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Background: Reversing heparin when managing coronary artery perforation (CAP) during percutaneous coronary intervention (PCI) can provide hemostasis but may cause coronary thrombosis if a device is still present in a coronary artery., Aims: To assess the impact of heparin reversal while an intracoronary artery device is in place for CAP., Methods: This study analyzed CAP cases during PCI from January 2006 to October 2023. Patients were grouped according to implementing heparin reversal while an intracoronary artery device was in place. The safety outcome was coronary thrombosis after CAP. The efficacy outcomes were successful hemostasis and death from any cause., Results: CAP occurred in 368 of 22,368 cases (1.6%). Patients who had heparin reversal with a device in place comprised 211 (57%). Among these, coronary thrombosis occurred in 16 (7.6%). An activated clotting time (ACT) 〈150 seconds was significantly correlated with coronary thrombosis. Heparin reversal with a device in place was significantly associated with successful hemostasis (heparin reversal 91% vs. no heparin reversal 73%; adjusted odds ratio 2.78; 95% confidence interval 1.27-6.13; p = 0.011), but was not different for death from any cause (heparin reversal 4.3% vs. no heparin reversal 5.7%; adjusted odds ratio 0.97; 95% confidence interval 0.28-3.43; p = 0.964)., Conclusion: Heparin reversal with a device in place was associated with an increased risk of coronary thrombosis when ACT was less than 150 seconds. While it may not have a substantial association with a reduced risk of mortality, it offers an advantage in achieving successful hemostasis., (© 2024 Wiley Periodicals LLC.)

Background: This study highlights the prevalence and conservative management strategies of iatrogenic ascending aortic dissection after percutaneous intervention (PCI) of chronic total occlusion (CTO)., Methods: Retrospective analysis on patients who underwent CTO PCI from one medical center from 2020 to 2022 was performed by two operators. Data was obtained from the Prospective Global Registry for the Study of CTO database., Results: Out of 318 patients, there were six reported cases of iatrogenic ascending aortic dissection. The causes of dissection included guiding catheter trauma, antegrade injection, two retrograde injection, and two cases of balloon rupture after lithotripsy. IVUS-guided stenting of the coronary back to the origin to seal the entry of the dissection flap occurred in two patients. All patients had a conservative management approach. No patient had to undergo urgent surgery., Conclusion: While the incidence remains rare, complications, including aortic dissection, are more frequent in CTO PCI as compared to non-CTO PCI. IVUS can be used to complete coronary intervention so long as the patient remains clinically and hemodynamically stable. Patients should have formal imaging with either transesophageal echocardiogram or computed tomography angiography. The outcomes of patients who experience iatrogenic aortic dissection during CTO PCI with stable coronary disease seem to be better than in patients with acute coronary syndrome., (© 2024 The Author(s). Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Dry tamponade is a rare complication of percutaneous coronary intervention. It encompasses a heterogenous pathophysiology and is used to describe hemodynamic compromise secondary to a coronary artery perforation, without free-flowing fluid in the pericardium. Tamponade physiology can result from compressive epicardial, intramyocardial, subepicardial hematomas, or dissecting intramyocardial hematomas. The diagnosis of dry tamponade requires hemodynamic derangement in the context of a compressive hematoma as demonstrated by imaging. Although echocardiography can often help identify dry tamponade, additional studies including right heart catheterization, computed tomography, or cardiac magnetic resonance imaging can inform the exact mechanism and help guide management. This article describes a case of dry tamponade, reviews the existing literature on the topic, and offers expert recommendations on diagnosis and management., (© 2024 Wiley Periodicals LLC.)

Mitral valve repair or replacement poses a potential risk of injury to the left circumflex coronary artery (LCx). Such injuries can arise from either direct LCx injury caused by encircling or transfixing stitches, or indirect occlusion resulting from the distortion of adjacent tissues. We provide and illustrate a representative image depicting LCx distortion. Additionally, we offer guidance to aid angiographers in comprehending the angiographic appearance and the underlying mechanism of occlusion., (© 2024 Wiley Periodicals LLC.)

Coronary perforation (CP) poses a significant risk of morbidity and mortality, particularly, in patients with a history of cardiac surgery. The occurrence of loculated pericardial effusion presents distinctive challenges in these postcardiac surgical patients. This study delves into the complexities arising from the formation of loculated pericardial effusions subsequent to CP, with a specific focus on the loculated effusion in the posterior wall leading to left atrial compression syndrome. This analysis is dedicated to elucidating pathophysiology diagnostic and treatment strategies tailored for addressing left atrium compression syndrome, providing invaluable insights into the intricacies of diagnosing, treating, and managing this entity in the postcardiac surgical patient., (© 2024 Wiley Periodicals LLC.)

