A prospective study of contrast preservation using ultra-low contrast delivery technique versus standard automated contrast injector system in coronary procedures

Background

We aimed to assess the decrease in contrast media volume (CMV) with ultra-low contrast delivery technique (ULCD) developed at our institution versus the usual automated contrast injector system (ACIS) contrast delivery in coronary procedures.

Methods

We analyzed the amount of contrast given in the consecutive 204 patients of the operators who use ULCD technique versus consecutive 200 patients of the other operators who use ACIS without ULCD technique for coronary angiograms and/or percutaneous coronary interventions (PCIs) from May 2017 to July 2018 at our center. We calculated the mean CMV between these groups.

Results

We observed a significant reduction in mean CMV with ULCD technique versus standard ACIS, respectively: angiogram 24.8 ± 15.8 mL (n = 194) vs 42.3 ± 25.1 mL (n = 200) (p < 0.0001); PCI 23.5 ± 19.7 mL (n = 52) vs 48.2 ± 30.8 mL (n = 16) (p < 0.0070); angiogram with ad hoc PCI 53.4 ± 32.1 mL (n = 23) vs 89.7 ± 35.6 mL (n = 16) (p < 0.0024); and overall angiogram and PCI 27.4 ± 20.5 mL (n = 204) vs 44.9 ± 28.0 mL (n = 181) (p < 0.0001).

Conclusion

Our study showed a highly significant reduction in CMV using ULCD technique compared to standard ACIS contrast delivery in coronary invasive procedures. Even in the standard ACIS arm, CMV was significantly lower than values reported in literature, possibly due to operators' bias toward contrast preservation.

Frequency Domain-optical Coherence Tomography of Coronary Arteries Using a Diluted Iodinated Contrast-saline Mix with 5-Fr Guide Catheters

Background

Optical coherence tomography (OCT) is currently mostly performed using 6-Fr coronary guide catheters via femoral access. Catheters with such large internal diameters are necessary to deliver viscous contrast media and achieve sufficient red blood cell washout. Currently, undiluted iodinated contrast media (15 mL/injection) is used to clear the coronary arteries of red blood cells (RBCs). This leads to an increase in the total amount of contrast used and often the need for femoral artery access. Our objective is to assess the feasibility of performance of OCT using a 5-Fr guide catheter via radial access using diluted iodinated contrast.

Methods

We present a case series of 11 patients where second-generation frequency domain (FD)-OCT was used to assess the coronary arteries using a novel 70:30 dilution mixture of iodinated contrast medium with heparinized normal saline. All procedures were performed with a 5-Fr coronary guide catheter via the radial artery approach.

Results

All procedures were successfully performed vial radial access with good quality imaging obtained. The target vessel was the left anterior descending artery in eight patients, the right coronary artery in two patients, and the left main coronary artery in one patient. OCT resulted in a change in management in 7/11 (64%) patients; no complications were reported with OCT. On average, 10 mL of contrast was used per injection.

Conclusions

The current study demonstrates the feasibility of FD-OCT using 5-Fr guide catheters and diluted iodinated contrast media. This approach lowers contrast exposure and potentially decreases vascular complications without sacrificing image quality.

Isolated Quadricuspid Aortic Valve as a Cause of Insufficiency-Predominant Aortic Valve Disease

Quadricuspid aortic valve is a rare cause of symptomatic aortic regurgitation. It tends to present earlier than degenerative native valve aortic regurgitation but with similar symptoms. The condition can occur in isolation or in association with other congenital cardiac abnormalities. Surgical intervention before the development of left ventricular failure is critical to improve long term survival. We describe a case of severe aortic regurgitation due to isolated quadricuspid valve morphology that was treated surgically.

Retained Coronary Balloon Requiring Emergent Open Surgical Retrieval: An Uncommon Complication Requiring Individualized Management Strategies

The entrapment of coronary intervention devices within the coronary vasculature is a rare but potentially devastating procedural complication. We report a case of an entrapped balloon and broken shaft that had to be retrieved by an open surgical approach. When device extraction is indicated and the use of snaring equipment is unsuccessful or inappropriate, a number of alternative percutaneous maneuvers can be attempted. These include (1) simple advancement and withdrawal of a trapped balloon, (2) use of a "buddy" wire to straighten the vessel and free the trapped device, (3) inflation of a buddy balloon adjacent to a trapped primary balloon to free the device, (4) partial inflation of a buddy balloon distal to a trapped device followed by gentle withdrawal, (5) use of an in-guide secondary balloon to trap the lost device, (6) advancement and twisting of guidewires to entwine the lost device, (7) saline dilution of trapped balloons, and (8) anchoring balloon and reverse-wire puncture of an undeflated and entrapped primary balloon. Careful consideration of various device retrieval strategies is indicated before resorting to open surgical retrieval in the rare instance of intracoronary device entrapment.

