Design and Fabrication of Environmentally Responsive Nanoparticles for the Diagnosis and Treatment of Atherosclerosis

Cardiovascular disease poses a significant threat to human health in today's society. A major contributor to cardiovascular disease is atherosclerosis (AS). The development of plaque in the affected areas involves a complex pathological environment, and the disease progresses rapidly. Nanotechnology, combined with emerging diagnostic and treatment methods, offers the potential for the management of this condition. This paper presents the latest advancements in environment-intelligent responsive controlled-release nanoparticles designed specifically for the pathological environment of AS, which includes characteristics such as low pH, high reactive oxygen species levels, high shear stress, and multienzymes. Additionally, the paper summarizes the applications and features of nanotechnology in interventional therapy for AS, including percutaneous transluminal coronary angioplasty and drug-eluting stents. Furthermore, the application of nanotechnology in the diagnosis of AS shows promising real-time, accurate, and continuous effects. Lastly, the paper explores the future prospects of nanotechnology, highlighting the tremendous potential in the diagnosis and treatment of atherosclerotic diseases, especially with the ongoing development in nano gas, quantum dots, and Metal-Organic Frameworks materials.

To flip or not: Case series of coronary angioplasty in patients with right-sided heart

Coronary angioplasty in patients with a right-sided heart may be difficult due to challenges in engaging the coronary arteries, interpreting angiogram, and further delivering intracoronary therapies. We present our experience of percutaneous coronary intervention in two cases and propose a practical algorithm to approach cardiac catheterization in these patients.

Post-angioplasty remodeling of coronary arteries investigated via a chemo-mechano-biological in silico model

This work presents the application of a chemo-mechano-biological constitutive model of soft tissues for describing tissue inflammatory response to damage in collagen constituents. The material model is implemented into a nonlinear finite element formulation to follow up a coronary standard balloon angioplasty for one year. Numerical results, compared with available in vivo clinical data, show that the model reproduces the temporal dynamics of vessel remodeling associated with subintimal damage. Such dynamics are bimodular, being characterized by an early tissue resorption and lumen enlargement, followed by late tissue growth and vessel constriction. Applicability of the modeling framework in retrospective studies is demonstrated, and future extension towards prospective applications is discussed.

Plaque heterogeneity and the spatial distributions of its components dictate drug-coated balloon therapy

Drug-coated balloon (DCB) angioplasty is one of the potential approaches to alleviating in-stent restenosis and treating peripheral artery disease. An in-silico model has been developed for sirolimus drug eluted from an inflated balloon in a patient-specific arterial cross-section consisting of fibrous tissue, fibrofatty tissue, dense calcium, necrotic core, and healthy tissue. The convection-diffusion-reaction equation represents the transport of drug, while drug binding, both specific and non-specific, can be modelled as a reaction process. The Brinkman equations describe the interstitial flow in porous tissue. An image processing technique is leveraged for reconstructing the computational domain. The Marker and Cell, and Immersed Boundary Methods are used to solve the set of governing equations. The no-flux interface condition and convection do amplify the tissue content, and the regions of dense calcium and necrotic core limited to or extremely close to the interface pose a clinical threat to DCB therapy. Simulations predict the effects of the positioning and clustering of plaque components in the domain. This study demands extensive intravascular ultrasound-derived virtual histology (VH-IVUS) imaging to understand the plaque morphology and determine the relative positions of different plaque compositions about the lumen-tissue interface, which have a significant impact on arterial pharmacokinetics.

Safety and feasibility of a novel total percutaneous post-closure technique after bedside Impella decannulation in patients with cardiogenic shock

OBJECTIVES

The Impella (Abiomed) is a widely used percutaneous mechanical circulatory support device for high-risk percutaneous coronary intervention in patients with cardiogenic shock. This study aimed to determine the safety and feasibility of a non-angio-guided post-closure approach using the Perclose ProGlide (Abbott) to decannulate the Impella in the intensive care unit.

METHODS

This retrospective study included consecutive patients who were successfully weaned from mechanical circulatory support using the Impella device between April 2019 and April 2022 at Hamamatsu University School of Medicine. Fifteen patients underwent complete post-closure of the femoral artery access sites at the bedside. Technical success of the post-closure hemostasis technique was defined as no evidence of bleeding or additional medical procedures after manual compression. The safety endpoints comprised the Valve Academic Research Consortium-3 and Bleeding Academic Research Consortium criteria.

