Side‐branch wire entrapment during bifurcation PCI: Avoidance and management

An LAD/D1 bifurcation intervention was complicated by side‐branch wire entrapment and unravelling requiring goose‐neck snare removal. Residual microfilaments were retrieved from the main branch after further balloon inflations with a satisfactory final angiographic result and one‐year follow‐up. Various methods are available to avoid and deal with this complication. © 2009 Wiley‐Liss, Inc.     

Common femoral artery stenosis after deployment of vascular clip closure device

We describe a case of symptomatic common femoral artery stenosis following use of a vascular clip closure device (StarClose). Operative repair was performed, with removal of the clip device and subsequent vein patch angioplasty. © 2008 Wiley‐Liss, Inc.     

Access site hematoma requiring blood transfusion predicts mortality in patients undergoing percutaneous coronary intervention: data from the National Heart, Lung, and Blood Institute Dynamic Registry.

OBJECTIVE: To determine both the etiology of and outcomes associated with access site hematoma requiring transfusion (HRT) in patients undergoing percutaneous coronary intervention (PCI). BACKGROUND: Access site hematoma in the setting of PCI is the most frequent periprocedural complication (2-12%). Antiplatelet and antithrombin therapy is designed to lower the incidence of adverse ischemic events while maintaining an acceptable rate of hemorrhagic complications. METHODS: This was a prospective, multi-center, cohort study of consecutive patients undergoing PCI during 3 NHLBI Dynamic Registry recruitment waves (1997-2002). The primary endpoints included the incidence of HRT, in-hospital death, and death at 1-year. RESULTS: The incidence of HRT was 1.8% and femoral access was common. Older age, lower BMI, female sex, concomitant renal, cerebrovascular, peripheral vascular, and pulmonary disease were significantly associated with HRT. Glycoprotein IIb/IIIa inhibitors, thrombolytic therapy, and postprocedure heparin were more commonly used in HRT patients, but there was no difference in thienopiridiene use. Attempted lesions in patients developing HRT were more often calcified, thrombotic, located in an ostial location, or class B2 or C. In-hospital mortality and 1-year death rate was 9 and 4.5 times higher in HRT patients respectively. Following adjustment, HRT remained independently associated with in-hospital mortality (OR 3.59, 95% CI 1.66-7.77) and 1-year death (hazard ratio [HR] 1.65, 95% CI 1.01-2.70, P = 0.048). Independent predictors of HRT included age, female sex, IIb/IIIa inhibitors, thrombolytic agents, and concomitant conditions. CONCLUSIONS: Access site complications, especially HRT, remain a very important predictor of adverse procedural success and patient outcome.     

Mechanisms underlying air aspiration in patients undergoing left atrial catheterization

Background : Air embolism in patients undergoing percutaneous interventions requiring access to the left atrium (LA) represents a potentially fatal complication. Here we tested if a decline in LA pressures following sedation represents an important mechanistic link underlying air intrusion into the LA. Methods and Results : Left atrial pressures were measured in 26 consecutive patients (49 ± 14 years; 27% male), who underwent percutaneous atrial septal occlusion for persistent foramen ovale or secundum atrial septal defects. Patients either received sedation by propofol allowing for guidance by transesophageal echocardiography (n = 13) or underwent occluder implantation without sedation and under fluoroscopic control only (n = 13). Whereas mean exspiratory LA pressures remained unchanged in either group, sedation provoked a marked decline in the mean inspiratory LA pressure as compared to non‐sedated patients (Δp 6.9 ± 8.6 mm Hg vs. 0.1 ± 1.2 mm Hg in nonsedated patients, P < 0.001). Ex vivo experiments evaluating the air‐tightness of different sheaths in response to negative pressures revealed air aspiration at –13.4 ± 1.2 mm Hg of suction in all cases, once a guide wire was inserted. Conclusions : Negative LA pressures in conjunction with air‐leaking sheaths are identified as potentially important factors for air intrusion into the LA with the patient's sedation being a primary risk factor to lower LA pressure levels. The results advocate close monitoring of LA pressures during intervention, prevention of airway collapse and protection of LA sheaths from communication with the atmosphere, during procedures under sedation. © 2008 Wiley‐Liss, Inc.     