Transfemoral transcatheter aortic valve replacement is the preferred primary access route whenever possible. Despite advancements in expertise and delivery system profiles, complications associated with the primary femoral access still significantly affect procedural morbidity and outcomes. The current standard for accurate main access planning involves proper preprocedural evaluation guided by computed tomography. Several baseline clinical and anatomical features serve as predictors for the risk of vascular injury occurring during or after transcatheter aortic valve replacement. In this paper, we aimed at reviewing the most up-to-date knowledge of the topic for a safe transfemoral access approach according to a paradigm we have called "PIGTAIL.", (© 2024 The Author(s). Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Large vessel perforation during coronary intervention is a rare but potentially fatal complication, often requiring implantation of a covered stent for resolution. While technology is improving, the long-term patency of covered stents is less than drug-eluting stents, and implantation of covered stents should be used sparingly. Large vessel perforations are complex and often the perforation inflow is not located at the site of extravasation seen on angiography. This can lead to geographic miss when implanting covered stents and necessitate the implantation of additional covered stents which increases the risk for short- and long-term complications. We present a case series to further investigate the anatomy and mechanism of large vessel perforations and guidance on effective covered stent implantation., (© 2024 Wiley Periodicals LLC.)

Ellis type 4 coronary artery perforation (CAP4), also referred to as Ellis type 3 cavity-spilling perforation, is a rare but life-threatening complication of percutaneous coronary intervention characterized by extravasation of blood into a cardiac chamber, anatomic cavity, or coronary sinus or vessel. CAP4 is uncommon, accounting for 1.9% to 3.0% of all CAP. Only 11 cases of CAP4 have been reported in detail; we report an additional two cases and review prior reports of this rare complication. Our first case highlights a patient with chronic anginal symptoms due to a 75% concentric stenotic lesion in the mid-LAD. Revascularization was complicated by perforation during pre-dilation with robust contrast extravasation into the left ventricle. Successful postperforation hemostasis was achieved with heparin reversal and covered stent placement. The second case demonstrates another major mechanism of CAP4: wire perforation. During intervention, the absence of blood flow distal to the lesion in the setting of an ST segment elevation myocardial infarction obscured the course of the nonhydrophilic floppy wire leading to perforation that was managed conservatively. In our scoping review, we found that the majority of CAP4 occurred in the LAD. The most frequently involved cavity was the left ventricle-other cavities involved were the right ventricle and coronary veins. Common etiologies of CAP4 included guidewire perforation (62%) and balloon dilation (31%). Perforation was managed with reversal of anticoagulation in 46% of cases, prolonged balloon inflation in 54% of cases, and covered stent deployment in 15% of cases. No patients required surgical repair or pericardiocentesis and perforations were successfully sealed in all cases. In-hospital mortality was 0%., (© 2023 Wiley Periodicals LLC.)

Coronary artery perforation (CAP) is a rare but lethal complication of percutaneous coronary interventions (PCIs), and its incidence has been increasing with advances in PCI techniques. Delayed CAP presents a highly challenging complication, as it occurs 30 min-9 days after intervention, making subsequent diagnosis and treatment difficult. We present the case of a 63-year-old male patient who underwent PCI for an obtuse marginalis II because of posterior wall myocardial infarction. Following 4 days of uneventful postoperative stay, the patient developed angina pectoris and hypotension 4 h after reinitiation of anticoagulant therapy with edoxaban. Angiography revealed distal vessel perforation from a side branch of the obtuse marginalis II. The vessel was occluded using autologous fat embolization via a microcatheter, resulting in complete sealing of the perforation. After discharge, 4 weeks after the infarction, the patient started rehabilitation therapy. Distal vessel perforations are typically caused by wire damage. In our case, we also suspected distal wire perforation, which was initially not recognized possibly due to distal occlusion through the thrombotic material. The temporal correlation between the re-initiation of anticoagulant therapy and the occurrence of cardiac tamponade suggests that the thrombotic material was resolved due to the former. The management of delayed CAP does not differ from that of CAP; thus, this rare complication should be considered even days after PCI as it could prove lethal if not recognized early., (© 2023 Wiley Periodicals LLC.)

Aim: The impact of Grade III coronary perforations (G3-CP) in the setting of CTO-PCI is not well assessed., Methods and Results: We reviewed 7773 CTO-PCI and 98,819 non CTO-PCI performed in 10 European centers: G3 perforation occurred in 87 patients (1.1%) during CTO PCI and 224 patients (0.22%) during non CTO-PCI (p < 0.001). G3-CP involved the CTO segment in 68% of patients and the retrograde channels in 14% of cases. In the CTO PCI group, wire induced G3-CP (50.5% vs. 32.5%, p = 0.02) occurred predominantly when dedicated CTO tapered and highly penetrative wires were used. Intra-procedural and in-hospital death rates were 4.6% vs. 5.8% and 3.6% vs. 7.5% respectively for CTO PCI and non-CTO PCI groups (p = NS). At a median follow up of 24 months, the overall mortality and MAE were respectively 7.8% and MAE 19% without difference among groups., Conclusions: We showed similar in-hospital and long-term outcomes when G3 perforations occurred during CTO PCI and non CTO-PCI., (© 2022 Wiley Periodicals LLC.)

We describe a female patient who received hybrid catheter intervention and occlusion of the patent ductus arteriosus (PDA) and left atrial appendage (LAA). Four hours after the procedure, pericardial tamponade suddenly occurred. Surgical exploration of the heart found that a fixation hook of the WATCHMAN device, had protruded through the LAA wall and tore the dilated pulmonary artery (PA). This is the first case report to describe PA perforation caused by barbs of the WATCHMAN device, and more attention should be paid to the relationship between the LAA and its adjacent structures before LAA closure., (© 2019 Wiley Periodicals, Inc.)