RESULTS

All patients achieved successful hemostasis with this novel technique without surgical conversion. There was no significant bleeding; however, procedure-related vessel occlusion was observed in 1 patient who was recanalized with balloon angioplasty.

CONCLUSIONS

Bedside post-closure using the Perclose ProGlide device is a safe and feasible alternative to manual compression and surgical removal of the Impella device with low bleeding or vascular complications rates.

Recurrent Revascularization at 10 Years After Percutaneous Treatment of Drug-Eluting Stent Restenosis

BACKGROUND

Treatment of patients with recurrence of in-stent restenosis (ISR) remains particularly challenging, with data and guideline recommendations for repeat percutaneous coronary intervention being scant.

OBJECTIVES

The aim of this study was to investigate the long-term incidence of recurrent revascularization events after percutaneous treatment of drug-eluting stent (DES) ISR.

METHODS

In this post hoc analysis, 402 patients (500 lesions) assigned to plain balloon (PB), drug-coated balloon (DCB), or DES treatment in the randomized ISAR-DESIRE 3 (Efficacy Study of Paclitaxel-Eluting Balloon, -Stent vs. Plain Angioplasty for Drug-Eluting Stent Restenosis) trial were followed up over a median of 10.3 years. The primary endpoint was total repeat target lesion revascularization (R-TLR) including all, first and recurrent, events.

RESULTS

At the end of follow-up, first R-TLR was required in 204 lesions, 82 in the PB group, 70 in the DCB group, and 52 in the DES group. The total number of R-TLRs was 373: 162 in the PB group, 124 in the DCB group, and 87 in the DES group. During the first year of follow-up, the risk for total R-TLR was reduced by DCB (HR: 0.36; 95% CI: 0.24-0.54) and DES (HR: 0.23; 95% CI: 0.14-0.38) treatment compared with PB treatment. After 1 year, the risk for total R-TLR was nonsignificantly reduced by DCB treatment (HR: 0.77; 95% CI: 0.51-1.16) and significantly reduced by DES treatment (HR: 0.61; 95% CI: 0.39-0.95) compared with PB treatment. Risk in the DCB and DES groups was similar during (HR: 1.54; 95% CI: 0.89-2.69) and after (HR: 1.26; 95% CI: 0.82-1.92) 1 year.

CONCLUSIONS

The total number of R-TLRs over 10 years after treatment of patients with DES ISR was high. DCBs and particularly DES were able to reduce the need for both first and recurrent revascularization compared with PB treatment.

Extra-plaque rotational atherectomy for treating a balloon uncrossable ostial right coronary artery chronic total occlusion

Performing atherectomy in the subintimal space remains controversial. We describe a case of successful ostial right coronary artery CTO recanalization using rotational atherectomy in subintimal space.

Possibilities of predicting adverse cardiovascular events based on the analysis of clinical and instrumental research methods, as well as sST2 in patients after myocardial infarction

OBJECTIVE

Aim: To determine the possibility of predicting adverse cardiovascular events based on the analysis of clinical and instrumental research methods, as well as sST2 in patients after myocardial infarction.

PATIENTS AND METHODS

Materials and Methods: The study included 64 patients who suffered an acute myocardial infarction and underwent PCI with balloon angioplasty and stenting of the infarct-related vessel in the acute period. The predictors of adverse cardiovascular events were assessed events during 1 year of observation. Indicators of echocardiography and coronary angiography were assessed and concentrations sST2.

RESULTS

Results: A worse prognosis was associated with intermediate ejection fraction (EF) (odds ratio (OR)=3.981, p<0.05), left aneurysm ventricle (LV) (OR=29.5, p<0.05), high concentrations of sST2 (OR=1.017, p<0.05) and scores on the Syntax scale (OR=1.001, p<0.05).

CONCLUSION

Conclusions: In patients who underwent percutaneous coronary intervention for myocardial infarction, adverse outcome during the next 2 years is associated with coronary and echocardiographic parameters, as well as biochemical indicators of myocardial stress and fibrosis. HF patients with intermediate EF, LV aneurysm, high sST2 concentrations, and high Syntax scores have the worst prognosis.

