Peripheral vascular complications following coronary interventional procedures

Claudication secondary to Perclose use after percutaneous procedures

The use of suture-mediated arterial closure devices has dramatically increased with the increased number of percutaneous procedures being performed. Complications from suture-mediated closure devices have been underreported. Specifically, arterial stenosis resulting in claudication has not been previously described in detail. We present nine patients who presented with various leg symptoms after Perclose was used to achieve arterial hemostasis following percutaneous procedures. All cases were found to have significant arterial stenoses from the Perclose sutures. Once diagnosis was correctly made, the patients either underwent surgical repair or percutaneous balloon angioplasty and in all cases the symptoms abated.

Peripheral arterial disease, acute coronary syndromes, and early invasive management: the TACTICS TIMI 18 trial

BACKGROUND

Patients with peripheral arterial disease (PAD) represent a high-risk patient subset in the setting of non-ST-segment elevation acute coronary syndromes (NSTE ACS). The efficacy and safety of early invasive management for such patients remains unclear.

HYPOTHESIS

Early invasive management would be well tolerated and effective among patients with NSTE ACS and PAD.

METHODS

Patients from the Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis In Myocardial Infarction (TACTICS-TIMI) 18 trial were stratified by the presence or absence of PAD and assessed with respect to baseline clinical factors. The outcomes of patients with PAD and NSTE ACS were examined with respect to treatment assignment to either early invasive therapy or conservative treatment of NSTE ACS. Finally, the bleeding and stroke rates of patients with PAD managed invasively were compared with patients with PAD managed conservatively.

RESULTS

Of 2219 patients with NSTE ACS overall, 166 (7.5%) had concomitant PAD. Compared with those patients without PAD, those with PAD were older (75 vs. 62 years, p < 0.001) and were more likely to have high-risk clinical features, including prior histories of bypass surgery (39 vs. 20%, p < 0.001) or diabetes mellitus (38 vs. 27%, p = 0.002), and more ST-segment depression on their 12-lead electrocardiogram (43 vs. 29%, p < 0.001). Among such patients, early invasive management was associated with significant reductions in the risk of myocardial infarction (MI) at 30 days (11.4 vs. 2.3%, p = 0.03). At 180 days, compared with early conservative management, early invasive treatment for patients with PAD and NSTE ACS was associated with similar reductions in MI (12.7 vs. 3.5%, p = 0.04), and was also accompanied by significant reductions in risk of death (10.1 vs. 2.3%, p = 0.05). No excess in bleeding or stroke rates was noted among patients with PAD managed invasively.

CONCLUSIONS

Among patients with NSTE ACS and a history of PAD, early invasive management is well tolerated and accompanied by significant reductions in morbidity and mortality when compared with a more conservative, ischemia-driven approach.

Meta-Analysis of Trials Comparing Oral Anticoagulation and Aspirin versus Dual Antiplatelet Therapy after Coronary Stenting

The combination of oral anticoagulation (OAC) and aspirin was the antithrombotic treatment initially adopted after coronary stenting (PCI-S). Although dual antiplatelet therapy with aspirin and a thienopyridine subsequently proved safer and more effective, OAC and aspirin combination is still used in patients with an indication for long-term OAC undergoing PCI-S. The absolute (AR) and relative (RR) risk of cardiac events and hemorrhagic/vascular complications of OAC and aspirin versus antiplatelet therapy were evaluated in a meta-analysis of four historical clinical trials. In 2,436 patients, the RR of a 30-day primary composite endpoint of death, myocardial infarction and the need for revascularization was significantly reduced by antiplatelet therapy (RR 0.41; 95% CI 0.25-0.69), whereas the RR of stent thrombosis (RR 0.26; 95% CI 0.06-1.14) and major bleeding (RR 0.36; 95% CI 0.14-1.02) was not statistically different. The 30-day AR of death, myocardial infarction, need for revascularization, major bleedings and vascular complications with OAC and aspirin were 0.65, 3.8, 4.2, 6.4 and 6.6%, respectively. In conclusion, due to the low AR of adverse events, the combination of OAC and aspirin appears an acceptable treatment after PCI-S in patients in whom long-term OAC is deemed mandatory.

