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Axial-flow ventricular assist devices are being increasingly used to support hemodynamically compromised patients undergoing percutaneous coronary intervention. Periprocedural valvular complications have been recognized in a few case reports. We present a unique case of entanglement of the Impella within he mitral subvalvular apparatus, retrieved successfully using a snare under fluoroscopic guidance. (Level of Difficulty: Advanced.), Central Illustration

Creation of a distal re-entry site is widely performed to treat subintimal hematoma. However, this method has a risk of further vessel damage. The present aspiration technique after sealing the entry site by stenting is more promising because the hematoma can be reduced without additional vessel damage. (Level of Difficulty: Advanced.), Graphical abstract

Coronary intramural hematoma can present with acute coronary syndrome. We present a 39-year-old man with post-assault stress-induced left main intramural hematoma. We used computed tomography coronary angiogram with lesion characterization and suspected the diagnosis of intramural hematoma despite its limited spatial resolution; computed tomography was used for follow-up imaging and proper monitoring of therapeutic measures. (Level of Difficulty: Advanced.), Graphical abstract

We present a case of iatrogenic aortocoronary dissection sustained during routine percutaneous coronary intervention for stable angina. Careful wiring of the true lumen and stent implantation to seal off the dissection flap prevented immediate complications, and computed tomography aortography guided a conservative approach to manage the residual aortic dissection. (Level of Difficulty: Intermediate.), Graphical abstract

Coronary artery embolism due to BioGlue surgical adhesive after repair of type A acute aortic dissection is a rare condition. We report a case of BioGlue coronary artery embolism after type A acute aortic dissection repair confirmed using intravascular ultrasound imaging and pathological examination. It was successfully treated with percutaneous coronary intervention. (Level of Difficulty: Advanced.), Central Illustration

We describe a patient who presents with chest discomfort 30 h after having an accident with an all-terrain vehicle. His follow-up coronary computed tomography angiogram revealed early recanalization of his coronary artery with conservative medical therapy. (Level of Difficulty: Intermediate.), Graphical abstract

Arteriovenous (AV) fistulae for hemodialysis in patients with end-stage renal disease usually prevents ipsilateral transradial access (TRA) for coronary angiography. We present a case of coronary angiography and percutaneous coronary intervention via left TRA with navigation through a dormant AV fistula in a patient with limited vascular access. (Level of Difficulty: Intermediate.), Graphical abstract, Arteriovenous (AV) fistulae for hemodialysis in patients with end-stage renal disease usually prevents ipsilateral transradial access (TRA) for…

Mycotic coronary aneurysm and pseudoaneurysm are rare infective complications of percutaneous coronary interventions, associated with poor prognosis. Multimodality imaging is recommended to achieve a correct diagnosis. We present a case of post-stenting mycotic coronary pseudoaneurysm complicated by myocardial abscess in which we used different imaging tools, each carrying additional information. (Level of Difficulty: Advanced.), Graphical abstract, Mycotic coronary aneurysm and pseudoaneurysm are rare complications of infective percutaneous coronary intervention, and they are associated with…

We describe the use of a fully percutaneous, biatrial extracorporeal membrane oxygenation circuit, to provide biventricular support with left heart unloading by using a single TandemHeart (LivaNova, London, United Kingdom) circuit during high-risk percutaneous coronary intervention. (Level of Difficulty: Advanced.), Graphical abstract, We describe the use of a fully percutaneous, biatrial extracorporeal membrane oxygenation circuit, to provide biventricular support with left…

Percutaneous transaxillary access is currently considered an acceptable alternative to transfemoral approach for large-bore access, especially in the setting of hostile iliofemoral arteries. Few published reports exist concerning complications of upper extremity access. We describe development of an axillary artery pseudoaneurysm and its management following transaxillary access. (Level of Difficulty: Advanced.), Graphical abstract, Percutaneous transaxillary access is currently considered an acceptable alternative to transfemoral approach for large-bore access, especially in…

Severely calcified coronary lesions remain a challenge in current percutaneous coronary interventions. Shockwave intravascular lithotripsy (Shockwave Medical, Inc., Santa Clara, California) is an alternative for rotational atherectomy in such lesions that supports stent deliverability and achieves optimal results. We describe a case of coronary artery perforation after use of this lithotripsy device. (Level of Difficulty: Advanced.), Graphical abstract, Severely calcified coronary lesions remain a challenge in current percutaneous coronary interventions. Shockwave intravascular lithotripsy…

