Recently, the tasks of the radiological technologists have the difference between hospitals. Angiographic equipments have been improved performance, as results, they are enhanced convenience and their operations are advanced automation. However, there are difficult to understand to change the tasks for the radiological technologists. In some hospitals, they are reduced, that are not associated with the angiography. On the other hands, the irradiated doses are more than ten times the gap in angiography at various hospitals. We, therefore, need to discuss that the irradiated doses will be optimized at them. Since they have been changed over from diagnostic procedures to be therapeutic interventional procedures in the examinations, the x-ray fluoroscopy has been extended long period and number of times radiography has been increased. There are also made complicated to be therapeutic interventional procedures by developments of new devices and improvement of their operations. It is clear that these complications are the serious problems by exposure dose. In this paper, we discuss about role sharing of the radiological technologists on advanced digital angiography.

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Purpose: It is not clear whether PCI contributes to improve prognoses for stable angina. The purpose of this study was to determine whether there is any difference for prognosis between triple-vessel disease (TVD) and non-TVD and whether PCI improves clinical outcomes of patients with stable angina. Method: We investigated clinical courses and major adverse cardiac events (MACE) of 200 consecutive patients treated with PCI for stable angina in our institution from 2005 to 2008. We compared event rates between TVD and non-TVD groups after PCI. Result: There was no significant difference for composite rates of all-cause deaths or non-fatal myocardial infarction between the two groups (non-TVD: 9.0%, TVD: 9.0%, p=0.9874). There was no significant difference for readmission for unstable angina between the two groups (non-TVD: 4.5%, TVD: 9.1%, p=0.3507). The target lesion revascularization rate was significantly higher in the TVD group than in the non-TVD group (non-TVD: 14.0%, TVD: 25.3%, p=0.0137). Conclusion: There was no significant difference for clinical outcomes after PCI for stable angina between non-TVD and TVD. PCI for stable angina seems to contribute to reduce acute coronary events, even in those with TVD.

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Objectives: We have used the saphenous vein graft (SVG) to revascularize the right coronary artery (RCA) in cases with <90% stenosis and the gastroepiploic artery (GEA) in cases with ≥90% stenosis. This study was conducted to assess the validity of our approach. Methods: 75 patients who had undergone isolated coronary artery bypass grafting including the RCA between March 2005 and July 2011 were studied. Early and mid-term outcomes were compared between 2 groups of patients who had received either the GEA or the SVG graft to revascularize the RCA. Results: Early graft patency rates were 89% in the SVG group and 91% in the GEA group, while the rate of freedom from cardiac adverse events at 48 months was 96.4% in the SVG group and 97.7% in the GEA group; there were no significant differences between the groups. Conclusion: Early and midterm outcomes demonstrated the validity of our approach for selecting grafts based on the rate of stenosis in the RCA.

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Background: It is widely recognized that late lumen loss of zotarolimus-eluting stent (ZES) was significantly higher than that of other drug-eluting stents (DES), therefore the restenosis rate and target vessel revascularization (TVR) rate after ZES deployment tend to be higher compared with those after other DES. But the patients with angiographic restenosis after ZES deployment in follow-up coronary artery angiography (CAG) are often good in the clinical course. Methods: We measured fractional flow reserve (FFR) of the coronary arteries with angiographic restenosis after ZES deployment, and assessed the usefulness of FFR measurement in decision of TVR. 25 cases (28 lesions) which were performed follow-up CAG in 62 cases (74 lesions) treated by ZES in Tokyo Medical University Hospital were enrolled. The rate of TVR which was decided by FFR measurement was evaluated. Results: Although angiographic restenosis was detected in 10 lesions, the rate of TVR based on functional assessment was 6% (4 lesions). Conclusion: Even if angiographic restenosis was detected in follow-up CAG, the cases that the functional assessment was significant and TVR was needed were 40%. Therefore, indeterminate TVR should not be performed impetuously for patients with angiographic restenosis after the deployment of ZES.

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Background: Operative mortality after coronary artery bypass grafting (CABG) with end-stage renal disease (ESRD) on hemodialysis (HD) is high. To improve early results, we aggressively selected off-pump coronary artery bypass graft (OPCAB). Since complete revascularization was sometimes difficult because of diffuse calcification, a preoperative cardiac computed tomography (CT) was used for complete revascularization using bilateral internal thoracic arteries (BITA). Methods: We reviewed thirteen patients on HD, including two patients with ischemic mitral regurgitation (IMR), who underwent CABG from April 2010 through July 2011. The period of HD was 7.2±6 years; wherein, nine of 13 patients had diabetic nephropathy. Results: OPCAB was completed in all cases, except for the two IMR. There was no operative mortality. One postoperative deep wound infection was completely cured by vacuum associated closure. In situ BITA usage rate of 89% and complete revascularization rate of 92% were comparable in the patients without ESRD. Median time of ventilation was 4.8 hours, feeding was resumed on the second day, and ambulation was initiated on 2.5 days. ITA patency rate confirmed by angiogram was 100%, and Fitz-Gibbon A accounted for 96%. Although 1 year survival rate was a 77%, freedom from cardiac event excluding non-cardiac death was 100%. Conclusion: In patients with ESRD on HD, preoperative cardiac CT was crucial in deciding the appropriate site of anastomosis. OPCAB improved operative mortality, and complete revascularization with in situ BITA was an acceptable strategy, which could improve long term outcome.