Initial experience with a new femoral artery closure device following percutaneous coronary intervention with glycoprotein IIb/IIIa inhibition

The aim of the study was to determine the safety and efficacy of a novel femoral artery closure device (StarClose, Abbott Vascular Devices, Redwood City, CA) following percutaneous coronary intervention employing aspirin, heparin, and glycoprotein (GP) IIb/IIIa inhibition. A prospective nonrandomized single-center pilot study of the StarClose device included a subset of patients undergoing percutaneous coronary intervention utilizing GP IIb/IIIa inhibitors. Those that fulfilled the inclusion criteria (age < 80, no periprocedural haematoma, puncture above the superficial femoral and profunda femoralis artery bifurcation, no significant femoral artery disease) underwent closure of the femoral artery puncture site with a StarClose device immediately on completion of the procedure. Time to hemostasis (TTH), bleeding, mobilization, and short-term clinical follow-up data were collected, and an ultrasound scan of the femoral artery was performed 2 weeks later. Twenty-five patients were recruited, of whom 23 underwent percutaneous coronary intervention (PCI). Their mean age was 58 +/- 12 years, 84% were male, and 63% had unstable angina. All were on aspirin 100-150 mg daily and all PCI patients received i.v. heparin 4-10,000 units at commencement of the procedure and clopidogrel 600 mg on completion. Two patients were on a tirofiban infusion and 23 received a double bolus of eptifibatide, each 0.18 mg/kg, separated by 10 min. The procedural success was 100% and device success 23/25 (92%), with 1 failure due to technical error. The median device delivery time was 36 sec (range, 11-178) and median TTH 37 sec (range, 10-509 sec). There were no major adverse events. In 10 patients, a moderate amount of tract ooze required a short period of adjunctive manual compression. Follow-up ultrasound femoral artery scans revealed no compromise of the vessel lumen. Femoral artery closure with the device following coronary angiography and intervention using glycoprotein IIb/IIIa receptor inhibitors is safe and effective. A randomized trial of a larger number of patients is warranted.

Bleeding Complications After Contemporary Pharmacoinvasive Therapy for ST Elevation Myocardial Infarction

BACKGROUND

Pharmacoinvasive therapy for the treatment of ST elevation myocardial infarction (STEMI) is a strategy that combines early restoration of coronary flow via pharmacologically induced thrombolysis with subsequent, prompt percutaneous coronary intervention (PCI). Prior studies suggesting a heightened bleeding risk of PCI performed early after fibrinolysis predated contemporary pharmacoinvasive practice including use of femoral closure devices (CD), fibrin specific thrombolytics, lower doses of heparin and stents.

METHODS

Consecutive patients were included in this retrospective registry study if they underwent emergent PCI for ST elevation myocardial infarction (STEMI) followed by immediate use of a groin closure device. Between Oct 1, 2002 and Jan 1, 2003, 27 patients were treated with immediate use of CD after post-thrombolytic PCI, performed within 12 hours of thrombolysis (pharmacoinvasive group). 58 patients were treated with immediate use of CD after primary PCI for STEMI. The two groups were compared with respect to the incidence of successful groin closure, bleeding complications, and clinical outcomes. Bleeding events were categorized according to the TIMI criteria. All baseline clinical and treatment variables were compared between the two groups to determine and the association of these variables (including use of thromblytic therapy) with TIMI major and TIMI minor bleeding was determined.

RESULTS

Pharmacoinvasive recanalization with PCI occurred 348 +/- 183 minutes after initiation of fibrinolytic therapy. Glycoprotein IIb/IIIa inhibitors were used less frequently in the patients treated with a thrombolytic agent (59% vs. 90%, p < 0.01). Successful immediate hemostasis was obtained with CD in greater than 85% of patients in both groups (89% for pharmacoinvasive group vs. 86% for primary PCI group, p = 0.89). No patient required vascular surgical intervention. TIMI major bleeding and transfusion requirements were less than 5% in both groups. Antecedent thrombolytic therapy was not a predictor of bleeding complications after PCI.

CONCLUSIONS

Use of CD as part of a contemporary pharmacoinvasive strategy is associated with a low rate of major bleeding complications.

Iliac Artery Stent Placement: Clinical Experience and Short-term Follow-up Regarding a Self-expanding Nitinol Stent

PURPOSE

To evaluate the effectiveness, safety, and short-term patency rates of a self-expandable nitinol stent (JostentSelfX; Abbott Laboratories, Chicago, IL) for treatment of iliac artery stenoses.

MATERIALS AND METHODS

In a prospective study, 34 chronic iliac artery stenoses were primarily treated in 27 patients (mean age, 61.7 years +/- 9.4) by placement of a JostentSelfX. Handling and visibility of the stent was scored on a 4-point scale. Before stent placement, within 3 days after stent placement and at 6 months follow-up, the clinical history, clinical stage according to the Rutherford classification, and the ankle-brachial index (ABI) were assessed. Intra-arterial digital subtraction angiography including measurement of the mean pressure gradient was performed at the time of stent placement and at 6 months follow-up or in case of recurrence of symptoms. The Wilcoxon signed rank test and Kaplan-Meier method were applied for statistical analysis.