One-year safety and effectiveness of the Agent paclitaxel-coated balloon for the treatment of small vessel disease and in-stent restenosis

The Agent device consists of a semi-compliant balloon catheter, which is coated with a therapeutic low-dose formulation of paclitaxel (2 µg/mm2) blended with an inactive excipient acetyl-tri-n-butyl citrate (ATBC). AGENT Japan SV is a randomized controlled study that enrolled 150 patients from 14 Japanese sites treated with Agent or SeQuent Please paclitaxel-coated balloon. This study also includes a single-arm substudy evaluating the safety and effectiveness of Agent in patients with in-stent restenosis (ISR). Patients with a single de novo native lesion (lesion length ≤ 28 mm and reference diameter ≥ 2.00 to  < 3.00 mm) were randomized 2:1 to receive either Agent (n = 101) or SeQuent Please (n = 49). The ISR substudy enrolled 30 patients with lesion length ≤ 28 mm and reference diameter ≥ 2.00 to  ≤ 4.00 mm. In the SV RCT, target lesion failure (TLF) at 1 year occurred in four patients treated with Agent (4.0%) versus one patient with SeQuent Please (2.0%; P = 1.00). None of the patients in either treatment arm died. There were no significant differences in the rates of myocardial infarction, target lesion revascularization and target lesion thrombosis through 1 year. In the ISR substudy, the 1-year rates of TLF and target lesion thrombosis were 6.7% and 0.0%, respectively. These data support the safety and effectiveness of the Agent paclitaxel-coated balloon in patients with small vessels and ISR.

Laser ablation on vascular diseases: mechanisms and influencing factors

Vascular diseases, such as venous insufficiency and coronary artery diseases, have been threatening the health of people. Efficient treatment with proper postoperative care is required to relieve the pain of the patients. Traditionally, venous insufficiency is treated with ligation and stripping, an open surgery whose complication rate cannot be ignored. Coronary artery disease is often treated with balloon angioplasty during which undilatable lesions may be encountered, limiting the efficacy of this approach. With advances in laser photonics and percutaneous coronary intervention procedure, laser ablation is emerging as an alternative and adjunctive therapy for these diseases. Endovenous laser ablation has the advantages of high success rate, low complication risk, and fast postoperative recovery. Laser ablation in arteries can handle uncrossable or undilatable lesions with a low incidence of serious complications. In this review, previously published research concerning vascular diseases and their therapies are analyzed in order to provide a clear explanation of the mechanisms and merits of laser ablation. For endovenous laser ablation, the main mechanisms are steam bubbles, heat conduction, and heat pipe, and three main influencing factors are wavelength, fiber types, and laser energy density. For excimer laser coronary atherectomy, the main mechanisms are photochemical, photothermal, and photomechanical effects, and three main influencing factors are catheter, medium, and laser parameters.

Stent composition and immune response after long-term coronary angioplasty

Background

There are limited data about the influence of stent composition on immune responses after percutaneous coronary intervention (PCI).

Objective

The aim was to compare the effects of PCI with conventional cobalt-chromium bare metal stent (BMS) and drug-eluting stent (DES) implantation on the modulation of humoral and cellular immune responses.

Methods

A randomised, single-centre, open pilot study involving patients with stable coronary artery disease eligible for PCI was performed. Blood samples were collected from the peripheral artery (PA) and the coronary sinus (CS) at baseline and 40 weeks following PCI. IgM and IgG autoantibodies (Abs), anti-oxLDL and anti-ApoB-D, as well as cytokine levels were evaluated by enzyme-linked immunosorbent assay.

Results

A total of 30 patients of 60 years mean age were included, 68% of whom were men. At the nine-month follow-up, a modulation in the levels of cytokines and autoantibodies was observed in both stent type groups. However, no difference was observed in the modulation of these markers between stents.

Conclusion

The stent type promotes modulations in cellular and humoral immune responses in the long-term, with differences in the magnitude of effects in specific immune responses.

A Prospective Randomized Trial Comparing Sirolimus-Coated Balloon With Paclitaxel-Coated Balloon in De Novo Small Vessels

BACKGROUND

There are no data comparing sirolimus-coated balloons (SCBs [MagicTouch, Concept Medical]) to paclitaxel-coated balloons (PCBs [SeQuent Please Neo, B. Braun]) for the treatment of de novo small vessel disease (SVD).

OBJECTIVES

This study sought to compare quantitative coronary angiographic outcomes at 6 months after treatment of de novo SVD with a PCB or SCB.

METHODS

This prospective, multicenter, noninferiority trial randomized 121 patients (129 SVD lesions) to treatment with an SCB or PCB, with balloon sizing determined using optical coherence tomography. The primary endpoint was noninferiority for the 6-month angiographic net lumen gain.