Objectives: This review aims to evaluate the adverse outcomes for patients after treatment with covered stents., Background: Coronary perforation is a potentially fatal complication of percutaneous coronary revascularization which may be treated using covered stents. Studies have evaluated long-term outcomes among patients who received these devices, but hitherto no literature review has taken place., Methods: We conducted a systematic review of adverse outcomes for patients after treatment with covered stents. Data from studies were pooled and outcomes were compared according to stent type., Results: A total of 29 studies were analyzed with data from 725 patients who received covered stents. The proportion of patients with chronic total occlusions, vein graft percutaneous coronary intervention (PCI), intracoronary imaging and rotational atherectomy were 16.9, 11.5, 9.2, and 6.6%, respectively. The stents used were primarily polytetrafluoroethylene (PTFE) (70%) and Papyrus (20.6%). Mortality, major adverse cardiovascular events, pericardiocentesis/tamponade and emergency surgery were 17.2, 35.3, 27.1, and 5.3%, respectively. Stratified analysis by use of PTFE, Papyrus and pericardial stents, suggested no difference in mortality (p = .323), or target lesion revascularization (p = .484). Stent thrombosis, pericardiocentesis/tamponade and emergency coronary artery bypass surgery (CABG) occurred more frequently in patients with PTFE stent use (p = .011, p = .005, p = .012, respectively). In-stent restenosis was more common with pericardial stent use (<.001, pooled analysis for first- and second-generation pericardial stents)., Conclusions: Cases of coronary perforation which require implantation of a covered stent are associated with a high rate of adverse outcomes. The use of PTFE covered stents appears to be associated with more stent thrombosis, pericardiocentesis/tamponade, and emergency CABG when compared to Papyrus or pericardial stents., (© 2019 Wiley Periodicals, Inc.)

Coronary sinus perforation is a life-threatening complication of transseptal puncture and needs to be repaired immediately. In this study, we report a case of a 74-year-old female patient with nonvalvular atrial fibrillation, who is a poor long-term anticoagulation candidate. During the manipulation of transseptal puncture, a perforation of the free right atrial wall at the coronary sinus ostium occurred, which was caused by the Brockenbrough needle and followed by the immediate advancement of an 8.5-French transseptal sheath. In consideration of the danger of cardiac tamponade after sheath removal, we decided to leave the 8.5-French sheath in the pericardial cavity. Then, we advanced a 6 mm ventricular septal occluder through the sheath. Finally, we achieved successful deployment of the device and closure of the perforation under the guidance of fluoroscopy and transthoracic echocardiography. Subsequently, the left atrial appendage orifice was occluded with a 21 mm Watchman device. This case illustrates that percutaneous device closure is feasible for inadvertent perforation of the free right atrial wall at the coronary sinus during transseptal puncture and should be considered as an alternative to surgery., (© 2019 Wiley Periodicals, Inc.)

Pseudoaneurysm of the non-coronary sinus of Valsalva is an exceptionally rare but potentially fatal complication of percutaneous coronary interventions (PCI). Here, we report a case of a 53-year-old man with pseudoaneurysm of the non-coronary sinus of Valsalva following PCI who presented with recurrent chest pain and was treated successfully by closure of the orifice of the pseudoaneurysm and coronary artery bypass grafting., (© 2019 Wiley Periodicals, Inc.)

Objectives: To expand on the limited available literature regarding the use of balloon expandable covered stents for the treatment of traumatic aortic injuries (TAI) in the pediatric population., Background: Although endovascular grafts have largely replaced surgery for TAI repair, there are significant limitations to the use of these grafts in pediatric patients., Methods: Multicenter, retrospective chart review of pediatric patients with TAI following blunt chest wall trauma. Procedural characteristics, follow-up, and reinterventions are described., Results: Six covered stents implanted in five patients. Median patient age was 12 years (11-13 years) and median weight 50 kg (44-54 kg). Procedural success was achieved in all cases. No procedural or postprocedural complications were noted. Median follow-up time was 24 months (11-36 months)., Conclusions: Balloon expandable covered stent treatment of pediatric patients with TAI is a feasible alternative to open surgical repair, and preferred over endovascular grafts due to graft size limitations and the large delivery systems., (© 2019 Wiley Periodicals, Inc.)

Coronary artery anomalies (CAA) are anatomical aberrations in the origin, structure, and course of the epicardial arteries. Literature has detailed common anomalies or fistulas formed because of coronary artery bypass grafting (CABG) manipulation of intrathoracic vessels. Despite the commonality of the CABG procedure, there are a few CAA and fistula findings which remain extremely rare. We present a case of left internal mammary artery to pulmonary artery fistula causing coronary steal syndrome that presented symptomatically as a malignant arrhythmia. Following a literature review of therapy, intervention, and management we recommend a team based approach when faced with this extremely rare case presentation. The goal of management should to reduce symptoms, and ischemia, by reducing or stopping flow through the fistula and out of the coronary blood supply., (© 2019 Wiley Periodicals, Inc.)

Cardiopulmonary resuscitation (CPR) is essential for the survival of cardiac arrest patients. High-quality chest compressions are critical for survival, but energetic resuscitation efforts can lead to chest injuries. Internal mammary artery (IMA) injury is a rare complication of CPR, but can lead to life-threatening intrathoracic hemorrhage. Early detection of IMA injury should be considered in all post cardiac arrest syndrome (PCAS) with anemia refractory to transfusion. To the best of our knowledge, no cases of CPR-associated bilateral IMA laceration have ever been reported. We report a unique CPR complication resulting in anterior mediastinal hemorrhage that was detected by ECHO, verified by computed tomography angiography, and treated with endovascular intervention., (© 2019 Wiley Periodicals, Inc.)