Endovascular treatment of Angio‐Seal™‐related limb ischemia—Primary results and long‐term follow‐up

Objectives : To investigate primary success rates and long term follow‐up of endovascular treatment of AngioSeal?‐related limb ischemia. Background : Current knowledge on optimal therapy of ischemic complications following application of AngioSeal? is limited. Methods : A single‐center prospectively maintained database was retrospectively interrogated and AngioSeal?—related complications requiring endovascular treatment over an 8‐year‐time period was identified. Results : Fifteen patients fulfilling the inclusion criteria were identified, resulting in an approximated incidence of 0.26% of all devices implanted at our institution. In all cases, the complication was managed successfully in the absence of complications. Eleven patients were treated with balloon angioplasty (PTA) and four with stent implantation because of suboptimal PTA results. Twelve patients were available for noninvasive vascular follow‐up examination for a median time of 40 months postinterventionally. Only two patients needed a second intervention consisting of balloon angioplasty due to symptomatic restenosis. At final follow‐up all patients were asymptomatic with no relevant restenosis. Conclusion : Endovascular treatment for AngioSeal?‐related limb ischemia with or without stent implantation results in an excellent immediate and long‐term clinical and hemodynamic outcome. © 2009 Wiley‐Liss, Inc.     

“Double wire” angio‐seal closure technique after balloon aortic valvuloplasty

Objectives : To report the feasibility of a collagen‐mediated closure device using a modified Angio‐Seal closure technique for access site management following percutaneous balloon aortic valvuloplasty (BAV). Background : With the advent of percutaneous aortic valve replacement therapies, there has been a resurgence of interest in BAV procedures. Vascular complications, including bleeding, are a common source of morbidity post procedure as a result of the requirement for large bore femoral artery access. The use of vascular closure devices may reduce bleeding complications. Methods : We describe a new technique for vascular closure in this setting. At the conclusion of the valvuloplasty procedure, two 0.035″ wires are inserted through the femoral artery sheath. A conventional collagen‐mediated closure device (8F Angio‐Seal) is deployed over the first wire and along side the second wire. If immediate hemostasis is not achieved, a second device is loaded onto the second wire and deployed to achieve hemostasis. Results : Percutaneous BAV was performed in 21 patients. Hemostasis was successfully achieved in all patients with either a single 8F Angio‐Seal closure device (18 patients) or after placement of a second device (three patients). Conclusions : The modified “Double Wire” Angio‐Seal technique is a feasible method for hemostasis following percutaneous BAV. © 2009 Wiley‐Liss, Inc.     

Percutaneous removal of an embolized port catheter: Description of a new coaxial recovery technique including a case‐report

The achievement of coaxiality between recovery device and embolized tubular foreign bodies like central venous catheters is a key point to achieve percutaneous removal. To facilitate this target, we designed a coaxial retrieval loop‐snare device using amodified coronary guiding catheter and a coronary 0.014″ guidewire. This new technique has been bench tested and then successfully used to remove a long Port‐A catheter's fragment embolized into the right sided heart. © 2008 Wiley‐Liss, Inc.     

Erroneous placement of central venous catheter in the subclavian artery: Retrieval and successful hemostasis with a femoral closure device

Central venous catheter (CVC) placement, even if performed under duplex scan control, may be associated with incidental arterial injury leading to increased morbidity, mortality, and prolonged hospital stay. Erroneous CVC placement in the carotid or subclavian arteries has been usually treated surgically because those puncture sites may not be efficaciously compressed manually. However, surgery in this setting may be challenging because of difficulty of access for the catheters positioned in the subclavian artery and of the risk of cerebrovascular complications for carotid catheters. Recently, several cases have been published, describing the successful endovascular management of iatrogenic arterial injury using different types of vascular closure devices (VCD). However, in this setting, it remains difficult to be completely sure that the VCD has achieved complete hemostasis and that the patient does not subsequently incur in a clinically silent intrathoracic bleeding. We report the case of an erroneous CVC placement in the right subclavian artery successfully retrieved using an Angioseal? VCD. The immediate and complete hemostasis at the puncture site was confirmed at angiography. © 2010 Wiley‐Liss, Inc.     

Acute cerebral rescue during carotid artery stenting: A stroke of good fortune?

Major stroke is a potentially devastating complication of carotid artery revascularization. Carotid artery stenting, unlike endarterectomy, offers the opportunity to attenuate this complication by allowing for the instantaneous detection and early endovascular treatment of neurologic defects complicating the procedure. We report a case that highlights the utility of aggressive endovascular cerebral rescue during a carotid artery stent procedure. © 2008 Wiley‐Liss, Inc.     