RESULTS

Angiographic follow-up was completed in 109 (90.1%) patients in the per-protocol analysis. The mean ± SD angiographic net gains were 0.25 ± 0.40 mm with SCBs vs 0.48 ± 0.37 mm with PCBs, resulting in SCBs failing to meet the 0.30 mm criterion for noninferiority (Pnoninferiority = 0.173), with an absolute difference of -0.23 mm (95% CI: -0.37 to -0.09) secondary to a smaller late loss (0.00 ± 0.32 mm vs 0.32 ± 0.47 mm; P < 0.001) and more frequent late lumen enlargement (53.7% vs 30.0%; OR: 2.60; 95% CI: 1.22-5.67; P = 0.014) with PCBs. Binary restenosis rates were 32.8% and 12.5% following treatment with SCBs and PCBs, respectively (OR: 3.41; 95% CI: 1.36-9.44; P = 0.012). The mean angiography-derived fractional flow ratio at follow-up was 0.86 ± 0.15 following treatment with SCBs and 0.91 ± 0.09 following PCBs (P = 0.026); a fractional flow ratio ≤0.80 occurred in 13 and 5 vessels after treatment with SCBs and PCBs, respectively.

CONCLUSIONS

The SCB MagicTouch failed to demonstrate noninferiority for angiographic net lumen gain at 6 months compared to the PCB SeQuent Please Neo.

A Novel Closed-Loop Balloon-Stent Embolization for the Treatment of Coronary Artery Perforation

Coronary artery perforation is a serious and potentially life-threatening complication of percutaneous coronary intervention. Although there are a few treatment options available, such as coil or fat tissue embolization and stent-graft implantation, the closed-loop balloon-stent technique can be especially effective for thin vessel ruptures. In this case report, we demonstrate the successful application of the closed-loop balloon-stent embolization for a perforation of the distal left anterior descending artery, a procedure which, to our knowledge, has not been previously documented in the literature.

Randomized clinical trial to compare the efficacy of self-expanding bare metal nitinol stent and balloon angioplasty alone for below-the-knee lesions following successful balloon angioplasty: 1-year clinical outcomes

This prospective, multicenter, randomized study aimed to compare the 1-year clinical outcomes after primary stenting with self-expanding bare metal nitinol stent (SENS) and plain old balloon angioplasty (POBA) in patients with critical limb ischemia (CLI) and below-the-knee (BTK) lesions. Overall, 119 patients with CLI and BTK lesions were randomized to POBA alone (POBA group, 61 patients) or primary stenting with SENS (stenting group, 58 patients) after achieving acceptable POBA results in target BTK lesions. Clinical outcomes including amputation and revascularization rates were prospectively compared for 1 year. After 1 year, similar incidence rates of individual clinical endpoints, including cardiac death (6.5% vs. 5.1%, p > 0.999), myocardial infarction (1.6% vs. 0.0%, p > 0.999), repeat revascularization (19.6% vs. 18.9%, p = 0.922), target lesion revascularization (13.1% vs. 17.2%, p = 0.530), and amputation (4.9% vs. 0.0%, p = 0.244), were observed. POBA appeared to have acceptable treatment outcomes compared with primary stenting with SENS after 1 year in CLI patients with BTK lesions undergoing percutaneous transluminal angioplasty (PTA).

Ping-pong snaring of a totally dislodged stent across left main ostium: "All is not lost"

Undeployed stent loss is a rare but potentially serious complication of percutaneous coronary intervention. Its management is not assisted by well-defined guidelines, and it is made even more difficult when the dislodged stent is not protected by in situ guidewire. In this work, we present the case of a total stent loss with a crushed device protruding out of the left main. In this hopeless circumstance, an innovative ping-pong technique was used to contralaterally perform a successful stent retrieval.

Severe thrombocytopenia induced by tirofiban after percutaneous coronary intervention: a case report

BACKGROUND

Tirofiban is a nonpeptide glycoprotein IIb/IIIa receptor antagonist used widely in patients subjected to percutaneous coronary intervention. While the usage of tirofiban sets an important clinical benefit, severe thrombocytopenia can occur with use of this agent.

CASE PRESENTATION

A 76-year-old Chinese man was admitted with 1-month history of sudden onset of chest tightness. He was diagnosed as having subacute inferior myocardial infarction, and percutaneous coronary intervention was performed. After the procedure, patient received tirofiban at 0.15 µg/kg/minute for 4 h. A blood sample was obtained for a complete blood count; severe thrombocytopenia was reported according to routine orders at our hospital. All antiplatelet drugs including tirofiban, aspirin, and clopidogrel were immediately discontinued. The patient received platelet transfusions and was treated with immunoglobulin G. Two days later, the patient's platelet count had increased to 75 × 109/L. There was a significant improvement after day 5, and the platelet count was 112 × 109/L. Seven days after the acute thrombocytopenia, he was discharged with normal platelet count.