Coronary artery perforation (CAP) during percutaneous coronary intervention is a rare but serious complication. Treatment options of CAP include prolonged balloon inflation, covered stent, and coil embolization. Although most cases of CAP can be treated with prolonged balloon inflation, some cases, especially Ellis grade III CAP require covered stents or coiling. Covered stents may require a large bore guide catheter and have a high rate of restenosis, which can be a limiting factor in patients with severe peripheral arterial disease. Coil embolization is generally used in distal CAP because coiling in the proximal vessels results in a large territory of infarction. We present a case of an Ellis grade III CAP during rotational atherectomy successfully treated with a novel coiling technique whereby the thrombogenic coil extends through the perforation outside of the vessel, and the intraarterial portion of the coil is excluded from the lumen by drug-eluting stent placement over the proximal portion of the coil., (© 2018 Wiley Periodicals, Inc.)

Objectives: We examined the contemporary incidence, types, predictors, angiographic characteristics, management and outcomes of coronary perforation., Background: Coronary perforation is a rare, but important, complication of percutaneous coronary intervention (PCI). There is lack of data on perforations stratified as large and distal vessel perforations., Methods: Retrospective, observational cohort study of all patients who underwent PCI at a high volume, tertiary hospital between the years 2009 and 2016. Angiograms of all coronary perforation cases were reviewed to determine the mechanism, type, and management of perforation. Risk-adjusted periprocedural complication rates were compared between patients with and without coronary perforation. One-year mortality outcomes of patients with large vessel vs. distal vessel perforation were also examined., Results: Coronary perforation occurred in 68 of 13,339 PCIs (0.51%) performed during the study period: 51 (75%) were large vessel perforations and 17 (25%) distal vessel perforations. Most (67%) large vessel perforations were due to balloon/stent inflation, whereas most (94%) distal vessel perforations were due to guidewire exit. Patients with coronary perforations had significantly higher risk for periprocedural complications (adjusted odds ratio 7.57; 95% CI: 4.22-13.50; P < 0.001). Only one patient with large vessel perforation required emergency cardiac surgery, yet in-hospital mortality was high with both large vessel (7.8%) and distal vessel (11.8%) perforations., Conclusions: Coronary perforation is an infrequent, but potentially severe PCI complication. Most coronary perforations are large vessel perforations. Although coronary perforations rarely lead to emergency cardiac surgery, both distal vessel and large vessel perforations are associated with high in-hospital mortality, highlighting the importance of prevention., (© 2018 Wiley Periodicals, Inc.)

Background: Covered stent (CS) implantation is considered a useful device in the setting of Grade III Coronary Perforation (G3CP), one of the most harmful PCI complication. However, data regarding efficacy of this device and clinical outcomes are still limited., Methods and Results: From 1993 to 2015, among 97,779 patients from 9 European centres undergoing PCI, 224 patients had G3CP (0.23%), and 102 patients were managed with CS implantation (96 with PTFE, 6 with pericardium). Device oriented composite endpoint (DOCE), a composite of cardiac death, target lesion revascularization, and stent thrombosis (ST) in-hospital and at long term follow-up were evaluated. G3-CP perforations were successfully sealed with CS in 88 patients (86.3%) with need of intraprocedural pericardiocentesis in one-third of cases. Protamine as heparin reversal agent was administered in 36 (35%) of cases. The cumulative incidence of in-hospital DOCE were 16.6% (17/102): death 14.7%, TLR 2.9%, ST 3.9%. At long-term follow-up (mean 42 ± 38 months), DOCE rates occurred in 19.7%: death 7.4%, TLR 11%, and ST 6.2%. Indication to Dual Antiplatelet Therapy (DAPT) was lifelong in 20% of cases, 1 to 6 months in 22.5% and 12-months in 57.5% without differences in long-term DOCE before and after DAPT interruption (8.0 vs. 6.6%, respectively, P = 0.20)., Conclusions: Use of CS was successful in sealing grade 3 coronary artery perforations in the majority of cases. Beside the high rate of clinical events at short and long-term, ST remains the leading cause of device failure., (© 2018 Wiley Periodicals, Inc.)

Objectives: The Tack implant is designed for focal, minimal metal management of dissections. This study evaluated Tacks for treating postpercutaneous transluminal angioplasty (PTA) dissection in patients with below-the-knee (BTK) arterial occlusive disease., Background: PTA is the most commonly used endovascular treatment for patients with occlusive disease of the BTK vessels. Post-PTA dissection is a significant clinical problem that results in poor outcomes, but currently there are limited treatment options for managing dissections., Methods: This prospective, single-arm study evaluated patients with CLI and BTK lesions; 11.4% were Rutherford category (RC) 4 and 88.6% were RC 5. BTK occlusive disease was treated with standard PTA and post-PTA dissections were treated with Tack placement. The primary safety endpoint was a composite of major adverse limb events (MALE) and perioperative death (POD) at 30 days. Other endpoints included: device success; procedure success (vessel patency in the absence of MALE); freedom from clinically driven target lesion revascularization (CD-TLR); primary patency; and changes in RC. Data through 12 months are presented., Results: Thirty-two of 35 (91.4%) patients had post-PTA dissection and successful deployment of Tacks. Procedural success was achieved in 34/35 (97.1%) patients with no MALEs at 30 days. The 12-month patency rate was 78.4% by vessel, 77.4% by patient, and freedom from CD-TLR was 93.5%. Significant (P < .0001) improvement from baseline was observed in RC (75% of patients improved 4 or 5 steps)., Conclusion: Tack implant treatment of post-PTA dissection was safe and effective for treatment of BTK dissections and resulted in reasonable 12-month patency and low rates of CD-TLR., (© 2018 The Authors Catheterization and Cardiovascular Interventions Published by Wiley Periodicals, Inc.)

