Pakistan Journal of Cardiovascular Interventions <p>Pakistan Journal of Cardiovascular Interventions is a biannual, open access, peer-reviewed journal of the Pakistan Society of interventional cardiology. The journal publishes original research, reviews, clinical reports, case studies, legal and policy perspectives articles focusing on interventional procedures and techniques.</p> Pakistan society of interventional cardiology en-US Pakistan Journal of Cardiovascular Interventions 2790-4415 <p></p> A Page from the Development of Modern Cardiology in Pakistan <p>Most cases needing coronary angiography were sent to the UK at that time. The first case of Coronary Angiography I performed was a young airline Pilot from an African country (probably Nigeria) who had come to Karachi for training with PIA. He had some chest pains, and his ECG showed deep T wave inversions in his chest leads2. A board was set up at NICVD to recommend that he be sent to the UK for it. I suggested to the then ED NICVD, Prof. Shaukat Ali Syed, let me do it here at NICVD Karachi. He was somewhat hesitant and said we had attempted it before at NICVD but with poor results! I told him not to fear as I was fully trained and routinely did it in the USA. He agreed, and I performed my first selective coronary angiography at NICVD.</p> Azhar Masood A Faruqui Copyright (c) 2021 The Author 2021-12-01 2021-12-01 1 1 01 03 Pakistan’s Intervention Cardiology History (1971-2021) <p>Cardiac catheterization is an invasive procedure for an accurate diagnosis of cardiac problems. Right, and left heart catheterization was initiated at NICVD by Dr. Abdul Haq Khan in the early ’70s. This helped establish the early open heart surgery for mitral and aortic valve replacement. With the rapidly increasing burden of coronary artery disease, the need for a coronary study was apparent. In 1979 that Prof. Azhar M.A. Farooqi performed the first selective coronary angiography in Pakistan at NICVD, thus laying the ground for revascularisation in the country. A coronary artery bypass surgery program was initiated.</p> Mansoor Ahmad Copyright (c) 2021 The Author 2021-12-01 2021-12-01 1 1 04 06 Successful PROMUS Stent Retrieval through Radial Access Site <p><strong>Background:</strong> Stent dislodgment is a rare but catastrophic complication of percutaneous coronary interventions. In this era of innovation and minimalist approach, successful trans-radial retrieval of dislodged stents and other scaffolds remains a significant challenge because of the small artery, small sheath and catheter sizes, multiple resistance points at acute turns, looped angulations, and curves.</p> <p><strong>Case presentation:</strong> A case of dislodged 4.0 x 12mm EES Promus (Boston scientific) in left circumflex coronary artery due to a calcified lesion.</p> <p><strong>Management and Results:</strong> We successfully retrieved the same assembly with two twisted run-through floppy wires and a 1.5 x 06mm Euphora balloon through the same right radial access site.</p> <p><strong>Conclusion:</strong> It can be safely retrieved through Radial Access points.</p> Javed Jalbani Naveedullah Khan Faisal Ahmed Sobia Masood Musa Karim Muhammad Hashim Copyright (c) 2021 The Author 2021-12-01 2021-12-01 1 1 24 29 Dyspnea and Recurrent Syncopal Episodes in Patient with Left Main Coronary Artery Stenosis <p><strong>Background:</strong> Ischemia is the clinical syndrome that stems from the mismatch of blood supply and demand. Syncope is one of the rare initial presentations of acute coronary syndrome patients. The paucity of incidence often causes ischaemia to be overlooked as a differential in patients with syncope.</p> <p><strong>Case presentation:</strong> We present a case of a 40-year-old woman with no cardiovascular risk factors presented with a history of recurrent syncope and dyspnea without any angina symptoms.</p> <p><strong>Management &amp; Results:</strong> A coronary angiogram was done for the patient, showing an ostio-proximal left coronary artery disease. A Xience Prime DES was placed, which ultimately achieved TIMI III flow. Post PCI, the patient exhibited improvement in the symptoms and didn’t report any syncopal episodes in the follow-up.</p> <p><strong>Conclusion:</strong> Syncope can be the only presenting symptom in patient with Acute Coronary Syndrome (Myocardial Ischemia).It should be explored as a differential in people with no obvious neurological cause.</p> Jabar Ali Muneeb Ullah Jan Copyright (c) 2021 The Author 2021-12-01 2021-12-01 1 1 30 33 Left Main Coronary Artery Perforation Treated with Conventional Stent (A Real Management Dilemma) <p><strong>Background:</strong> Left main coronary artery (LMCA) perforation is a very rare complication of percutaneous coronary intervention (PCI); there is a scarcity of data for its treatment and almost a lack of literature for the use of regular coronary stent for its management.</p> <p><strong>Case Presentation:</strong> We report a case of 90 years old male who presented with anterior wall myocardial infarction (AWMI) and developed Ellis Type 3 coronary artery perforation in calcified LMCA. Post dilatation of ostial Left anterior descending artery (LAD) stent was successfully managed with the deployment of regular drug-eluting stent (DES), preceded by immediate balloon tamponade.</p> <p><strong>Management &amp; Results:</strong> The patient remained hemodynamically stable, and his echocardiogram did not show pericardial effusion or tamponade and was discharged home eventually in a stable condition.