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A 57-year-old man was admitted to an emergency department with chest pain which radiated to the left shoulder at rest. An electrocardiography showed sinus tachycardia with ST segment depression in the lateral leads. The blood tests did not reveal elevated serum cardiac enzymes, and echocardiography did not show regional asynergy. Coronary angiography showed no significant coronary stenosis but the left anterior descending artery exhibited severe compression during systole, which returned to normal during diastole. On iodine-123 beta-methyl-p-iodophenyl-pentadecanoic acid (¹²³I-BMIPP) imaging, a decreased uptake of ¹²³I-BMPP was observed in the anteroseptal segment. The etiology of ischemia in this case was considered to be myocardial bridging. He was treated with bisoprolol, and no ischemic changes were subsequently provoked on exercise electrocardiography tests. Myocardial bridging sometimes causes myocardial ischemia from the compression of the coronary artery at systole. In this case, tachycardia exacerbated myocardial ischemia due to myocardial bridging, which was confirmed by ¹²³I-BMIPP imaging and exercise electrocardiography tests, and improved by the administration of beta adrenergic blockers.

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Case 1: An 80-year-old man was admitted because of exertional chest pain. Triple vessel disease was diagnosed from coronary angiography (CAG) results, and coronary bypass surgery was performed (the left and right internal thoracic arteries were anastomosed with the left anterior descending artery and left circumflex artery, respectively, and the gastroepiploic artery was anastomosed with the right coronary artery). CAG performed after recurrence of exertional chest pain showed occlusion of both the left and right internal thoracic artery graft. Thus, 3 years after the coronary bypass surgery, the internal thoracic artery graft showed occlusion. Case 2: A 73-year-old woman was admitted because of exertional chest pain. A stent was inserted because of severe stenosis from the left main trunk to the left descending artery. After stent insertion, the patient experienced unstable angina. CAG showed restenosis inside the stent. Thus, coronary bypass surgery was performed (left internal thoracic artery graft was anastomosed with the left descending artery, and saphenous vein graft was anastomosed with the left circumflex artery). CAG performed after recurrence of exertional chest pain showed occlusion of the left internal mammary artery graft. Thus, 1.5 years after the coronary bypass surgery, the internal thoracic artery showed occlusion. Cases 1 and 2 were considered to show different mechanisms in causing the early occlusion of the internal thoracic artery graft.

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A 78-year-old man was admitted with unstable angina pectoris. His coronary risk factors included hypertension and dyslipidemia. Coronary angiography revealed 90% stenosis at the segment 6 of the left anterior descending coronary artery. We intended to perform percutaneous coronary intervention for the lesion. We estimated with angiography and intracoronary ultrasound that there was a lot of plaque in the lesion. We tried a direct stent implantation in order to decrease the risk of slow-flow phenomenon. While delivering the stent to the lesion, we were not sure if the stent was in the appropriate position or not, because the tight stricture and the stent itself prevented contrast medium from filling into the lumen. We pushed the stent into the lesion immediately after the injection of contrast medium for the purpose of stuffing the stent into the lesion. By this technique (plugged stent technique), we could deliver the stent in the proper position because the lesion was filled with contrast medium that was not carried away and the positional relationship between the lesion and the stent became clear. We succeeded in the procedure without any complications. This technique is especially effective when a lesion cannot be filled with contrast medium due to a tight gap between a stent and the lesional lumen.

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We report two cases where carotid artery stenting (CAS) and percutaneous coronary intervention (PCI) were performed at the same time on patients with advanced carotid artery stenosis, with impending symptoms of transient ischemic attack (TIA) complicated by advanced coronary artery stenosis. Case 1 was a 78-year-old male suffering from frequent occurrence of intermittent paralysis of the right upper and lower extremities. Advanced stenosis of his left internal carotid artery and left anterior descending (LAD) coronary artery was demonstrated in catheter angiography. Semi-urgent treatment of carotid artery stenosis was deemed necessary and, as the subject’s coronary artery stenosis was also advanced, CAS was performed immediately following PCI. Case 2 was a 77-year-old female whose angina symptoms persisted despite undergoing PCI at another hospital. She visited our hospital after she began to experience amaurosis fugax. Advanced bilateral carotid stenosis and lesions in three coronary artery vessels were observed in catheter angiography. PCI and CAS were performed on three coronary artery vessels and her right internal carotid artery on the same day. CAS was performed on her left internal carotid artery at a later date, and her treatment was completed with no sequellae. We believe that the aforementioned method should be selected in the treatment of advanced carotid artery stenosis complicated by severe coronary artery disease if the patient’s background and situation of the facility renders it appropriate.

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A case was 57-year old man with hemodialysis, distal abdominal aorta obstruction, post right axilla bi-femoral bypasssurgery and left forearm shunts construction. Catheter approach to the coronary arteries was limited. It was able to beapproached only from the right arm's brachial artery, but the high tortuousness and the high calcification wereobserved from the subclavian artery to the brachiocephalic trunk. Although the chronic total occlusion of rightcoronary artery and the left main trunk stenosis were observed by the coronary angiography, revascularized it by thepercutaneous coronary intervension (PCI). He was deemed a high-risk surgical candidate and underwent PCI withright transbrachial approach. Because of the high calcification, the anatomical characteristics, etc., operating theguiding catheter was hard. We experienced the case in which the PCI in an easy way had become possible by using along guiding sheath. For the patients with a limited artery approach, mechanical cardiac supports such as intra-aorticballoon pumping or percutaneous cardio-pulmonary support are not available, and a deft and safe procedure isrequired. For such cases, it is thought that use of a long guiding sheath is useful, expecting the operability, theapproachability, and the kink-resistant character.

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