Coronary Sinus Reducer (Neovasc, Inc., Richmond B.C., Canada) has shown to be an effective and safe treatment option for the treatment of refractory angina. Until now, a few number of complications related to its implantation have been reported. Coronary sinus perforation is a rare complication, more often related to cardiac surgery procedures. We report the first case of coronary sinus perforation after a sinus Reducer implantation., (© 2018 Wiley Periodicals, Inc.)

Objectives: We sought to investigate the possible impact of transaortic valve replacement (TAVR) on common femoral artery (CFA) integrity as assessed by angiography., Background: CFA represents the most adopted access for TAVR but various degrees of vascular damage may be induced by the procedure., Methods: Patients underwent percutaneous transfemoral TAVR who had both pre- and post-TAVR access-site angiography were retrospectively selected. Clinical and procedural data (including technique and complications) were prospectively recorded into a structured TAVR database. Pre-TAVR and post-TAVR angiograms were analyzed using a quantitative angiographic analysis software to assess reference diameters, minimum luminal diameter (MLD), and percentage of diameter stenosis (DS)., Results: A total of 124 patients entered the study (mean age: 85 years, mean Euroscore II: 10%). ProStar (13.5%) and double ProGlide (82.2%) preclosure were the main hemostatic techniques. CFA exhibited a significant shrinkage with TAVR as assessed by significant MLD reduction (5.6 mm after TAVR vs. 6.8 mm before, P < .001) and DS increase (30.3% after vs. 17.0%, P < .001). Such differences remained statistically significant after exclusion of 18 patients (14.2%) who had (minor or major) vascular complications. At multivariable analysis, pre-TAVR DS (P = .03) and history of peripheral arterial disease (P = .01), were significantly associated with vascular complications., Conclusions: Percutaneous TAVR induces an angiographically detectable CFA lumen reduction. Such findings call for further studies assessing clinical impact of this phenomenon and open the door for further refinements of the TAVR access management aimed at preserving vessel integrity., (© 2017 Wiley Periodicals, Inc.)

Background: Complex lower extremity trauma still poses a formidable challenge for micro vascular reconstruction. The extensive surrounding zone of trauma can make it difficult to find a suitable recipient pedicle for anastomosis. A need was felt for exploration of newer recipient vessels in lower extremity which could be harnessed for reliable and tension free micro anastomosis. The purpose of the present report is to highlight the possibility of using medial sural artery for safe micro vascular anastomosis in selected scenarios like vessel depleted extremity., Methods: Between 2008 and 2013, we used the medial sural vessels for micro anastomosis in 10 cases of lower extremity trauma. All the cases had severe soft tissue trauma with or without a bony defect. A computed tomography angiogram (CTA) of the involved extremity revealed either severe perivascular scarring around the standard recipient vessels or patency of just a single vessel. However, in all cases a patent medial sural pedicle was identified on CTA. Interposition vein grafts (IVGs) were used in most cases to ensure a tension free anastomosis., Results: In all cases, unscarred medial sural vessels were identified with average dissected length and diameter being 6.2 cm (range 4 to 7.5 cm) and 2 mm (range 1.5 to 2.5 mm) respectively. Vein graft [average length 5.6 cm (range 4 to 15 cm)] was interposed in seven cases, while in remaining three, long saphenous vein was used for vein anastomosis. All the flaps survived after the surgery. There was one re-exploration for evacuation of peri-anastomotic hematoma with no adverse effect on flap survival. The mean follow up period was 27.6 months. In the four cases with bone reconstruction, bony union was seen between 5 and 8 months. They were able to walk without aids and resume work after 10-14 months, following a structured rehabilitation program. The patients with soft tissue reconstruction (6 cases) could carry out aid free locomotion and resume their routine after 4-6 weeks. There were no long term complications in any of the flap., Conclusions: Medial sural artery may prove to be a reliable recipient pedicle for use in complex lower extremity trauma cases and could possibly provide a safer alternative in cases with severe perivascular scarring or in a "single vessel" extremity., (© 2017 Wiley Periodicals, Inc.)

Background: This retrospective study assesses the safety and efficacy of using a thrombus injection for treatment a peripheral artery perforation., Methods and Results: From March 2013 to April 2016, we performed 1,152 endovascular treatment (EVT) at our hospital. Of these, 28 peripheral artery perforations occurred during the EVT procedure and 20 were treated with a thrombus, which we artificially created. The thrombus comprised the patient's blood and thrombin. It was injected into the perforation site from the tip of an over-the-wire balloon using ballooning method. The perforated arteries occurred in below-the-knee artery (45%), superficial femoral artery (35%), deep femoral artery (10%), popliteal artery (5%), and external iliac artery (5%). Thrombus injection was successful in 19 of the 20 perforations (95%). One patient required coil embolization. There were no complications during or after admission., Conclusions: Thrombus injection is a safety method and might be considered as one of the approaches for stopping peripheral artery perforation., (© 2017 Wiley Periodicals, Inc.)

