aims to improve both short and long term outcomes through improved penetration of anti-proliferative drug, maximising luminal gain, reducing the need for stent placement and minimising intimal injury. Some forms of vessel preparation appear to improve short term outcomes; long-term outcomes remain uncertain. An overview of some of the multiple devices available for vessel preparation is presented.

Improved crossability with novel cutting balloon versus scoring balloon in the treatment of calcified lesion

Cutting balloons and scoring balloons are commonly used for the preparation of calcified lesion. However, problems with crossability occasionally limit the use of cutting balloons. We prospectively selected 173 calcified lesions treated using a novel cutting balloon (Wolverine™, C group). As control, we retrospectively analyzed 146 calcified lesions treated using a scoring balloon (Lacrosse NSE ALPHA™, S group). Either intravascular ultrasound (IVUS) or optical coherence tomography (OCT) was used by the operator's discretion. The primary outcome was delivery success, which was defined as successful passage to the target lesion immediately after IVUS or OCT evaluation. The secondary outcome was acute cross-sectional area (CSA) gain, which was defined as post-interventional minimum stent area minus pre-procedural minimum lumen area. A multivariate analysis evaluated the independent predictors for delivery success. The delivery success rate was significantly higher in the C group versus the S group (90.8% versus 79.5%, P = 0.006). However, the acute CSA gain was similar between the two groups (IVUS: 3.2 ± 1.8 mm² versus 3.4 ± 1.9 mm², P = 0.53; OCT: 3.6 ± 1.4 mm² versus 4.1 ± 1.9 mm², P = 0.11). Usage of cutting balloon was an independent predictor for delivery success even after the adjustment for the patient and lesion characteristics [odds ratio (OR): 2.72 (95% confidence interval 1.38-5.33), P = 0.004] as well as the procedural characteristics [OR: 2.34 (1.15-4.86), P = 0.018]. Novel cutting balloons demonstrated better crossability and similar acute CSA gain compared with scoring balloons in calcified lesion.

Successful treatment of a spontaneous right coronary artery dissection with a 4-mm diameter cutting balloon: a case report

Background

Guidelines recommend conservative management for a spontaneous coronary artery dissection (SCAD) in the absence of ongoing ischaemia, haemodynamic instability, or left main dissection. Conventional percutaneous coronary intervention methods for SCAD are associated with an unfavourable prognosis due to difficulties wiring the lesion, dissection propagation, and potential ‘milking’ of the intramural haematoma along the vessel or into other vessels. These factors promote implantation of multiple stents which are often undersized, increasing the risk of in-stent restenosis significantly. There have been several case reports demonstrating the novel use of small diameter cutting balloons in the left anterior descending artery system. Here, we describe the successful use of a larger 4 mm cutting balloon to treat a spontaneous right coronary artery (RCA) dissection.

Case summary

A 53-year-old woman with troponin negative chest pain and was diagnosed with unstable angina due to ischaemic electrocardiographic features. Coronary angiography revealed a tight discrete lesion in the RCA. Intravascular imaging confirmed SCAD and a 4 mm cutting balloon was used to dissect the tunica intima to allow complete resorption of the intramural haematoma and resolution of symptoms.

Discussion

This case demonstrates the safe use of a larger 4 mm cutting balloon to treat an RCA SCAD, resulting in complete resolution of the haematoma.

A pilot study evaluating cutting and high-pressure balloon valvuloplasty for dysplastic pulmonary valve stenosis in 7 dogs

INTRODUCTION

This case series describes early experience and technical aspects of cutting balloon dilation followed by high-pressure balloon pulmonary valvuloplasty in dogs with dysplastic pulmonary valve stenosis.

ANIMALS

Seven client-owned dogs were enrolled in this study.

METHODS

Dogs were prospectively enrolled based on echocardiographic diagnosis of severe pulmonary valve dysplasia, defined as marked valve thickening with variable degrees of annular hypoplasia or subvalvar fibrous obstruction and a peak echocardiography-derived transpulmonary pressure gradient higher than 100 mmHg. Preinterventional and postinterventional hemodynamic data and transthoracic pressure gradients were obtained for all dogs. Recheck echocardiography varied in timing by client convenience, with maximum follow-up 35 months after intervention.

RESULTS

No intraprocedural or periprocedural mortality was observed. The only major complication was partial avulsion of a cutting blade related to exceeding recommended burst pressure of the device, which was not associated with obvious clinical consequence. Invasive hemodynamic measurements demonstrated an average reduction of 46% in peak systolic right ventricular-to-pulmonary artery pressure gradient (range, 31-77%). The echocardiographic results 24 h after procedure demonstrated an average reduction in pressure gradient of 43% (range, 20-66%), with late follow-up demonstrating an average reduction of 35% (range, 10-57%) compared with preprocedural echocardiography.

CONCLUSIONS

This procedure is a feasible therapeutic transcatheter intervention for dogs with dysplastic pulmonary valves and appears safe in this small cohort. The ideal selection criteria and rate of restenosis for this procedure is under investigation, and long-term follow-up and a large, randomized, controlled study are necessary to demonstrate efficacy.

