tent implantation in the peripheral arteries is a safe and effective treatment not only for obstructive diseases, but also non-obstructive conditions such as aneurysm formation. 1,2 More than 50% of all obstructive lesions are located in the femoropopliteal segment where they tend to be longer and have multiple coexisting atherosclerotic lesions at different levels. Surgical revascularization is the treatment of choice for these diffuse femoropopliteal stenoses and although percutaneous transluminal angioplasty (PTA) has a high risk of occlusion, it is the recommended primary treatment. Stent implantation for femoropopliteal occlusions is not recommended because of poor patency rates, and should only be considered for major dissections after PTA because stenting has been associated with acute thrombosis, stent embolization or migration, distal embolization by plaque contents, vessel rupture or dissection. [3][4][5][6] In addition to these acute complications, late stent restenosis remains an unresolved clinical problem. Although stent fracture occurs rarely, it may contribute to or cause late stent failure when implanted in arteries near or at flexion points in the peripheral arteries. Stent fracture has occurred after iliac arterial stenting 7 and we describe a case of fracture in overlapping stents implanted in the left popliteal artery. Case ReportA 48-year-old man was referred for coronary and peripheral arteriography. He reported left calf claudication of 3 years' duration that had progressively worsened in the past few months. His complaints were pain and numbness with mild exercise. He had had non-insulin dependent diabetes mellitus for 1 year and had smoked 1 pack of cigarettes per day for 33 years. On physical examination, both his lower limbs were pale and cool. His left femoral pulse was present, but the left popliteal and left lower extremity pulses were absent. Right femoral and popliteal pulses were present, and the distal pulses in right lower extremity were also palpable. The ankle -brachial index was 0.32 for the left limb. There was not any ulcer formation related to occlusive arterial disease on either leg.The diagnostic coronary and peripheral arteriography revealed 2-vessel coronary artery disease: a severe stenosis in the proximal segment of the left popliteal artery and 50% narrowing of the right popliteal artery. There was late filling of the vasculature distal to the severely narrowed left popliteal artery (Fig 1). We used a standard angioplasty technique from an antegrade, ipsilateral puncture of the left common femoral artery with an 8F sheath. The lesion was crossed Circ J 2003; 67: 643 -645 (Received November 14, 2001; revised manuscript received January 21, 2002; accepted February 15, 2002

Abstract. The aim of this prospective cross-sectional study was to investigate the hypertrophic effects of endogenous subclinical hyperthyroidism on myocardium and early development of left ventricular hypertrophy (LVH) in essential hypertensive patients accompanied by endogenous subclinical hyperthyroidism. A total of 31 consecutive patients with stage I hypertension were included in the study. Sixteen of them also had endogenous subclinical hyperthyroidism that they were unaware before. The patients and the controls formed out of ten healthy subjects all underwent an investigation of thyroid functions and cardiologic evaluation. The mean wall thickness of the left ventricle in the stage I hypertensive group with endogenous subclinical hyperthyroidism (group I) was significantly increased as compared with both hypertensive patients without thyroid disease (group II) and the control subjects. The mean left ventricle mass was also significantly higher in group I than group II. Both of the patients' groups had an increased prevalence of LVH as compared with the controls. In this study, hypertensive patients with subclinical hyperthyroidism presented more increase in left ventricular mass, suggesting that subclinical hyperthyroidism may contribute to left ventricular hypertrophy forming a natural progression to hypertension. The hypertensive population should always be screened for endogenous subclinical hyperthyroidism, and should be examined for the criteria of left ventricular hypertrophy by echocardiography in early stages. SUBCLINICAL hyperthyroidism is characterized by persistently suppressed plasma thyroid stimulating hormone (TSH) concentrations and the presence of normal levels of free thyroxine (fT 4 ) and free triiodothyronine (fT 3 ) hormones. Subclinical hyperthyroidism can be the result of the same causes of overt clinical hyperthyroidism but patients with subclinical hyperthyroidism do not usually show specific symptoms and signs of hyperthyroidism [1,2]. It has been demonstrated that exogenous subclinical hyperthyroidism, in which patients treated with TSHsuppressive doses of levothyroxine, may affect the heart as in subjects with overt hyperthyroidism, but it remains controversial whether endogenous subclinical hyperthyroidism affects the heart [3][4][5].Situations in which thyroid hormones were increased have been shown to stimulate myocardial hypertrophy. Left ventricular hypertrophy (LVH) is an independent risk factor for cardiovascular morbidity and mortality. Hypertension may also cause left ventricular myocardial hypertrophy. The importance of LVH in the prognosis of hypertension is well known because it clearly shows the duration and the severity of high blood pressure [6][7][8].Since hypertension and hyperthyroidism both may result in myocardial hypertrophy, we designed a crosssectional study to investigate the early development of LVH in essential hypertensive patients accompanied by endogenous subclinical hyperthyroidism. It could

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Radiation-induced heart disease must be considered in any patient with cardiac symptomatology who had prior mediastinal irradiation. Radiation can affect all the structures in the heart, including the pericardium, the myocardium, the valves and the conduction system. In addition to these pathologies, coronary artery disease following mediastinal radiotherapy is the most actual cardiac pathology as it may cause cardiac emergencies requiring interventional cardiological or surgical interventions. Case A 36-year-old man was admitted to the clinic with unstable angina pectoris of one month duration. The patient had no coronary artery disease risk factor. The history of the patient revealed that he had mediastinal radiotherapy due to Hodgkin's disease at 10-year of age. Coronary arteriography showed total occlusion of the left anterior descending artery and 70% stenosis of the proximal right coronary artery. Both arteries are dilated with placement of two stents. Control coronary arteriography at the end of the first year showed patency of both stents and the patient is free of symptoms. Previous radiotherapy to the mediastinum should be considered as a risk factor for the development of premature coronary artery disease. Percutaneous transluminal coronary angioplasty with stent placement or surgical revascularization are the preferred methods of treatment. Preoperative assessment of internal thoracic arteries should be considered prior to surgery. As the radiation therapy is currently the standard treatment for a number of mediastinal malignancies, routine screening of these patients and optimal cardiac prevention during radiotherapy are the only ways to minimize the incidence of radiation-induced heart disease.

SUMMARYBidirectional flow in patients with normal coronary arteries is an indicator of intercoronary continuity, a rare variant of coronary circulation, distinct from collaterals. The case of an 18 year old Turkish male with bicuspid aorta and intercoronary artery is reported and different aspects of this interesting entity are emphasized. (Jpn Heart J 2004; 45: 153-155) Key words: Coronary angiography, Coronary circulation, Coronary anomalies, Bidirectional flow BIDIRECTIONAL coronary flow is frequently seen in patients with severe coronary stenosis and after coronary artery by-pass surgery. In patients with normal coronary arteries, it is an indicator of intercoronary continuity or the so called "coronary cascade". CASEAn 18 year old boy presented with exertional chest pain in the left arm. His past medical history was unremarkable. He had none of the classical risk factors for coronary artery disease. Physical examination revealed a 4/6 systolic ejection sound radiating to the carotids and a 2/6 diastolic murmur. ECG revealed sinus rhythm with signs of marked left ventricular hypertrophy. Echocardiography showed left ventricular dilatation and hypertrophy, a severely calcified aortic valve with severe regurgitation and a mean gradient of 52 and peak gradient of 75 mmHg. Transesophageal examination demonstrated a bicuspid aorta as the underlying pathology. Coronary angiography showed normal coronaries but during left coronary injection the distal part of the right coronary artery (RCA) was From the