We report a new technique of arterial access through the ipsilateral interosseous artery in a case of late radial artery occlusion (RAO). RAO, although not frequent, is a limiting iatrogenic complication after transradial intervention (TRI) and precludes repeat use of the same radial artery for future procedures. Our technique involves obtaining access to the ipsilateral radial artery (RA) in the distal postocclusion segment and use of collateral channel between this segment and the interosseous artery (IOA) for advancing a guidewire and sheath in the IOA lumen and in brachial artery thereafter. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Distal coronary perforation can cause early or late tamponade and is usually treated with fat or coil embolization. An alternative treatment strategy is occlusion of the ostium of the perforated vessel via implantation of a covered stent in the main vessel, which is typically achieved using the ping-pong guide catheter technique. In this technique, a balloon is inflated over one guide catheter to stop pericardial bleeding and a covered stent is delivered through a second guide catheter due to inability to fit both a balloon and a covered stent through a single guide catheter. With development of lower profile rapid exchange covered stents, a single guide catheter can be used to both occlude the target vessel and deliver the covered stent. We describe a case of distal vessel perforation in which a balloon was inflated to stop pericardial bleeding, followed by delivery of a covered stent (Graftmaster, Abbott Vascular) through a single 8-Fr guide catheter. This "block and deliver" technique represents a novel paradigm for treating coronary perforations through a single guide catheter, obviating the need for the ping-pong guide catheter technique. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

We report a new technique for treatment of radial artery pseudoaneurysm (RAP) caused by transradial access (TRA) for coronary angiography. Traditional extrinsic compression with radial flow cessation leads to a local milieu likely associated with an increase in probability of radial artery occlusion (RAO). Our technique involves obtaining ipsilateral radial artery access distal to the neck of the RAP followed by a prolonged sheath dwell time covering the neck of the RAP which allows the RAP sac to thrombose and maintains radial artery lumen patency. © 2016 The Authors. Catheterization and Cardiovascular Interventions Published by Wiley Periodicals, Inc., (© 2016 The Authors. Catheterization and Cardiovascular Interventions Published by Wiley Periodicals, Inc.)

Coronary perforation (CP) is a rare but potentially lethal complication of percutaneous coronary intervention (PCI). Management of CP is mainly conditioned by the extension of coronary rupture and location of the perforation. Successful treatment is highly affected by the operator's familiarity with tools and dedicated techniques to achieve prompt sealing of the disruption. We describe a "Balloon-Microcatheter" technique that may allow fast, safe, and effective management of CP with a single ≥ 6 Fr guiding catheter. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Complications of transseptal puncture are significant and potentially life threatening. Aortic perforation is one of these complications and it needs to be repaired immediately. We report the case of a 48-year-old female with a history of rheumatic mitral valve disease. She underwent three previous mitral valve replacements. Her last echocardiogram reported an anterolateral leak in the mitral prosthesis. Catheterization was performed. During the procedure, when attempting to perform transseptal puncture, catheterization was complicated by a forcefully puncture of the aortic root by the Brockenbrough needle followed by an immediately advancement of an 8-Fr Mullins sheath. We decided to leave the 8-Fr sheath in the aortic root recognizing the danger of removing the sheath and finally we advanced a 6/4 mm Amplatzer ductal occluder (ADO I) through the Mullins sheath and under fluoroscopy and TEE guidance we achieved a successful deployment of the device and closure of the perforation. Subsequently, the paravalvular leak was closed with an Amplatzer Vascular Plug (AVP III 10/5 mm). There are only three cases of a similar technique for the same injury in which the authors describe successful closing of aortic perforation with percutaneous closure devices. Our case is the first described during a mitral paravalvular leak closure. It is also the first to describe a different technique of leaving the Mullins sheath in the aortic root and advancing the Amplatzer device through it to achieve successful closure of the aortic perforation. We preferred the percutaneous closure over open-heart repair. © 2015 Wiley Periodicals, Inc., (© 2015 Wiley Periodicals, Inc.)

Background: The use of covered stent grafts during percutaneous coronary intervention (PCI) is a life saving solution to seal acute iatrogenic vessel rupture. However, the presence of an impenetrable mechanical barrier is also appealing during treatment of friable coronary plaques but the synthetic PTFE-membrane that might trigger excessive neointimal proliferation has limited its elective-use. Pericardium tissue may offer an appealing "natural" alternative. Aim of our study is to report the consecutive 5-year single center experience with the use of pericardium-covered stents (PCS) (ITGI-Medical, Israel) in a variety of emergency and elective applications., Methods: Nineteen consecutive patients undergoing implantation of PCS at the Royal Brompton in the last 5-years. Reasons for PCS implantation included treatment of degenerated vein grafts, large coronary aneurysms, and acute iatrogenic vessel rupture., Results: Angiographic success, defined as the ability of the device to be deployed in the indexed lesion with no contrast extravasation with residual angiographic stenosis <30% and a final thrombolysis in myocardial infarction (TIMI)-3 flow was achieved in all cases. Procedural success, defined as the achievement of angiographic success without any major adverse cardiovascular event (MACE) was achieved in 94.7% of patients. In-stent restenosis (ISR) was observed in 26.3% and all patients underwent successful target vessel revascularization with DES (mean time to restenosis 9.0 ± 4.0 months). At a mean follow-up of 32.5 ± 23.3 months no acute or late stent thrombosis was observed., Conclusion: PCSs were effective in the treatment of friable embolization-prone coronary plaques, sealing of acute iatrogenic vessel rupture and exclusion of large aneurysms with no thrombosis but high target lesion revascularization., (© 2015 Wiley Periodicals, Inc.)