CONCLUSIONS

Clinicians should be particularly aware of tirofiban-induced thrombocytopenia in routine practice.

Load-sharing characteristics of stenting and post-dilation in heavily calcified coronary artery

In this work, stenting in non-calcified and heavily calcified coronary arteries was quantified in terms of diameter-pressure relationships and load transfer from the balloon to the artery. The efficacy of post-dilation in non-calcified and heavily calcified coronary arteries was also characterized in terms of load sharing and the changes in tissue mechanics. Our results have shown that stent expansion exhibits a cylindrical shape in non-calcified lesions, while it exhibits a dog bone shape in heavily calcified lesions. Load-sharing analysis has shown that only a small portion of the pressure load (1.4 N, 0.8% of total pressure load) was transferred to the non-calcified lesion, while a large amount of the pressure load (19 N, 12%) was transferred to the heavily calcified lesion. In addition, the increasing inflation pressure (from 10 to 20 atm) can effectively increase the minimal lumen diameter (from 1.48 to 2.82 mm) of the heavily calcified lesion, the stress (from 1.5 to 8.4 MPa) and the strain energy in the calcification (1.77 mJ to 26.5 mJ), which are associated with the potential of calcification fracture. Results indicated that increasing inflation pressure can be an effective way to improve the stent expansion if a dog bone shape of the stenting profile is observed. Considering the risk of a balloon burst, our results support the design and application of the high-pressure balloon for post-dilation. This work also sheds some light on the stent design and choice of stent materials for improving the stent expansion at the dog bone region and mitigating stresses on arterial tissues.

Design of percutaneous transluminal coronary angioplasty balloon catheters

BACKGROUND

Eight commercially available percutaneous transluminal coronary angioplasty (PTCA), including semi-compliant and non-compliant balloons, have been assessed in detail on their tip, balloon, shaft, RX-Port, and hypotube design. Important performance characteristics such as tip deformation, balloon elongation, and deflation rate have been quantified.

METHODS

Five catheters of each model were evaluated during various tests. The robustness of the tips was evaluated through compression, measuring any occurrence of damage. The longitudinal growth of the balloons was recorded during inflation up to Rated Burst Pressure (RBP). The forces required to move the catheter forward and retract it into the guide catheter were measured in a simulated use test setup. The deflation behavior was studied by measuring extracted contrast media over time. Furthermore, balloon compliance and catheter dimensions were investigated.

RESULTS

The outer dimensions of the catheter were found to be smallest at the hypotube (0.59-0.69 mm) and highest at the balloon, respectively, the crossing profile (0.9-1.2 mm). The tip diameter increased after compression by 1.7-22%. Cross-sections of the folded balloons revealed a tri- and two-fold, respectively. The measured balloon elongation ranged from 0.6 to 2.0 mm. After the inflation of the balloon, an increase in friction between the guide wire and the catheter was observed on four catheters. A maximum increase of 0.12 N to 1.07 N was found. Cross-sections of the RX-Port revealed a semicircular-shaped inflation lumen and a circular guide wire lumen. The measured deflation rate ranged from 0.004 to 0.013 µL/s, resulting in an estimated balloon deflation time of 10.2-28.1 s.

CONCLUSION

This study provides valuable insights into the design characteristics of RX PTCA balloon catheters, which can contribute to facilitating the development of improved catheter designs and enhancing clinical outcomes. Distinctions between SC and NC catheters, such as balloon performance and dimensions, are evident. It is important to note that no single catheter excels in all aspects, as each possesses unique strengths. Therefore, it is essential to consider individual intervention requirements when selecting a catheter. The research also identifies specific catheter weaknesses, such as reduced wall thickness, fringes at the tip, and reduced performance characteristics.

Smooth muscle differentiation of coronary intima in autopsy tissues after sirolimus-eluting stent implantation

BACKGROUND

In coronary atherosclerotic disease, the proliferation of intimal smooth muscle cells (SMCs) is regarded as beneficial with respect to stable and unstable plaques, but is thought detrimental in discussions on coronary stent restenosis. To resolve this discrepancy, we focused on the quality, not quantity, of intimal SMCs in coronary atherosclerotic disease.