Post-Complex Myocardial Infarct Pseudoaneurysm Rupture and Subsequent Complications

Ventricular pseudoaneurysm is an uncommonly encountered complication of myocardial infarction (MI) in the era of percutaneous coronary intervention. Its presentation can be very non-specific, and diagnosis requires a high index of suspicion. Urgent surgical repair is generally warranted to prevent potentially catastrophic complications. We present a case of patient who presented several days after his index MI. He was ultimately diagnosed with a ruptured pseudoaneurysm, and despite best efforts had a complicated hospital course.

Prosthetic Aortic Valve Endocarditis Following Transcatheter Aortic Valve Implantation

Infective endocarditis after transcatheter aortic valve implantation is a life-threating complication, resulting in high in-hospital and one-year mortality. With the ongoing evolution of transcatheter aortic interventions, the proportion of endocarditis cases encountered by health care providers will continue to rise. Early diagnosis of infective endocarditis is of paramount importance to institute appropriate treatment with antibiotics and/or surgery to avoid negative clinical outcomes. In this review, we outline our experience with two cases of infective endocarditis following transcatheter aortic valve implantation and briefly review the literature on the incidence, microbiology, diagnosis, and management of this condition.

Coronary Artery Perforation Spilling into Right Ventricle: A Rare Complication of Percutaneous Coronary Intervention

Injury to the coronary circulation during percutaneous interventions is an existent risk. One of these is coronary artery perforation that can have grave consequences. Fortunately, this is rare and overall there is a declining incidence of complications due to technological advances and extensive experience over time. Predictors of coronary artery perforation include the administration of glycoprotein IIb/IIIa inhibitors, the use of hydrophilic guide wires, and the use of noncompliant high-pressure intracoronary balloons. Complex coronary lesions and the presence of total chronic occlusion are additional risk factors. In this paper, we present a rare class III coronary artery perforation with spilling into the right ventricle. Our case exemplifies all the aforementioned risk factors for perforation. The perforation was successfully sealed with a polytetrafluoroethylene covered stent and the patient remained hemodynamically stable.

The "Chimney Sweep Technique" and Recurrent Coronary Artery Dissections

We are reporting a case of a 65-year-old female who experienced three ST elevation myocardial infarctions (STEMI) during the course of 3 weeks. The first infarct was related to intramural coronary hematoma that propagated proximally after stenting, the second involved progression of this hematoma with obstruction of the vessel lumen, and the third caused subacute stent thrombosis that required "stent cleaning" using the inflated balloon technique.

Robotic-Assisted Percutaneous Coronary Intervention of a Saphenous Vein Graft Stenosis using a FilterWire EZ Embolic Protection

Robotic-assisted coronary angioplasty has been utilized to decrease radiation exposure to cardiologists, and to diminish risk of orthopedic and ergonomic injuries caused by wearing heavy lead during long procedures. The efficacy and safety of robotic-assisted percutaneous coronary intervention for relatively low-risk lesions was demonstrated in the PRECISE study. Successful percutaneous coronary interventions using robotic system for treatment of complex high-risk lesions have been reported in few case series so far. We describe a successful robotic-assisted coronary angioplasty for a complex lesion of saphenous vein graft using a FilterWire EZ embolic protection. This case illustrates the feasibility to use robotic-assisted angioplasty for complex cases.

Recurrent In-stent Restenosis in the Area of Previous Stent Fracture: A Management Dilemma

Drug eluting stents (DES) have been increasingly being used for treatment of coronary artery disease (CAD) and have been shown to be very effective in prevention of primary in-stent restenosis (ISR). However DES have been increasingly associated with acute to subacute risk of stent fractures (SF). There is also a paucity of data about different management strategies for SF, especially in the long term. We present a case of recurrent ISR in an area of previous acute SF at the touchdown of saphenous venous graft (SVG) to first diagonal artery (D1). In our knowledge this is the first case reported of recurrent ISR due to prior acute stent fracture in a saphenous venous graft. It presents an interesting management dilemma with multiple layers of stent in the area of recurrent ISR which was managed with balloon angioplasty with good results.

Clinical factors associated with physician choice of femoral versus radial access: A real-world experience from a single academic center

OBJECTIVES

To analyze clinical factors associated with operator's preference in selection of femoral versus radial access for angiography and percutaneous intervention (PCI) procedures.

BACKGROUND

There has been an increase in radial access in cardiac catheterization and PCI in the last few decades.

METHODS

Data from 11 226 consecutive cardiac catheterization procedures were collected from Sanford University Medical Center (University of South Dakota, Sanford School of Medicine) from 2011 to 2015.

RESULTS

In the overall cases, clinical factors that favored upfront femoral access include patients presenting as ST-elevation myocardial infarction (STEMI) or emergent, coronary artery bypass graft, body mass index (BMI) <30 kg/m² and age ≥70 years, whereas morbidly obese patients (BMI ≥35) and age <70 favored upfront radial access. Radial access in the overall group had lower fluoroscopy time (6.5 vs 8.4 min, P < 0.0001) and lower contrast use (68.8 vs 80.6 cc, P < 0.0001). In the PCI group, efficacy of upfront radial access is less evident with radial fluoroscopy time (10.1 vs 11.0 min, P < 0.0028) and contrast use being higher in radial group (113.8 vs 108.2 cc, P < 0.037). Interventional cardiologists were more efficient in diagnostic cases than non-interventional cardiologists.