The Brockenbrough (BB) procedure is becoming the necessary procedure for radiofrequency ablation for supravalvular tachycardia in patients after a Fontan procedure. We experience Fontan-rout to aorta communication caused by the BB procedure. The communication was successfully occluded using a detachable coil. This complication was rare but could still happen as an increasing necessity of the catheter ablation in patients with a Fontan procedure. Coil embolization is a potential option for recovery from this complication., (© 2015 Wiley Periodicals, Inc.)

Coronary perforation is an infrequent, but serious complication of percutaneous coronary intervention (PCI), and is more likely to occur with complex (such as chronic total occlusion) PCI and use of atheroablative devices. For main vessel perforations, the "dual catheter" technique is usually employed in which a balloon is delivered over the first guide catheter to stop bleeding, whereas the covered stent is delivered through a second guide catheter. This is required because the large profile of the currently commercially available covered stents precludes fitting within even an 8-French guide together with a balloon. However, coil embolization for distal artery wire perforation and collateral vessel perforation can be achieved through a microcatheter that can fit along with a balloon within an 8-French guide catheter, obviating the need for a second guide catheter. We describe a case in which a distal artery wire perforation was successfully treated using a single 8-French guide catheter., (© 2015 Wiley Periodicals, Inc.)

Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) is one of the greatest challenges in coronary interventions. A retrograde approach via the collateral channel has been recently proposed to improve the success rate of PCI in CTO lesions of the coronary arteries. We describe an accidental complication encountered during transradial PCI to recanalize right coronary artery CTO in a patient with unstable angina. A long spiral dissection has been created by antegrade wiring and extended from the ostium all the way down to mid RCA segment. Subsequent attempts with antegrade wiring into the true lumen were unsuccessful. Ad-hoc retrograde recanalization has been employed to rescue the vessel via septal collateral from left anterior descending artery. Retrograde wiring and dilatation were performed followed by successful antegrade wiring into the true lumen under IVUS guidance, which revealed significant intramural hematoma extending distally to the posterolateral branch. Bailout stenting was achieved with sealing of the multiple entry and exit sites created by the spiral dissection and complete coverage of the intramural hematoma. This report highlights the role of the retrograde approach as a rescue option in the setting of complicated antegrade approach and to improve the success rate of CTO-PCI. Moreover, IVUS was a valuable tool to confirm the true lumen course of the successful wire and to guide the stenting procedure., (Copyright © 2012 Wiley Periodicals, Inc.)

Aim: To evaluate differences in strut coverage, inflammation and endothelialization between two second-generation polymer-based drug-eluting stents (DES) in an atherosclerotic rabbit double-injury iliac artery model at 28 days follow-up., Methods and Results: Rabbits with induced atheroma received bilateral iliac artery stents: everolimus-eluting stent (Xience V EES; Abbott Vascular), zotarolimus-eluting stent (Resolute ZES; Medtronic CardioVascular), or bare-metal stent (BMS; MultiLink Vision; Abbott Vascular). After 28 days, total neointimal coverage examined by scanning electron microscopy was >98% for all three stent types. Neointimal thickness above stent struts was decreased by 50% in Xience V EES (0.06 ± 0.01 mm; P = 0.00001) compared with BMS (0.15 ± 0.03 mm) and Resolute ZES (0.12 ± 0.04 mm). Luminal area was largest for Xience V EES (3.79 ± 0.33 mm(2) ; P = 0.0003 for Xience V EES vs. BMS), followed by Resolute ZES (3.46 ± 0.45 mm(2) ; P = 0.083 for Resolute ZES vs. BMS) and BMS (3.07 ± 0.53 mm(2) ). Percentage area stenosis was smallest for Xience V EES (17.23 ± 3.64%; P = 0.00001), while BMS (30.25 ± 7.48%) and Resolute ZES (30.79 ± 7.15%) did not differ. Endothelial monolayer regrowth was significantly lower in Resolute ZES (65 ± 13%) versus BMS (79 ± 11%; P = 0.004). There was no difference between Xience V EES (74 ± 10%) and BMS. Xience V EES was further associated with a lower number of inflammatory cells surrounding the stent struts (7 ± 2 per strut) in comparison to Resolute ZES (15 ± 6; P = 0.0001) and BMS (17 ± 9; P = 0.0005)., Conclusion: In this atherosclerotic rabbit model, Xience V EES suppressed neointimal thickening better, with normal endothelial regrowth as compared with BMS, and less strut-induced inflammation., (Copyright © 2012 Wiley Periodicals, Inc.)