METHODS

Autopsied coronary artery specimens from seven patients implanted with bare metal stents (BMS), three with paclitaxel-eluting stents (PES), and 10 with sirolimus (rapamycin)-eluting stents (SES) were immunostained for SMC markers. Cultured human coronary artery SMCs were also treated with sirolimus and paclitaxel.

RESULTS

Intimal SMC differentiation, estimated by the ratio of h-caldesmon+ cells to α-smooth muscle actin+ (α-SMA+) cells, was significantly increased whereas dedifferentiation, estimated from the ratio of fibroblast activation protein alpha (FAPα)+ cells to α-SMA+ cells, was significantly decreased, in tissues of SES compared with BMS cases. No difference in the degree of differentiation was found between PES and BMS cases or between the three groups in nonstented arteries used as controls. Correlation analyses for each field of view revealed a significant positive correlation between h-caldesmon and calponin staining but significant negative correlations with FAPα staining in α-SMA+ cells. Cultured SMCs were shorter (dedifferentiated) and showed an increased FAPα/α-SMA protein when treated with paclitaxel, whereas they became elongated (differentiated) and showed increased calponin/α-SMA proteins with sirolimus.

CONCLUSIONS

The SMCs of the coronary intima may differentiate after SES implantation. SMC differentiation may explain both the plaque stabilization and reduced risk of reintervention associated with SES.

Safety and Efficacy of OPN Balloon in Patients With Calcified Coronary Artery Disease

BACKGROUND

Patients with symptomatic calcified coronary lesions have poor outcomes. Such lesions require additional atherectomy devices for bed preparation.

AIM

To assess the safety and efficacy of OPN balloon in patients with calcified coronary lesions.

METHODS

This is an investigator-initiated, prospective, observational study. The primary outcome of the study was a procedural success.

RESULTS

We studied 71 patients (133 lesions). Maximum lesions were located in LAD [46.6 %]. The OPN balloon was used for pre-dilatation alone in 28.6 % (Pre-stent OPN group), post-dilatation alone in 63.2 % of lesions (Post-stent OPN group), and in both situations in 8.3 % of lesions with procedural success in 98.5 % of patients. Further dilatation with different NC balloons was required in both groups (30 %). The median (IQR) OPN balloon diameter in the pre- and post-stent OPN group were 2.5 (2.5, 3.0) and 3.0 (3.0,3.0) mm (p = 0.001), respectively. The difference between the diameter of the stent and OPN balloon used in pre-stent OPN group was 0.5 (0.2, 0.5) mm while it was 0.0 (0.0,0.2) mm in the post-stent OPN group (p < 0.001). Eight complications and two deaths occured. Distal shaft rupture was also noticed.

CONCLUSION

OPN balloon is safe, and effective in treating calcified coronary lesions. We propose to undersize the balloon by 0.5 mm for pre-dilatation followed by 0.25 mm larger NC balloon if needed. In the post-dilatation group, use a 1:1 size balloon in a non-tortuous straight segment. Use imaging especially when (1) the pressure taken more than the rated burst pressure, (2) an OPN balloon size is ≥3 mm (3) using 1:1 size OPN balloon in a tortuous segment.

Giant right coronary artery aneurysm in a dominant right system

Giant coronary artery aneurysms (GCAAs) are unusual and extremely rare. Due to their rarity, there is a lack of data on managing GCAAs. A man in his 70s who presented with worsening shortness of breath and bilateral lower extremity oedema was found to have non-ST elevation myocardial infarction. Coronary angiography showed a tortuous Shepherd's crook right coronary artery with ectasia and a gigantic 4.5×4 cm saccular aneurysm in the mid-right coronary artery with limited flow to the distal vasculature. He subsequently underwent aneurysmal clipping and excision with coronary artery bypass grafting. GCAAs are usually silent and diagnosed incidentally but can also present with variable cardiac symptoms. Treatment options include medical management, percutaneous coronary angioplasty and surgery. As per limited available literature, surgical resection has shown favourable outcomes, especially in symptomatic GCAAs. The patient reported significant symptomatic improvement on the follow-up office visit.

Spontaneous Dissection of Left Internal Mammary Artery Graft: A Case Report and Literature Review

Spontaneous left internal mammary artery (LIMA) graft dissection is a rare condition, and clinical findings remain to be elucidated. We report a case of LIMA graft dissection diagnosed by a coronary computed tomography and intravascular ultrasound. The patient was successfully treated with percutaneous intervention. We also conducted a literature review of published cases and summarized the clinical presentation, pathophysiology, diagnosis, and treatment.