Correlates and outcomes of retroperitoneal hemorrhage complicating percutaneous coronary intervention.

BACKGROUND: Retroperitoneal hemorrhage (RPH) is an infrequent but occasionally fatal complication of percutaneous coronary intervention (PCI). Therefore, it has been studied in relatively small numbers of patients. METHODS: Prospectively collected data on 28,378 consecutive patients treated between 1992 and 2003 were examined, supplemented by a date-based case control cohort study (76 RPH and 76 non-RPH patients) to examine elements not routinely recorded prospectively. Independent correlates of RPH were determined using logistical regression analysis. RESULTS: One hundred sixty-three patients (0.57%) developed RPH; of these 73.5% required blood transfusions and 10.4% expired during hospitalization (P < 0.001 for both compared with patients without RPH). RPH was independently associated with femoral artery sheath placement superior to the inferior epigastric artery (P < 0.001), female sex (P < 0.001), use of Angioseal Device (P < 0.001), glycoprotein IIb/IIIa inhibitor use (P = 0.001), and patient presentation with the acute myocardial infarction (P = 0.035), and was inversely related to patient weight (P = 0.014). Of the 17 patient deaths, 6 were directly related to RPH, 2 of which occurred in association with delays in resuscitation efforts consequent to attempts to obtain diagnostic confirmation with CT imaging. CONCLUSIONS: RPH remains an infrequent but serious complication of PCI. Appropriate management of the femoral access site and the patient once this complication is suspected may minimize adverse outcomes.     

Angiographic predictors of femoral access site complications: implication for planned percutaneous coronary intervention.

This study examined the relationship between the femoral arteriotomy location and the risk of femoral access site complications after diagnostic and interventional cardiac catheterization procedures. One of the most common complication of cardiac catheterization and percutaneous coronary intervention (PCI) involves the vascular access site. The femoral approach is the most frequent site of vascular access during invasive cardiac procedures. This approach is associated with vascular complications, such as retroperitoneal bleeding, which can be life-threatening. If angiographic predictors of retroperitoneal bleeding can be identified, this complication could be avoided. A prospective cohort of 33 patients with femoral access site complications was subgrouped based on the angiographic arteriotomy site. Concurrent patients without complications were randomly selected to form a control group. Study and control patients were compared on presenting risk factors and outcomes. Logistic regression analysis was used to identify independent predictors for femoral access site complications. Arteriotomy location above the most inferior border of the inferior epigastric artery in patients undergoing PCI was associated with 100% of all retroperitoneal bleeds (P < 0.001). Low, high middle, and high femoral arteriotomy sites were associated with 71% of all vascular access complications. The combination of these locations for the femoral arteriotomy was an independent predictor of adverse vascular access site complications beyond traditional risk factors (odds ratio = 28.7; CI = 6.73-122.40; P < 0.0001). Vascular complications occurred more frequently in patients who were of older age (72 vs. 66 years; P < 0.001). The location of the femoral arteriotomy site assessed by a femoral angiogram is predictive of life-threatening complications. Patients undergoing PCI with an arteriotomy above the most inferior border of the inferior epigastric artery are at an increased risk for retroperitoneal bleeding. This complication may be avoided by risk-stratifying patients prior to intervention with a femoral angiogram.     

A dedicated Y-shaped percutaneous ECMO cannula for femoral 2-in-1 vascular access during high-risk procedures

High-risk transcatheter procedures requiring hemodynamic support are growing and require multiple vascular access that may be challenging in cases of peripheral artery disease or lack of radial access and exposure to a higher risk of vascular complications. We report the novel utilization of a Y-shaped arterial extracorporeal membrane oxygenation (ECMO) cannula used as a single femoral access to perform percutaneous coronary intervention (PCI) and aortography during high-risk transcatheter aortic valve replacement (TAVR). The utilization of this 2-in-1 ECMO cannula may simplify vascular access and reduce vascular and bleeding complications during high-risk ECMO-supported transcatheter procedures.     