Vascular complications are a major concern during transcatheter aortic valve replacement and can occur independently of introducer size. Arterial and venous access must be meticulous to avoid potentially life-threatening bleeding, which most commonly results from injury to the common femoral or iliac arteries. We report an unusual case of perforation of the medial circumflex branch of the common femoral artery resulting from attempted femoral venous cannulation. Injury to this vessel is characteristically associated with silent retroperitoneal extravasation and is notoriously difficult to recognize and treat. Despite identification of the perforation on contrast-enhanced computed tomography, the anatomical site could only be localized to the medial circumflex branch on highly selective contrast angiography. Thereafter, it was successfully treated percutaneously by embolization and coiling., (Copyright © 2012 Wiley Periodicals, Inc.)

Inferior vena cava filters can provide lifesaving protections in patients with recurrent venous thromboembolic disease that are not candidates for anticoagulation. They are, however, associated with short- and long-term complications necessitating frequent follow-up. The authors report, in this article, a case of migration of Bird's Nest filter strut into the descending aorta and its percutaneous retrieval by snaring and capture. This case also underscores the trend to use retrievable filters to avoid longer-term complications., (Copyright © 2012 Wiley Periodicals, Inc.)

Introduction: Radial artery access for diagnostic and therapeutic procedures offers clear advantages in terms of vascular complications. While radial artery occlusion may occasionally complicate radial artery access, new methods of hemostasis are now utilized to avoid this complication. In contrast, pseudoaneurysm following radial artery access is an extremely uncommon complication., Methods: We describe a series of patients who developed radial artery pseudoaneurysm after their procedure., Results: Five patients developed radial pseudoaneurysm after diagnostic and interventional procedures, likely reflecting inadequate hemostasis following the procedure and delayed bleeding complicating systemic anticoagulation., Conclusions: While uncommon, radial artery pseudoaneurysm may complicate cardiac catheterization procedures, with anticoagulation an important contributor. The clinical presentation, likely precipitating mechanisms and treatment options are discussed., (Copyright © 2011 Wiley Periodicals, Inc.)

Inferior epigastric artery injury after cardiac catheterization and percutaneous coronary intervention is sporadically reported in the literature, yet it is a serious complication that can lead to life-threatening retroperitoneal hemorrhage and poor clinical outcomes after percutaneous coronary intervention. We present two cases of inferior epigastric artery injury from inadvertent puncture during cardiac catheterization and a discussion in the management and prevention of this potentially fatal complication., (Copyright © 2011 Wiley Periodicals, Inc.)

A 58-year-old man underwent an elective coronary bypass graft for severe four-vessel stenosis. Cardiogenic shock developed just after coronary bypass grafting with a left internal mammary artery (LIMA) to left anterior descending (LAD) artery and superficial venous graft to 1st and 2nd obtuse marginal (OM1/OM2) arteries the posterior descending artery (PDA) was too small to graft. Despite significant inotropes and an intra-aortic balloon pump, the patient deteriorated in intensive care unit with cardiogenic shock and ventricular arrhythmia. Urgent coronary angiography revealed a rupture or torn LIMA graft with extravasation of contrast into the left pleural cavity. There was no distal LIMA to LAD flow probably due to graft thrombosis. Revascularisation was performed on the severe ostial native LAD stenosis with a drug eluting stent. The rupture graft was then stented with a polytetrafluoroethylene-covered stent, which stopped the bleeding, and latter, led to total graft thrombosis. The patient improved significantly and supportive inotropes could be weaned down. At 11 month follow-up, the patient had mild left ventricular dysfunction, widely patent ostial LAD stent and thrombosed LIMA graft., (Copyright © 2011 Wiley Periodicals, Inc.)

We hereby describe a complex late postoperative veno-venous fistula in a child, successfully treated by an interventional percutaneous procedure. It is a unique complication of diaphragmatic hernia surgery that has never been reported before: a late postoperative iatrogenic fistula, between the inferior vena cava and the right lower pulmonary vein, discovered in a 6-year-old boy operated at the age of 4 months for a right diaphragmatic hernia. The right to left shunt was completely and uneventfully suppressed by a percutaneous procedure separating the systemic venous return from the pulmonary venous return with an Amplatzer Vascular Plug II., (Copyright © 2011 Wiley-Liss, Inc.)

Perforation and disruption of the artery used for access is a recognized complication of coronary angiography. There is an increasing trend toward use of the radial artery for angiography and angioplasty, particularly in the primary angioplasty setting, because of the reduced risk of hemorrhagic complications. On the rare occasions when radial artery perforation occurs, operators have had a tendency to switch to a second arterial access route. This article describes a technique for managing peri-procedural perforation which does not require use of a second artery for access. We show two cases where this technique was used successfully, demonstrating an angiographically normal radial artery at the end of the procedure., (Copyright © 2011 Wiley-Liss, Inc.)

Transcatheter aortic valve implantation (TAVI) has become an established technique for the treatment of aortic stenosis in patients who cannot undergo surgery. Although TAVI is obviously less invasive than open surgical repair, it is not free of complications. We report a case of unexplained refractory shock during transfemoral TAVI with subsequent autopsy demonstrating a 1-cm large perforation of the descending thoracic aorta as the cause of death. To the best of our knowledge, this is the first case ever reported., (Copyright © 2011 Wiley-Liss, Inc.)