RESULTS

The immediate technical success rate was 94%. The clinical success rate immediately after the procedure was 96% and 85% at 6 months follow-up. Stent placement significantly decreased the severity of stenoses as well as the mean pressure gradients and significantly increased the ABI. Handling of the stent was judged good. No misplacement occurred. Foreshortening during deployment was negligible and no stent migration was seen. However, visibility of the stent during fluoroscopy was ranked as moderate to bad. Follow-up at 6 months revealed the cumulative angiographic primary patency rate (<50% restenosis and <10 mm Hg mean pressure gradient) to be 0.96.

CONCLUSION

The evaluated self-expandable nitinol stent is an effective tool in treating iliac artery stenoses. Apart from poor visibility, handling was good. The angiographic patency rate is comparable with data reported in other stent trials.

Effect of peripheral arterial disease in patients undergoing percutaneous coronary intervention with intracoronary stents

OBJECTIVE

To compare the short-term and long-term outcomes of patients with coronary artery disease and peripheral arterial disease (PAD) who underwent intracoronary (IC) stent Implantation during percutaneous coronary intervention (PCI) with the outcomes of patients with isolated coronary artery disease but without PAD who underwent IC stent implantation.

PATIENTS AND METHODS

We analyzed the outcomes of 7696 patients who underwent IC stent implantation during PCI at the Mayo Clinic in Rochester, Minn, between January 1996 and December 2002. Outcomes of 6299 patients (82%) with Isolated coronary artery disease and without PAD who underwent IC stent implantation (group 1) were compared with outcomes of 1397 patients (18%) with coronary artery disease and PAD (group 2) who underwent PCI with IC stent implantation.

RESULTS

Patients in group 2 were older (71.1+/-10.2 years vs 65.0+/-12.0 years; P<.001) and had a higher prevalence of hypertension (79% vs 61%; P<.001), diabetes mellitus (33% vs 20%; P<.001), hyperlipidemia (76% vs 70%; P<.001), and history of smoking (70% vs 63%; P<.001) compared with group 1. Prevalence of multivessel disease was higher in group 2 (79% vs 68%; P<.001). Procedural success was significantly lower In group 2 (95% vs 97%; P<.001). In-hospital complications were higher in group 2: death (3% vs 1%; P<.001), any myocardial Infarction (MI) (8% vs 5%; P<.001), death/MI/coronary artery bypass grafting (CABG)/target vessel revascularization (11% vs 7%; P<.001), and blood loss requiring transfusion (11% vs 5.8%; P<.001). After adjustment for other risk factors, the odds ratio for in-hospital death was 1.84 (95% confidence interval [CI], 1.16-2.90; P=.009), and for death/MI/CABG/target vessel revascularization, the odds ratio was 1.25 (95% CI, 1.00-1.55; P=.048) in patients with PAD treated with IC stents. Median follow-up was 3.1 years. Six-month, 1-year, and 2-year Kaplan-Meier estimates of survival free of death/MI/CABG/target vessel revascularization were 84%, 77%, and 69%, respectively, for group 2 and were significantly worse compared with group 1 (89%, 85%, and 80%, respectively; P<.001). This effect remained after adjustment for other risk factors (hazard ratio, 1.36; 95% CI, 1.22-1.51).

CONCLUSIONS

Compared with patients who had isolated coronary artery disease but no PAD, patients with coronary artery disease and PAD had lower procedural success and higher in-hospital major cardiovascular complications, including higher blood loss requiring transfusion, after PCI with stent Implantation. On follow-up, the short-term and long-term outcomes of patients with PAD were worse, with higher mortality, MI, and need for repeated target vessel revascularization.

To plug or not to plug?

Coronary artery disease remains a common problem in industrialized countries. Percutaneous coronary interventions are usually performed utilizing the femoral approach. Arterial puncture-closing devices have been developed in hope to avoid manual compression and shortening the period of rest. In a recent meta-analysis in the Journal of the American Medical Association these devices have shown only marginal benefits over manual compression. Further, well designed studies are necessary to document the comparative effects of these devices versus manual compression.

‘The Closer’-percutaneous vascular suture device: evaluation of safety and performance in neuroangiography

OBJECTIVE

To evaluate the use of the suture mediated vascular closure device concerning practicability and safety in clinical angiography practice.