Use of the sheathless guide catheter during routine transradial percutaneous coronary intervention: A feasibility study

Objective : The aim of this study is to investigate the feasibility of using a 6.5 Fr sheathless guide catheter as a default system in transradial (TRA) percutaneous coronary intervention (PCI). Background : TRA PCI has been shown to reduce mortality rates through a reduction in access site related bleeding complications compared with procedures performed though a femoral approach. Complications associated with the TRA route increase with the size of sheath used. These complications may be reduced by the use of a sheathless guide catheter system (Asahi Intecc, Japan) that is 1–2 Fr sizes smaller in diameter than the corresponding introducer sheath. Methods : We performed PCI in 100 consecutive cases using 6.5 Fr sheathless guides to determine the procedural success, rates of symptomatic radial spasm and radial occlusion. Results : Procedural success using the 6.5 Fr sheathless guide catheter system was 100% with no cases requiring conversion to a conventional guide and catheter system. There were no procedural complications recorded associated with the use of the catheter. Adjunctive devices used in this cohort included IVUS, stent delivery catheters, distal protection devices, and simple thrombectomy catheters. The rate of radial spasm was 5% and the rate of radial occlusion at 2 months was 2%. Conclusion : Use of the 6.5 Fr sheathless guide catheter system, which has an outer diameter <5 Fr sheath, as the default system in routine PCI is feasible with a high rate of procedural success via the radial artery. © 2009 Wiley‐Liss, Inc.     

Reduction in vascular access site bleeding in sequential abciximab coronary intervention trials.

We analyzed vascular access site bleeding from the EPIC, EPILOG, and EPISTENT trials to quantify the decrease in vascular bleeding complications in these three trials, especially those attributable to abciximab. The incidence of combined major and minor vascular access site bleeding in nonabciximab (heparin plus placebo) patients progressively decreased from EPIC (8.2%) to EPILOG (2.9%) to EPISTENT (1.7%; P < 0.001). Combined major and minor vascular access site bleeding in abciximab (heparin plus abciximab) patients decreased from EPIC (20%) to EPILOG (5.8%) to EPISTENT (2.2%; P < 0.001). There were more major vascular access site bleeds with abciximab compared to placebo in EPIC (odds ration 3.2; P < 0.001) but not in EPILOG or EPISTENT. Modified abciximab and heparin dosing and improved vascular access site management strategies have decreased the risk of vascular access bleeding during coronary intervention and have essentially eliminated the excess access site bleeding associated with abciximab.     

Peripheral vascular complications of coronary angioplasty by the femoral and brachial techniques

In order to monitor the incidence and types of peripheral vascular complications in a single institution, we prospectively entered 1,579 coronary angioplasty cases into a computer data base during the years 1991 and 1992. Various periprocedural risk factors were analyzed. The patients were followed closely to identify complications that occurred outside the laboratory or after discharge from the hospital. Peripheral vascular complications occurred in 37 patients (2.37%) and included hematoma 20 (1.27%), retroperitoneal bleeding 7 (.44%), false aneurysm 6 (.38%), occlusion 1 (.06%), infection 2 (.13%), and cholesterol emboli 1 (.06%). Risk factors for complications by multivariate analysis were older age, female gender, and clinical evidence of peripheral vascular disease. Other factors potentially related to vascular trauma or bleeding tendency that were not risk factors in this series were clinical presentation, use of heparin or thrombolytic agents, blood clotting parameters, and arterial sheath size. There was no significant difference between the femoral and brachial approaches in frequency of complications (2.5% vs. 1.6%), but femoral complications tended to carry greater morbidity.     

Impact of coronary artery calcification on percutaneous coronary intervention and postprocedural complications

BackgroundExcessive coronary calcification can lead to adverse outcomes after percutaneous coronary intervention (PCI). We therefore evaluated the impact of coronary calcium score (CCS) measured by multidetector computed tomography (MDCT) on immediate complications of PCI and rate of restenosis.MethodsWe performed a single-center retrospective analysis of 84 patients with coronary stenosis diagnosed by MDCT who underwent PCI. The Agatston method was used to measure total, target-vessel, and segmental (stent deployment site) CCS.ResultsIn 108 PCI procedures, 32 lesions (29.5%) were American College of Cardiology/American Heart Association type A, 60 (55.5%) were type B, and 16 (15%) were type C. ANOVA showed significantly higher segmental CCS in type C than in type A lesions (29 ± 51 vs. 214 ± 162; p = 0.03). Six patients (7.1%) had periprocedural complications and seven (8.3%) had in-stent restenosis and angina. Mean total, target-vessel, and segmental CCS was significantly higher in complicated than in successful PCI (199 ± 325 vs. 816 ± 624, p = 0.001; 92 ± 207 vs. 337 ± 157, p = 0.001; and 79 ± 158 vs. 256 ± 142, p = 0.003, respectively), but there was no significant difference in CCS between successful PCI and PCI complicated by late restenosis.ConclusionsCCS measured by MDCT has an important role in predicting early, but not late, complications from PCI.     