Percutaneous Coronary Intervention for the Treatment of Spontaneous Coronary Artery Dissection

Most patients presenting with myocardial infarction owing to spontaneous coronary artery dissection can be managed conservatively. Revascularization should be pursued in the presence of high-risk features. Percutaneous coronary intervention is preferred over coronary artery bypass grafting, except in left main dissection. Interventionists should exercise extreme caution and meticulous techniques. Using a cutting balloon to fenestrate and decompress the false lumen is appealing and may avoid the need for long stents. Other percutaneous approaches may also be feasible, and interventionists should be familiar with these various approaches when embarking on spontaneous coronary artery dissection percutaneous coronary intervention.

How Should We Treat Heavily Calcified Coronary Artery Disease in Contemporary Practice? From Atherectomy to Intravascular Lithotripsy

Heavily calcified and densely fibrotic coronary lesions continue to represent a challenge for percutaneous coronary intervention (PCI), as they are difficult to dilate, and it is difficult to deliver and implant drug-eluting stents (DES) properly. Poor stent deployment is associated with high rates of periprocedural complications and suboptimal long-term clinical outcomes. Thanks to the introduction of several adjunctive PCI tools, like cutting and scoring balloons, atherectomy devices, and to the novel intravascular lithotripsy technology, the treatment of such lesions has become increasingly feasible, predictable and safe. A step-wise progression of strategies is described for coronary plaque modification, from well-recognised techniques to techniques that should only be considered when standard manoeuvres have proven unsuccessful. We highlight these techniques in the setting of clinical examples how best to apply them through better patient and lesion selection, with the main objective of optimising DES delivery and implantation, and subsequent improved outcomes.

Cutting balloon treatment of anastomotic biliary stenosis after liver transplantation: Report of two cases

Biliary stenosis is a common complication after liver transplantation, and has an incidence rate ranging from 4.7% to 12.5% based on our previous study. Three types of biliary stenosis (anastomotic stenosis, non-anastomotic peripheral stenosis and non-anastomotic central hilar stenosis) have been identified. We report the outcome of two patients with anastomotic stricture after liver transplantation who underwent successful cutting balloon treatment. Case 1 was a 40-year-old male transplanted due to subacute fulminant hepatitis C. Case 2 was a 57-year-old male transplanted due to hepatitis B virus-related end-stage cirrhosis associated with hepatocellular carcinoma. Both patients had similar clinical scenarios: refractory anastomotic stenosis after orthotopic liver transplantation and failure of balloon dilation of the common bile duct to alleviate biliary stricture.

The use of a cutting balloon in contemporary reverse controlled antegrade and retrograde subintimal tracking (reverse CART) technique

The key concept of reverse controlled antegrade and retrograde tracking (CART) technique is retrograde puncture with a tapered wire to an antegrade balloon (contemporary reverse CART) or new connections between the antegrade and retrograde subintimal space (classical reverse CART). In our case, a 75-year-old man with severe chronic total occlusion of the right coronary artery, reverse CART with conventional balloons could not be accomplished. Externalization wiring was completed by contemporary reverse CART using a cutting balloon as an antegrade balloon to improve the fenestration force of the retrograde guidewire. Thus, the use of a cutting balloon for contemporary reverse CART might be promising.

Intensive plaque modification with rotational atherectomy and cutting balloon before drug-eluting stent implantation for patients with severely calcified coronary lesions: a pilot clinical study

BACKGROUND

This study investigated whether, for patients with severely calcified coronary lesions, use of a cutting balloon (CB) during rotational atherectomy (RA) before placing a drug-eluting stent will improve periprocedural outcomes, compared to RA with a conventional plain balloon.

METHODS

In a randomized controlled trial, patients with severely calcified lesions of calcium arc ≥180° were apportioned to receive intensive plaque modification with RA and CB (RA + CB; n = 35) or RA with conventional plain balloon (RA; n = 36). Intravascular ultrasound was applied for quantitative or qualitative analyses of percutaneous coronary intervention outcomes. The primary outcome was acute lumen gain after drug-eluting stent.

RESULTS

The RA + CB and RA groups were similar in baseline mean arcs of superficial calcium, and minimum lumen cross-sectional areas (CSAs). The mean minimum stent CSA after percutaneous coronary intervention (PCI) of the RA + CB group (5.9 ± 1.7 mm(2)) was significantly larger than that of the RA group (5.0 ± 1.4 mm(2); P = 0.021). Patients in the RA + CB group achieved significantly larger acute CSA gain after PCI (4.5 ± 1.5 mm(2)) relative to the RA group (3.8 ± 1.5 mm(2); P = 0.035). The groups were similar in rates of periprocedural complications, but at the 1-year follow-up the RA + CB had a lower rate of revascularization for restenosis of the target vessel and MACE (5.7 %) than did the RA group (22.2 %, P = 0.046).

CONCLUSION

Aggressive plaque preparation with RA and CB seems to be safe and effective for patients with severely calcified coronary lesions.

TRIAL REGISTRATION

Current Controlled Trials ChiCTR-INR-16008274 . Retrospectively registered 12 April 2016.