CONCLUSION

STEMI or emergent cases and elderly patients favor upfront femoral access. As BMI increases and age decreases, radial access is progressively favored. In diagnostic cases, radial access appears to be superior to femoral access in efficacy, but the distinction is less obvious in PCI and STEMI or emergent cases.

A Case of an Acute Myocardial Infarction Post Thrombolytic Treatment of Ischemic Stroke - A Management Dilemma

Acute ischemic stroke and myocardial infarction are emergency clinical events that require prompt intervention. Concurrent occurrence of both events magnifies the complexity of the clinical management. We present a case of a patient who presented with acute ischemic stroke, complicated by acute myocardial infarction shortly after thrombolytic was administered. This case highlights the importance of individualization of management especially in complex cases where there are no clear specific guidelines to follow.

Abstract 143: Procedural Efficacy in Radial vs. Femoral Approach in Coronary Catheterization and Percutaneous Intervention in a Tertiary Care Teaching Hospital

Background: The practice of trans-radial artery (TRA) approach for coronary angiography and percutaneous coronary intervention (PCI) has been steadily increasing in the United States since 2007 from 1% to 16% in 2012. However, when compared to trans-femoral artery (TFA) approach the procedural efficacy for TRA was found to be worse in large studies. The aim of this study was to explore procedural efficacy of TRA vs TFA approach in a tertiary care teaching hospital.

Methods: We performed a retrospective review of data from 10,145 consecutive patients from our coronary catheterization lab database from 9/2011 to 5/2015 at University of South Dakota, Sanford Heart Hospital. Cases were analyzed for procedural efficacy as defined by duration of procedure, fluoroscopic time, and total contrast utilization.

Results: Overall, 7,581 (76%) patients underwent TRA approach and 2,564 (24%) patients underwent TFA approach. There was a shorter procedural duration for TRA approach vs TFR approach (60.1 minutes vs 78.3 minutes; p<0.0001), shorter fluoroscopic time for TRA approach vs TFR approach (6.06 minutes vs 9.01 minutes; p<0.0001), and less contrast utilization for TRA approach vs TFA approach (64.23 ml vs 72.15 ml; p<0.0001). The procedural duration trend over the past four years in quarterly increments is seen in Figure 1.

Conclusion: Contrary to what was seen in major trials; in our center, procedural efficacy was substantially better for TRA approach compared to TFA approach. Though procedural duration for TRA approach has remained the same over the past four years, there was also a general trend toward lengthening procedural duration for TFA approach.

Abstract 153: Rural Systems of Care: Real World Observations and Trends in ST Elevation Myocardial Infarction Patient Characteristics, and Correlations of Arrival Mode to Outcomes

Background: Minnesota, North Dakota and South Dakota have been enhancing statewide systems through infrastructure and clinical education regarding ST-elevation myocardial infarction (STEMI) since 2010 in an attempt to equalize access to timely reperfusion in rural areas. A trend in faster time to reperfusion has been observed for STEMI patients who transfer directly to Percutaneous Coronary Intervention (PCI) capable facilities via Emergency Medical Services (EMS) and receive a pre-hospital 12-lead ECG in comparison to those who first present to a non PCI capable facility. This improved time to STEMI recognition and reperfusion may be associated with improved outcomes.

Methods: Data was collected via ACTION Registry-GWTG from 2012-2015. The cohort was defined as STEMI patients who received PPCI with interfacility transfer (n=1010) and without (n=376) and who receive a pre-hospital 12-lead ECG (n=1078) and do not (n=308). The association between mode of transport, time to PPCI, and outcomes including LV function, in hospital clinical events, and in-hospital mortality were analyzed by unadjusted association. Multivariable adjustment was performed using covariates from the previously developed and validated ACTION mortality model to determine the independent association between arrival mode and outcomes.

Results: The direct transfer group demonstrated shorter cumulative times (79 vs. 145 min., p=<0.001) to coronary reperfusion as compared to the interfacility transfer group. The pre-hospital ECG group experienced a shorter time to transfer (40 vs. 55 min., p=<0.001) to a PPCI center consistent with earlier system recognition and activation for a STEMI patient. The direct transfer and pre-hospital ECG groups had a statistically significant less risk of in-hospital cardiogenic shock, congestive heart failure, cardiac arrest and death as a composite end-point, p=0.011 & <0.001 respectively. During the years of 2012 to 2015, the performance of pre-hospital ECGs has increased.

Conclusion: Implementation of Mission Lifeline programming was associated with significantly lower risk of in-hospital shock, congestive heart failure, cardiac arrest and death in STEMI patients presenting via EMS through increased utilization of pre hospital ECG, education, and hospital triage and procedural PPCI streamlining.