Orbital and rotational atherectomy during percutaneous coronary intervention for coronary artery calcification

Severe coronary artery calcification (CAC) increases the complexity of percutaneous coronary intervention (PCI) by inhibiting optimal stent expansion, leading to an increased risk of death, myocardial infarction, repeat revascularization, and stent thrombosis. Coronary atherectomy modifies and debulks calcified plaque to facilitate PCI. Although there is no clear consensus, and further studies are needed, the decision to perform atherectomy should be based upon the presence of fluoroscopic CAC or with the use of intravascular imaging. The management of CAC in the modern era relies on rotational and orbital atherectomy to prepare the lesion to facilitate stent delivery and optimal expansion. While the two technologies differ in equipment, technique, and mechanism of action, the available literature suggests similar efficacy and safety of the two systems, although head‐to‐head comparisons are limited. While rotational and orbital atherectomy have been shown to have excellent procedural success in terms of facilitating stent delivery, no system has been shown to reduce long‐term major adverse cardiovascular events, although the definitive trial for orbital atherectomy has not been completed. Additional trials are needed to find the population who would derive the most benefit of atherectomy and to compare the two systems in a prospective manner.     

Neuroimaging patterns of ischemic stroke after percutaneous coronary intervention

Even a regular lumen of radial artery may create difficulty in smooth negotiation and propagation of a 7F guide catheter while performing intervention through transradial approach. We describe successive five cases of a simple and innovative “Combo” technique, which helps relatively atraumatic tracking of a 7F guide catheter through the course of arm and chest vasculature for successful completion of procedure without significant damage and local pain. © 2015 Wiley Periodicals, Inc.     

经皮冠状动脉介入治疗术中冠状动脉穿孔32例临床分析

目的总结经皮冠状动脉介入治疗(PCI)术中冠状动脉穿孔的临床特点。方法回顾性分析2004年4月至2006年8月阜外心血管病医院PCI术中发生的32例冠状动脉穿孔患者的临床资料。结果32例冠状动脉穿孔患者占同期7102例PCI患者的0.5%。病变特点按美国心脏病学会(ACC)/美国心脏协会(AHA)标准进行分型,其中B2+C型病变占81.3%,慢性完全闭塞病变占62.5%。冠状动脉穿孔的Ellis分型:Ⅰ型14例(43.8%),Ⅱ型10例(31.2%),Ⅲ型8例(25.0%)。发生原因:钢丝引起21例(65.6%),球囊预扩张引起6例(18.8%),球囊后扩张引起3例(9.4%),支架置入引起2例(6.2%)。处理措施:鱼精蛋白中和肝素14例(43.8%),穿孔近端球囊封堵9例(28.1%),心包穿刺引流7例(21.9%),置入带膜支架4例(12.5%),急诊外科修补加冠状动脉旁路移植术(CABG)2例(6.2%)。预后:死亡3例(9.4%),急诊外科修补加CABG2例(6.2%),急性心脏压塞6例(18.8%),迟发性心脏压塞1例(3.1%),急性心肌梗死9例(28.1%)。结论Ⅲ型冠状动脉穿孔后果严重,需积极处理。     

Distal radial access for coronary angiography and percutaneous coronary intervention: A state‐of‐the‐art review

Since its introduction by Lucien Campeau three decades ago, percutaneous radial artery approach at the forearm has been shown to provide advantages over the femoral approach and has become the standard approach for coronary angiography and intervention. Though infrequent, vascular complications still remain, mainly radial artery occlusion. Therefore, a more distal radial approach at the snuffbox or at the dorsum of hand has been suggested, initially by anethesiologists for perioperative patient monitoring, and more recently by Babunashvili et al. for retrograde radial artery recanalization of radial artery occlusion and then for coronary angiography and intervention. This distal radial approach has been advocated to reduce the risk of radial artery occlusion at the forearm (which precludes reintervention through the same access site) and bleeding and vascular access site complications, as well as to improve operator and patient comfort, especially when using left radial approach. This review describes in detail the anatomy of the radial artery at the wrist and the hand, the history of distal radial access, the rationale underlying use of this technique, the results published by experienced operators, the technique, the limitations, and potential role of this approach. This journey from the very proximal to the very distal part of the radial artery was indeed initiated and conceptualized by Lucien Campeau himself.