MATERIAL AND METHODS

One hundred and seventeen patients (59 female, 58 male, mean age 40.9+/-13.4) underwent percutaneous closure of common femoral arterial puncture sites following diagnostic neuroangiography using the suture device 'the Closer' (Perclose Inc., Redwood City, CA, USA). Primary success, early problems (within 24 h) and late complications were evaluated. Complications were graded as minor and severe with or without need of surgical intervention and categorized by type. Parameters such as age, gender, sheath size and number of previous arterial punctures were evaluated with respect to complications.

RESULTS

Percutaneous closure was primary successful in 85% (100/117). The overall complication rate was 32% (28% mild n=35, 4% severe n=6, which needed surgical intervention). All but one problem occurred within the first 24 h after the suture. Additional manual compression was necessary in 32 cases (25%). There was no significant difference in age and gender between the groups with and without complications. Sheath size was significantly larger (P<0.01) and numbers of preceeding angiograms were significantly higher (P<0.01) in the complications group compared with uncomplicated cases.

CONCLUSION

The evaluated percutaneous vascular suture device is useful in clinical practice but limitations concerning patient selection seem to emerge in order to avoid complications.

Trash feet after coronary angiography

Cholesterol crystal embolisation is a frequently underdiagnosed condition. While coronary catheterisation is safe and commonly performed, the reported patient developed very painful trash feet after undergoing this routine procedure. Ulceration and gangrene occurred after catheter manipulation during cardiac angiography, which caused occlusion of the small arteries in his feet. The triad of pain, livedo reticularis, and intact peripheral pulses is pathognomonic for cholesterol embolisation. The prognosis depends on the extent of the systemic disease and a high rate of mortality (75-80%) is observed. Prognosis is poor and the treatment is only supportive. It is suggested that while cardiac catheterisation is largely safe and a very commonly performed procedure, it can still lead to complications with serious side effects and can even prove fatal.

Periprocedural routines of coronary angioplasty--extreme diversity with unrevealed consequences

Our objective was to evaluate the current trends of coronary angioplasty periprocedural care in the state of Israel. PTCA technology has undergone through some major developments and refinements, which have yielded new algorithms and routines. With this shift of paradigms, some of the periprocedural routines (these include medications and dosing before, during and after the procedure, as well as the handling of anti-coagulation, femoral sheath removal and the extent of patient monitoring post-PTCA) have been partially re-established. In order to assess trends in periprocedural care, we elected to analyze the current state of practice in the state of Israel. A questionnaire was sent to every cardiac catheterization laboratory in Israel that performs PTCA. An authorized senior cardiologist representing the laboratory submitted the information required for our survey. A nurse-to-nurse telephone questionnaire was conducted simultaneously to cross-examine the validity of the data. All centers submitted results. The average heparin dose for PTCA varied between 5000 and 15 000 units, ACT was monitored routinely by some and not at all by others, post-PTCA heparin administration was routinely administered by some institutions and not by others, and the mean femoral sheath dwell time ranged from 4 to 18 h. Post-PTCA cardiac monitoring varied from 6 to more than 24 h. Some institutions prescribed to all patients nitrates, calcium channel blockers and low-molecular-weight heparin, while others did not. We conclude that there is profound variability in the periprocedural routines that may translate into a significant cost increase, patient discomfort, a prolonged monitoring and hospital stay, and potential patient morbidity. We suggest that these routines should be critically evaluated, and that if they do not contribute to the procedural success and patient well-being they should be abandoned.

Central nervous system vasculitis in the intensive care unit

Intensivists are sometimes faced with unexplained neurologic defects in ICU patients. A subacute presentation over weeks or months characterized by headache and mental status change with focal deficits in the absence of evidence of secondary vasculitis or other diseases mentioned in the differential diagnosis should arouse suspicion of PACNS. Delay in diagnosis of this rare condition may lead to additional morbidity and prolong ICU stay. There is also a risk of permanent cognitive dysfunction with untreated PACNS. A reactive CSF picture, ischemic changes on MR imaging, and alterations in vessel caliber on cerebral angiography are not diagnostic but strengthen the evidence for PACNS. A brain biopsy may be required to confirm the diagnosis. High-dose steroid therapy with a prolonged course and gradual taper controls the disease in most cases. Additional immunosuppressive therapy is needed in some patients.

