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Advances in coronary intervention have increased the opportunity to intervene on complex lesions, resulting in an increase in PCI-related complication, including coronary artery perforation. However, treatment options for coronary perforation are limited, with delivery of devices to complex lesions being problematic. Balloon hemostasis is the usual bailout method, despite the risk of myocardial ischemia. In this report, we describe an over-the-wire balloon method to treat a patient with coronary perforation. Ischemia was avoided by injecting autologous blood through the catheter, while hemostasis was achieved by prolonged balloon inflation. This new technique is applicable when a perfusion balloon is not indicated.

An 80-year-old woman was admitted to our emergency department with ongoing dyspnea for 2 weeks. The patient was immediately intubated endotracheally because of the hypoxia with flush pulmonary edema. Electrocardiogram showed ST depression and echocardiogram showed hypokinesis of anterior left ventricular wall with poor systolic function. Also her cardiac enzymes were elevated, emergency coronary angiogram was performed from radial artery because both femoral arteries were not fully palpable. Coronary angiogram showed three vessels disease including chronic total occlusion of right coronary artery and left main bifurcation lesion. Also blood flow of left anterior descending coronary artery was delayed. Acute coronary syndrome was the cause of acute heart failure and revascularization was needed but aortography revealed total occlusion of infrarenal aorta. Patient was relatively hemodynamically stable; we planned treating total occlusion of infrarenal aorta with endovascular therapy to maintain a rout for cardiopulmonary support system. With bi-directional approach from both femoral artery and left brachial artery, occlusion site with heavy calcification was finally passed through by guide wire from retrograde approach. After pull-through technique, self-expanding nitinol stent was implanted after pre dilation with small balloon. Considering her EURO score, supposed perioperative mortality was high, percutaneous coronary intervention was performed. A 7 fr sheath was inserted from right femoral artery and intra-aortic balloon pump was inserted from left femoral artery. Sirolimus-eluting stent was implanted to left circumflex artery and also from ostium of left main to mid left anterior descending coronary artery after using an atherectomy device. After successful revascularization, patient became hemodynamically stable and weaning off the respirator was successful. Reporting case achieved successful revascularization to severe coronary artery disease after endovascular recanalization with infrarenal aortic occlusion.

To investigate the long-term outcome of Percutaneous transluminal intervention (PCI) for chronic total occlusion (CTO). The subjects were 606 patients (1,145 lesions) who were treated for CTO between January 1996 and December 2003 at our institution. Among them, 436 patients with early success and confirmed patency at the CTO by follow-up coronary angiography after 6 months were classified as the patent group (Group P), while 170 patients without early success or with occlusion on follow-up angiography were classified as the occluded group (Group O). In April 2006 (mean: 660 ± 602 days), the outcome of CTO was investigated and the major adverse cardiac events (MACE)-free rate was calculated. Multivariate analysis was performed to identify determinants of death. The early success rate was 76.4% before 2003 when Conquest guidewires were not available. However, it subsequently showed significant improvement to 89%. The cumulative survival rate was significantly higher for Group P (92%) than for Group O (64%) and the MACE-free rate (free from, death, bypass surgery, myocardial infarction, and revascularization) showed a similar trend. The cumulative survival rate of patients without myocardial viability in the territory of the vessel with CTO was significantly higher for Group P (88%) than for Group O (55%). The outcome was significantly worse for patients with occlusion of other vessels (90%) than for patients without additional occlusion (42%). It was significantly better when the left ventricular ejection fraction (LVEF) was ≥40% than when the LVEF was ≤40% (90 vs. 68%). Multivariate analysis identified occluded CTO, other vessel occlusion, low ejection fraction (EF), unimproved EF, and old age as determinants of death from CTO. If early success is obtained and patency is maintained, the long-term outcome after PCI for CTO is significantly better than when failure occurs Occluded CTO, other vessel occlusion, low EF, unimproved EF, and old age are important determinants of the outcome.