Left ventricular support with Impella requires a large-bore sheath. Alternate access sites have often been required in patients with severe peripheral artery disease. This paper reports the first case in which an aortofemoral bypass graft for Impella access was used in a patient without other alternatives and the method of access closure. (Level of Difficulty: Advanced.), Graphical abstract, Left ventricular support with Impella requires a large-bore sheath. Alternate access sites have often been required in patients with severe peripheral…

Stumpless chronic total occlusion is associated with a higher failure rate of recanalization. Intravascular ultrasound (IVUS) is useful for identifying the entry point; however, 8-F guide catheters are necessary for real-time IVUS-guided wiring. This case reports the novel use of the “ping-pong” guide catheter technique to facilitate real-time IVUS-guided wiring for a stumpless chronic total occlusion. (Level of Difficulty: Advanced.), Graphical abstract, Stumpless chronic total occlusion is associated with a higher failure rate of recanalization. Intravascular ultrasound (IVUS) is useful for…

Burr entrapment remains a serious complication of rotational atherectomy. This report describes an advanced technique for the management of entrapped atherectomy burrs. Commonly strategies were unsuccessful. A chronic total occlusion angioplasty technique was used successfully: the subintimal dilation and “external crushing” plaque modification technique. (Level of Difficulty: Advanced.), Graphical abstract, Burr entrapment remains a serious complication of rotational atherectomy. This report describes an advanced technique for the management of entrapped…

After an unsuccessful left internal mammary artery (LIMA) to left anterior descending percutaneous coronary intervention (PCI) in an outside hospital…, After an unsuccessful left internal mammary artery (LIMA) to left anterior descending percutaneous coronary intervention (PCI) in an outside hospital, a patient presented with ST-segment elevation myocardial infarction. The patient was found to have LIMA occlusion and underwent a second PCI. However, there was a residual disruption of LIMA, subsequently, the patient was found to have complete LIMA recanalization, which emphasized the self-reparative nature of LIMA. (Level of Difficulty: Intermediate.), Graphical abstract

A 68-year-old man with a biventricular implantable cardioverter-defibrillator who was pacemaker dependent was admitted for percutaneous coronary intervention. The patient had an asystolic cardiac arrest as a result of electromagnetic interference during an orbital atherectomy. We should keep electromagnetic interference from the machine in mind when performing orbital atherectomy. (Level of Difficulty: Beginner.), Graphical abstract

Objectives To compare the pharmacodynamic effects of clopidogrel reloading vs. switching to prasugrel or ticagrelor in high on treatment platelet reactivity (HTPR) patients undergoing percutaneous coronary intervention (PCI). Methods Prospective, single-centre study wherein consecutive patients undergoing nonemergent PCI showing HTPR on 600 mg clopidogrel loading were randomized to either clopidogrel reloading (300 mg load, 75 mg OD) or prasugrel (60 mg load, 10 mg OD-in patients > 60 kg) or ticagrelor (180 mg load, 90 mg BD). HTPR is defined as maximum platelet aggregation (MPA) > 46% assessed by 5 μmol/L adenosine diphosphate light transmission aggregometry (ADP-LTA) assay after more than 6 h of clopidogrel loading. Platelet function were assessed at baseline, 6 h or more after clopidogrel loading, 2 h after reloading, day 1 and day 30 post-PCI. Results 107 patients enrolled in the study, 32 (29.9%) were found to have HTPR. 10 (9.3%) patients were reloaded with clopidogrel, 10 (9.3%) with prasugrel and 12 (11.2%) with ticagrelor. Mean MPA in clopidogrel, prasugrel and ticagrelor reloaded patients was 42.6 ± 12.5%, 15.8 ± 8.6% and 14.6 ± 7.2% respectively at 2 h after reloading and was 43.7 ± 13.5%, 15.4 ± 5.6% and 12.6 ± 4.6% on day 1 post-PCI. The MPA significantly reduced in prasugrel and ticagrelor cases and not in clopidogrel, also prasugrel and ticagrelor had almost similar MPA after the reload. There was no patient with continued HTPR with ticagrelor or prasugrel while 50% (5/10) of clopidogrel reloaded patients had HTPR. The pharmacodynamic efficacy of maintenance with prasugrel or ticagrelor was better than clopidogrel (MPA at day 30 post-PCI; 15 ± 9.7%, 13.9 ± 5.1% and 50.4 ± 13.1% respectively). Conclusion In patients undergoing PCI exhibiting HTPR after clopidogrel loading, ticagrelor or prasugrel reloading produced improved platelet inhibition which was better than clopidogrel reload and this effect was sustained during maintenance phase.