Successful treatment of a femoral artery pseudoaneurysm mimicking a deep venous thrombosis following cardiac catheterization

Access site pseudoaneurysms are uncommon but well-known complications of cardiac catheterization. We report the first known case of a pseudoaneurysm mimicking the presentation of a deep venous thrombosis by causing extrinsic compression of the venous system. The patient had complete resolution of the pseudoaneurysm and his symptoms following treatment with ultrasound-guided percutaneous thrombin injection.

Self-sealing, large bore arterial punctures: a counterintuitive new phenomenon

The human femoral artery can bleed dangerously following the removal of a catheter uring cardiac catheterization. In this study, a modified technique of needle insertion, simply inserting the needle bevel-down instead of the standard bevel-up approach, was tested as a means to reduce bleeding after catheter removal. Large bore needle punctures were made in surgically exposed arteries of anesthetized pigs using either a standard technique (45 degree approach, bevel up) or a modified technique (25 degree approach, bevel down). For half the punctures, topical phenylephrine solution (1 mg/ml) was applied to the adventitia of the artery to cause constriction. Median bleeding rates were reduced from 81 to less than 1 ml/min/100 mmHg intraluminal pressure by the modified technique with application of phenylephrine. In most cases zero bleeding, that is self-sealing, of the arteries occurred. It is postulated that a flap-valve of tissue created by the modified technique produced this self-sealing behavior. Sophisticated modeling studies are needed to fully understand this new phenomenon.

Pseudoaneurysms

Vascular complications that are the result of invasive diagnostic or therapeutic procedures requiring arterial access occur frequently. A common complication, pseudoaneurysm, has significant risk of expansion, extrinsic compression on native arteries, rupture, embolization, and infection. A pseudoaneurysm represents a persistent defect in the walls of the artery, resulting in extravasation of blood outside of the artery. This extravascular blood is confined to the surrounding soft tissues. Clinical suspicion and duplex ultrasonography are the primary diagnostic modalities. There are several options for treatment of pseudoaneurysms, including surgical repair and ultrasound-guided compression. However, a new therapeutic option, ultrasound-guided thrombin injection, has become the treatment of choice for pseudoaneurysms. This procedure is highly effective, rapid, and very safe. Using direct, real-time visualization of the pseudoaneurysm, a needle is inserted percutaneously into the pseudoaneurysm sac, and a small amount of dilute bovine thrombin is injected. Thrombosis of the sac is rapidly evident. Rare complications include thromboembolism into the native artery and hypersensitivity reaction to bovine thrombin.

Immediate protamine administration and sheath removal following percutaneous coronary intervention: a prospective study of 429 patients

We tested the approach of reversing anticoagulation following PCI and immediate sheath removal in 429 consecutive patients. On completion of the PCI, protamine was administered, and the vascular sheath was immediately removed. Stents were used in 364 patients (85%) and GP IIb/IIIa inhibitors were used in 52 patients (12%). Time to achieve hemostasis was 30 +/- 17 min. Minor groin bleeding occurred in six patients. One patient required repair of femoral pseudoaneurysm. Mean creatine kinase at 8 and 16 hr post-PCI were 129 +/- 35 and 145 +/- 32 units, respectively. Creatine kinase rose to > 3 times normal in 12 out of 350 patients (3.4%). Prior to 48 hr, eight patients (1.9%) required emergency PCI or coronary bypass surgery. Follow-up at 30 days observed no deaths and only three target vessel revascularizations (0.7%). In conclusion, immediate reversal of anticoagulation and sheath removal after PCI is safe and feasible.

Cholesterol embolization syndrome: cutaneous histopathological features and the variable onset of symptoms in patients with different risk factors

Cholesterol embolization syndrome (CES) may not only be due to direct dislodgement of cholesterol crystals from atherosclerotic plaques on the walls of arteries by surgery, angiogram or trauma, but may occur after anticoagulant and thrombolytic therapy. The latter two therapies both weaken the fibrin clot that stabilizes the atheromas in place; however, these two therapies commonly have different onsets of CES after their institution. We present three patients with different risk factors for CES who all presented with the pathognomonic triad of leg and/or foot pain, livedo reticularis and good peripheral pulses. In all three patients cholesterol emboli were demonstrated in cutaneous biopsy sections. In two patients there was associated renal involvement, which was fatal in one case. These cases illustrate that cutaneous biopsy may be diagnostic in patients with livedo reticularis, which progresses to necrosis and gangrene. In addition, they illustrate the problems and contradictions involved in treating patients with CES.