To evaluate the 2-year results obtained with self-expandable stent for chronic total occlusion (CTO) of the iliac artery, a retrospective study was performed of patients who underwent endovascular therapy (EVT) for chronic iliac artery CTO who presented from April 2007 to September 2012. 82 patients with 86 occluded iliac arteries underwent successful recanalization and stenting with a self-expandable stent. The primary equivalence end point was a composite of restenosis, mortality, target vessel revascularization, and limb salvage rates. Patients were followed up with the presence of a palpable femoral artery pulse, resolution of symptoms, and noninvasive vascular laboratory testing reviewed at 1, 3, and 6 months after EVT and then were evaluated at 6-month intervals. In patients who gave consent, repeat angiography was done in sixty-one of 86 lesions (70.1 %) for follow-up. The mean follow-up was at 27.6 ± 17.8 months (range 3–60 months). All stents were placed in the true lumen under intravascular ultrasound (IVUS) guidance. There were no cases of peripheral embolization or iliac artery rupture after the procedure. The ankle-brachial index increased significantly from 0.55 ± 0.19 to 0.88 ± 0.17 (P

Carotid artery stenting (CAS) was approved by the government and reimbursement was started in 2008 in Japan, probably the last country in the world. CASCARD is a retrospective registry study performed by cardiologists to assess initial results of CAS in Japan. CAS was indicated for patients with at least one high risk factor for carotid endarterectomy and with >50 % stenosis in symptomatic or >80 % stenosis in asymptomatic patients. Primary endpoint was major adverse events (MAE) including death, myocardial infarction and any stroke at 30 days. Between April 2008 and March 2010, a total of 704 cases were enrolled from 55 centers. The study population with an average age of 74 ± 8 years included 62 % asymptomatic patients, with 23 % of cases with contralateral carotid artery occlusion or significant stenoses. Angioguard filter wire was exclusively used as a primary protection device and successfully passed the lesion in 701 cases (99.6 %). Precise stent was implanted successfully in all cases. MAE at 30 days was 3.7:0.3 % death, 0 % myocardial infarction, and 3.4 % stroke (0.4 % major ipsilateral stroke). Death or any stroke rate at 30 days was 2.7 % in asymptomatic and 5.5 % in symptomatic patients. The CASCARD study showed that the initial results of CAS in Japan are acceptable for both symptomatic and asymptomatic cases.

To evaluate 6-month clinical outcomes after below-the-knee (BTK) angioplasty for critical limb ischemia (CLI) in patients on hemodialysis (HD). Subjects were 69 serial patients (81 limbs, 123 vessels) who underwent percutaneous transluminal angioplasty (PTA) for primary treatment of infrapopliteal lesions in CLI from June 2004 to December 2008. Subjects were classified into two groups for the comparative study of clinical outcomes: the patients on HD: the HD group (35 patients, 45 limbs, 71 vessels, 66 ± 11 years) and the patients not on HD: the non-HD group (34 patients, 36 limbs, 52 vessels, 69 ± 9 years). A non-randomized retrospective comparative study was conducted to obtain clinical outcomes at 6 months. In clinical results at 6 months, a higher percentage of tendency toward repeat PTA for the treated leg in the HD group (28.9 vs. 11.1%, p = 0.059), but it was not statistically significant. There was no significant difference in the rate of major amputation (11.1 vs. 5.5%) between the two groups. However, the percentage of repeat PTA performed twice or more times (13.3 vs. 0%, p = 0.031) and all-cause mortality (17.1 vs. 0%, p = 0.012) in the HD group was significantly higher than in the non-HD group. The HD group had a significantly lower rate of freedom from all-cause mortality, major amputation, or repeat PTA in the 6-month follow-up compared to the non-HD group, with the HD group 51.4% and the non-HD group 85.3% (logrank test p = 0.003). Although there are more HD patients requiring repeat revascularization compared to the general population, the 6-month outcomes of limb salvage after BTK angioplasty for CLI in HD patients were not significantly different from the general population.