</p> <p><strong>Conclusion:</strong> In conclusion, LMCA perforation may occur during high-pressure post dilatation of calcified artery as evident from earlier studies but can be managed successfully with conventional coronary artery stent placement, provided there will be no hemodynamic compromise or tamponade. This case report has introduced a new concept of managing coronary artery perforation, which may reduce the risk of in-stent restenosis significantly associated with using a covered stent.</p> Kamran Ahmed Khan Danish Qayyum Usman Bhatti Dileep Kumar Tahir Saghir Copyright (c) 2021 The Author 2021-12-01 2021-12-01 1 1 34 38 Challenging Rotablation assisted Percutaneous Coronary Angioplasty to LAD and LCX <p><strong>Background:</strong> Rotational atherectomy (RA) is used for treating severely calcified and complex lesions during percutaneous coronary interventions (PCI).</p> <p><strong>Case Presentation:</strong> A 70 years old male, diabetic and hypertensive, with failed PCI at another facility for calcified dominant left circumflex artery disease (LCX) was scheduled for rotablation assisted PCI.</p> <p><strong>Management:</strong> The angiogram showed a calcified critical lesion in the proximal part of the Left anterior descending artery (LAD). A large dominant LCX with a severely calcified and badly dissected lesion in the mid part. LAD was rotablated with 1.75mm burr followed by a 3.5mm DES. Guidezilla was deep throated in LCX and to support Corsair half way across the mid LCx lesion. Re-Wired from here with Rota floppy. Distal LCX was rotablated with a 1.25mm burr and proximal to the mid part with a 1.75mm burr. The lesion was dilated with noncompliant balloon. Two overlapping DES were deployed via Guidezilla. Both stents were post-dilated with a 3.5mm NC balloon. The patient went home the next day without any complications. At one year follow-up, he was asymptomatic with improved ejection fraction (EF) of 50%.</p> <p><strong>Conclusion:</strong> Patient with reduced EF usually requires LV assist devices such as Impella during such complex interventions, which is considered unaffordable in our setting. Multivessel rotablation is considered high risk in elderly patients with reduced EF, however if planned and performed correctly can help in such cases.</p> Madiha Bashir Asad Akbar Khan Copyright (c) 2021 The Author 2021-12-01 2021-12-01 1 1 39 45 When your tools turn against you; a nightmare for Interventional Cardiologist <p><strong>Background:</strong> One of the rarest but potentially life-threatening complications of coronary angiography and angioplasty is an iatrogenic dissection of the left main coronary artery (LMCA). Risk factors for left main dissection included coronary artery anomalies, atherosclerotic changes-left main stenosis, aortic root calcification, Marfan syndrome, arterial hypertension, older age, and bicuspid aortic valve4. Iatrogenic left or separate origin LAD/ LCX dissections result from catheter manipulation, forceful injection of contrast medium, balloon dilatation, and stenting.</p> <p><strong>Case Presentation:</strong> 54 year old hypertensive woman with family history of ischemic heart disease presented with unstable angina, who underwent iatrogenic dissection of anomalous origin of ostio-proximal left anterior descending artery.</p> <p><strong>Management:</strong> Patient received bail out percutaneous coronary intervention with drug-eluting stent (DES) 2.75 x 28 mm but there was distal shifting during deployment which resulted in placement of another DES 3.0 x 12 mm to cover the ostium.</p> <p><strong>Conclusion:</strong> A diagnostic catheter-induced proximal LAD dissection during a diagnostic coronary angiogram and bailout stenting of an anomalous left system course with an absent left main stem and separate origins of LAD and LCX was performed.</p> Bilal Ahmed Furqan Yaqub Pannu Bilal S Mohydin Copyright (c) 2021 The Author 2021-12-01 2021-12-01 1 1 07 12 Multiple Plague Rupture in Setting of Acute Myocardial Infarction <p><strong>Background:</strong> ST-segment elevation myocardial infarction (STEMI) due to the simultaneous formation of thrombi in multiple arteries, known as multiple culprits, is an infrequent angiographic finding in clinical practice. Current guidelines for managing STEMI patients with multiple culprits are not very clear. However, various studies reported the beneficence of complete revascularization in such patients.</p> <p><strong>Case Presentation:</strong> We presented a series of five cases presented with STEMI with multiple culprits who underwent complete revascularization.</p> <p><strong>Management:</strong> The successful intervention of multiple culprits with closed contrast monitoring leads to a good outcome and a short hospital stay. Although, the optimal management strategy for the simultaneous multiple culprit lesions has yet to be established.</p> <p><strong>Conclusion:</strong> Acute myocardial infarction caused by simultaneous multi-vessel coronary occlusion is rarely reported. The successful intervention of multiple culprits with closed monitoring of the contrast leads to a good outcome and short hospital stay. Although, the optimal management strategy for the simultaneous multiple culprit lesions has yet to be established.</p> Muhammad Hashim Muhammad Naeem Mengal Naveedullah Khan Syed Nadeem Hassan Rizvi Tahir Saghir Copyright (c) 2021 The Author 2021-12-01 2021-12-01 1 1 13 23