Safety and efficacy of the Perclose suture-mediated closure device after diagnostic and interventional catheterizations in a large consecutive population

Arterial puncture sites after cardiac catheterization are a troublesome cause of complications. Closure devices have been developed to improve on patient comfort and safety. We evaluated a suture-mediated closure device, the Prostar-Plus device, in a consecutive population of over 10,001 diagnostic and interventional catheterizations. A significantly higher complication rate was noted for both major and minor complications in the diagnostic catheterization patients treated with the Prostar-Plus device compared to diagnostic catheterization patients treated with manual compression (2.6% major and 4.6% minor complication rate for the Prostar-Plus treatment group vs. 0.2% major and 1.8% minor complication rate for the manual compression treatment group). For the interventional patients, there were no statistical differences noted for both major and minor complications between patients treated with the Prostar-Plus device vs. manual compression. Subgroup analysis showed that older, thinner women were more likely to have complications related to the Prostar-Plus device.

Therapeutic thrombin injection of pseudoaneurysms: a multicenter experience

The standard non-invasive treatment of pseudoaneurysms has been ultrasound-guided compression (UGC). Problems with UGC include pain at the site of compression, long compression times and incomplete closure. Each of these difficulties is exacerbated with large pseudoaneurysms. Recently, ultrasound-guided injection of pseudoaneurysms with thrombin has gained popularity. The goal of this study was to report a multicenter registry using this technique and in so doing detail the clinical utility and safety of this emerging procedure. The medical records of all patients diagnosed with pseudoaneurysm in the vascular laboratory who underwent thrombin injection over the past year were reviewed for patient characteristics and clinical outcome. There were 91 patients (55 male) with a mean age of 69 years. Three patients also had an arteriovenous fistula. The majority of patients were receiving one or more antiplatelet agents and/or anticoagulants. All patients underwent pseudoaneurysm injection with bovine thrombin. The mean aneurysm diameter was 3.3 cm, with a range of 1.5-6.3 cm. Successful thrombosis of the pseudoaneurysm was achieved in 89/91 (98%) of cases. Anticoagulation with heparin was used in one of the unsuccessful cases. In two cases, UGC was used to close a small active region that did not completely thrombose after thrombin injection. There were two patients who had recurrence of pseudoaneurysm the day after successful injection and thrombosis of the pseudoaneurysm. There were no local complications after injection; however, one patient suffered a pulmonary embolus that was thought to be unrelated to the procedure. In conclusion, thrombin injection for the treatment of pseudoaneurysms is safe and effective, even in patients receiving anticoagulation. This procedure should be considered as the initial therapeutic approach for peripheral pseudoaneurysms.

Vascular complications after percutaneous coronary interventions following hemostasis with manual compression versus arteriotomy closure devices

OBJECTIVES

We evaluated the vascular complications after hemostasis with arteriotomy closure devices (ACD) versus manual compression after percutaneous coronary interventions (PCI).

BACKGROUND

Previous clinical studies have indicated that ACD can be used for achievement of hemostasis and early ambulation after PCI. This study investigated the safety of ACD in achieving hemostasis after PCI compared with manual compression in a large cohort of consecutive patients.

METHODS

A total of 5,093 patients were followed after PCI was performed with the transfemoral approach. Univariate and multivariate analysis were used to identify the predictors of vascular complications with ACD (n = 516) or with manual compression (n = 5,892) as a hemostasis option after sheath removal.

RESULTS

The use of ACD was associated with a more frequent occurrence of hematoma compared with manual compression (9.3 vs. 5.1%, p < 0.001). There was also a higher rate of significant hematocrit drop (>15%) with ACD versus manual compression (5.2% vs. 2.5%, p < 0.001). Similar rates of pseudoaneurysm and arteriovenous fistulae were noted with either hemostasis technique. Vascular surgical repair at the access site was required more often with ACD versus manual compression (2.5 vs. 1.5%, p = 0.03).

CONCLUSIONS

In this early experience with ACD after PCI, their use was associated with higher vascular complication rates than hemostasis with manual compression.

A unique complication during coronary angiography: peripheral embolism by selective right coronary engagement--a case report

"Micro" and "macro" peripheral embolisms during coronary angiography have been described. In all these cases, the aorta or the left heart chambers have been the source of embolus. A patient who during coronary angiography for acute inferior myocardial infarction experienced acute embolism of the left common femoral artery. The source of the embolus was a thrombus-filled right coronary artery, and the precipitating cause was its selective engagement with a diagnostic Judkins right catheter. A brief review of literature is also presented.

Five French (5 Fr) guiding catheters for percutaneous coronary angioplasty and stent placement: An initial feasibility study

Thirty patients were treated with percutaneous coronary intervention (PCI) using a 5 Fr guiding catheter. A recently developed, mechanically advantaged hand injector was used to deliver contrast and achieved excellent visualization through the 5 Fr system. Stent sizes ranged from 2.25 to 4.00 mm in diameter and from 8 to 24 mm in length. All primary lesions were successfully treated. The average contrast use was 70 cc per case. There were no major complications and only one minor femoral hematoma. In selected patients, a balloon angioplasty and stent placement can be performed safely and successfully with 5 Fr guiding catheters using currently available products. This technique creates a smaller arterial puncture site, which may obviate the need for a closure device and allow early and safe ambulation. With 5 Fr systems, it appears that contrast usage is reduced, thereby potentially decreasing cost and morbidity. Cathet. Cardiovasc. Intervent. 51:352-357, 2000.

A safe and effective regimen without heparin therapy after successful primary coronary stenting in patients with acute myocardial infarction

Short-term heparin therapy has been administered routinely after primary coronary stenting. However. heparin therapy results in a significantly higher incidence of bleeding and vascular complications. A new therapeutic regimen of ticlopidine and aspirin without further heparin after coronary stenting in patients without AMI has been shown to be safe and reduce the incidence of stent thrombosis. The aim of this study was to evaluate whether a new therapeutic regimen of aspirin and ticlopidine without heparin is safe and effective in patients with acute myocardial infarction (AMI) who have undergone primary coronary stenting and have Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow in the infarct-related artery. Between January 1997 and September 1999, one hundred and fifty two consecutive patients with AMI on Killip score 1 or 2 who underwent primary coronary stenting resulting in TIMI grade 3 flow were enrolled and divided into two groups: Group 1 (n = 95 patients) received aspirin, ticlopidine and further intravenous heparin infusion for 48 hours following primary coronary stenting; Group 2 (n = 57 patients) received only aspirin and ticlopidine without further heparin therapy following primary coronary stenting. No in-hospital major cardiac events were observed in either group. However, the combined incidence of bleeding and vascular complications (27.4% vs 12.3%, p = 0.029) and the need for blood transfusions (9.5% vs 0%, p = 0.013) were significantly higher in Group I patients. Furthermore, hospital stay was also longer in Group I patients (5.8+/-2.4 vs 4.7+/-1.7 days, p = 0.0003). At the 30-day follow-up, there were no differences (1.05% vs 0%, p = 0.63) in the combined incidence of vascular complications and the major cardiac events were similar (1.05% vs 1.75%, p = 0.71) between the groups. The results suggest that further heparin therapy following primary coronary stenting increases the combined incidence of bleeding and vascular complications as well as the need for blood transfusions and prolongs the length of hospital stay without further benefit to those patients with coronary flow restored to TIMI 3 grade flow.

Suture-mediated closure of the femoral access site after cardiac catheterization: results of the suture to ambulate aNd discharge (STAND I and STAND II) trials

Despite advances in other aspects of cardiac catheterization, manual or mechanical compression followed by 4 to 8 hours of bed rest remains the mainstay of postprocedural femoral access site management. Suture-mediated closure may prove to be an effective alternative, offering earlier sheath removal and ambulation, and potentially a reduction in hemorrhagic complications. The Suture To Ambulate aNd Discharge trial (STAND I) evaluated the 6Fr Techstar device in 200 patients undergoing diagnostic procedures, with successful hemostasis achieved in 99% of patients (94% with suture closure only) in a median of 13 minutes, and 1% major complications. STAND II randomized 515 patients undergoing diagnostic or interventional procedures to use of the 8Fr or 10Fr Prostar-Plus device versus traditional compression. Successful suture-mediated hemostasis was achieved in 97.6% of patients (91.2% by the device alone) compared with 98.9% of patients with compression (p = NS). Major complication rates were 2.4% and 1.1%, and met the Blackwelder's test for equivalency (p <0.05). Median time to hemostasis (19 vs 243 minutes, p <0.01) and time to ambulation (3.9 vs 14.8 hours, p <0.01) were significantly shorter for suture-mediated closure. Suture-mediated closure of the arterial puncture site thus affords reliable immediate hemostasis and shortens the time to ambulation without significantly increasing the risk of local complications.

Heparin after percutaneous intervention (HAPI): a prospective multicenter randomized trial of three heparin regimens after successful coronary intervention

OBJECTIVES

The purpose of this study was to determine the incidence of bleeding, vascular, and ischemic complications using three different heparin regimens after successful intervention.

BACKGROUND

The ideal dose and duration of heparin infusion after successful coronary intervention is unknown.

METHODS

Patients were randomized to one of three heparin strategies after coronary intervention: Group 1 (n = 157 patients) received prolonged (12 to 24 h) heparin infusion followed by sheath removal; Group 2 (n = 120 patients) underwent early removal of sheaths, followed by reinstitution of heparin infusion for 12 to 18 h; Group 3 (n = 137 patients) did not receive any further heparin after intervention with early sheath removal. The primary end point of the study was the combined incidence of in-hospital bleeding and vascular events. Secondary end points included in-hospital ischemic events, length of stay, cost and one-month outcome.

RESULTS

After successful coronary intervention, 414 patients were randomized. Unstable angina or postinfarction angina was present in 83% of patients before intervention. The combined incidence of bleeding and vascular events was 21% in Group 1, 14% in Group 2 and 8% in Group 3 (p = 0.01). The overall incidence of in-hospital ischemic complications was 2.2%; there were no differences between groups. Length of hospital stay was shorter (p = 0.033) and adjusted hospital cost was lower (p < 0.001) for Group 3. At 30 days, the incidence of delayed cardiac and vascular events was similar for all three groups.

CONCLUSIONS

Heparin infusion after successful coronary intervention is associated with more minor bleeding and vascular injury, prolonged length of stay and increased cost. In-hospital and one-month ischemic events rarely occur after successful intervention, irrespective of heparin use. Routine postprocedure heparin is not recommended, even in patients who present with unstable ischemic syndromes.

Severe cutaneous cholesterol emboli syndrome after coronary angiography

Cholesterol embolization syndrome is due to dislodgment of cholesterol crystals from the atherosclerotic plaques lining the walls of major arteries resulting in an occlusion of small arteries. We describe a case of severe cutaneous cholesterol emboli syndrome following repeat coronary angiography showing by our observation that this syndrome is often unrecognized or misdiagnosed and that a better evaluation of risks factors in patients undergoing invasive procedures could prevent this severe complication.

Complications of lower-limb percutaneous transluminal angioplasty: a prospective analysis of 410 procedures on 295 consecutive patients

PURPOSE

To evaluate complications and their predictors in percutaneous transluminal angioplasty (PTA) of lower-limb arteries.

METHODS

Complications in 410 angioplasty procedures in 295 consecutive patients (192 claudicants and 103 suffering from chronic critical ischemia) were prospectively analyzed.

RESULTS

The total complication rate was 10.5% (43/410). There were 21 major complications (5%), eight of which required surgical treatment, including four hematomas, two arteriovenous fistulae, and two pseudoaneurysms at the puncture site, two retroperitoneal hematomas, and 11 thrombotic/thromboembolic complications. There were significantly more complications with treatment of occlusions compared with stenoses (18% vs 7%, p = 0.002). Women had significantly more bleeding complications than men (15% vs 6%, p = 0.032). The 30-day mortality rate in patients with critical ischemia was 10%.

CONCLUSION

In lower-limb PTA a few target lesion- and patient-related determinants of complications could be identified. In patients with critical ischemia, the 30-day mortality was rather high and mainly due to associated coronary and cerebrovascular diseases.

Cholesterol emboli syndrome--uncommon or unrecognized?

Cholesterol emboli syndrome is a multisystem disorder that can be precipitated by angiographic procedures. We report 5 cases in which the presentation was renal failure. All patients had undergone angiography, but the temporal relation of the procedure to the clinical presentation was highly variable, the interval ranging from one day to four months. With the increase in diagnostic and therapeutic uses of angiography, the cholesterol emboli syndrome is likely to become more frequent and needs to be recognized.

Use of a pneumatic compression system (FemoStop) as a treatment option for femoral artery pseudoaneurysms after percutaneous cardiac procedures

Pseudoaneurysm (PA) formation is a well-documented complication of femoral arterial puncture in patients undergoing percutaneous cardiac procedures. Besides surgical repair, there has been success in obliterating the PAs by Duplex ultrasound guided compression (mostly those < 4.0 cm). We analyzed the use of prolonged femoral compression using a pneumatic compression system (FemoStop by USCI) in 10 patients who developed femoral PAs following an interventional cardiac procedure. All PAs were diagnosed by ultrasound and had unsuccessful duplex-guided compression. The size of the PA ranged from 2.8-4.0 cm in diameter. All patients had the FemoStop system placed over the PA with continuous pressure for 12-18 hr. PA obliteration was successful in 90% of cases as confirmed by ultrasound. The only complication observed was skin abrasion in two patients. Our results indicate that the FemoStop system is a simple and effective technique for treatment of femoral artery PAs.