Utilization of an aspiration thrombectomy catheter (Pronto) to treat acute atherothrombotic embolization during percutaneous revascularization of the lower extremity

Acute limb ischemia is typically a surgical emergency and can occur secondary to distal embolization during catheter‐based percutaneous revascularization. We present a case of acute atherothrombotic embolization to the left lower extremity after stenting of the left proximal popliteal and anterior tibial arteries. This was successfully treated with the use of the coronary aspiration thrombectomy device Pronto (Vascular Solutions, Minneapolis, MN) resulting in flow restoration. © 2008 Wiley‐Liss, Inc.     

Use of a low‐profile,compliant balloon for percutaneous aortic valvuloplasty

Objectives : To determine the safety and immediate efficacy after balloon aortic valvuloplasty (BAV) with a new, low‐profile balloon. Background : BAV has a continuing role in the management of high‐risk patients with severe aortic stenosis (AS). BAV with traditional noncompliant balloons requires a large femoral arteriotomy and is associated with high rates of access site complications. Methods : We retrospectively reviewed medical records of 20 consecutive patients undergoing BAV for severe AS. Retrograde transfemoral BAV was performed with a low‐profile, compliant valvuloplasty balloon. Before and after BAV, transaortic gradients were measured invasively and by echocardiography, and aortic valve area (AVA) calculated. Access site complications, functional class and survival were recorded. Results : Patients were 79 ± 12 years old and had an estimated mortality from open aortic valve replacement of (12.5 ± 9.6)%. By catheterization, mean aortic gradient fell from 44 ± 15 to 29 ± 10 mm Hg (P < 0.001) and AVA increased from 0.63 ± 0.22 to 0.89 ± 0.33 cm² (P < 0.001). New York Heart Association functional class improved from 3.5 ± 0.7 to 2.7 ± 0.8. Procedural mortality was 0%. There were no vascular complications or significant worsening of aortic regurgitation. Conclusion : Transfemoral BAV using a low‐profile compliant balloon is feasible with acceptable immediate results and safety. © 2009 Wiley‐Liss, Inc.     

Thrombus formation after left atrial appendage exclusion using an amplatzer cardiac plug device

The feasibility and safety of left atrial appendage closure with the Amplatzer cardiac plug (AGA Medical Corp., Minneapolis, MN) have been recently published; no thrombus formation on the device surface has been reported previously. We describe a case of a 66‐year‐old man with permanent atrial fibrillation, previous stroke, and contraindication for long‐term oral anticoagulant therapy. A 22‐mm ACP device was deployed successfully without complications. The patient was discharged on acetyl salicylic acid 100 mg and clopidogrel 75 mg daily. After 4 weeks, the patient was admitted for a lower gastrointestinal bleeding and clopidogrel was stopped. A 3‐month follow‐up echocardiogram confirmed the exclusion of the LAA but it demonstrated the presence of a thrombus on the atrial surface of the device. It was decided to keep the patient on acetyl salicylic acid 100 mg with the addition of enoxaparin 60 mg bid. Transesophageal echocardiogram demonstrated total resolution of the thrombus after 2 months. © 2011 Wiley Periodicals, Inc.     

A randomized comparison of TR band and radistop hemostatic compression devices after transradial coronary intervention

Background : The transradial route for coronary intervention has proven to be safe, effective, and widely applicable in different clinical situations. Several compressive hemostatic devices have been introduced that have shown to be safe and are effective in achieving hemostasis. Methods : Seven hundred ninety patients were randomly assigned to receive either TR band or Radistop hemostatic compression devices after transradial coronary procedure. The outcome measures were patient tolerance of the device, local vascular complications, and the time taken to achieve hemostasis. Results : The mean age was 62.88 years, and 74.2% of the patients were men. Patient age, height, weight, wrist circumference, body mass index, male sex, hypertension, diabetes, hypercholesterolemia, and smoking incidences were similar in both groups. There were significantly more patients reporting no discomfort in the TR band group compared to the Radistop group (77% vs. 61%; P = 0.0001). Patients in the Radistop group reported significantly more pain across all categories of severity and three patients in the Radistop group were crossed over to TR band because of severe discomfort. Oozing and ecchymosis were seen in about 16% of the patients. Local small hematoma and large hematoma were seen in 5.4% and 2.2% patients respectively, and similar in both groups. Radial artery occlusion at the time of discharge was seen in 9.2% of the patients though only 6.8% showed persistent occlusion at the time of follow‐up. The time taken to achieve hemostasis was significantly longer in the TR Band group (5.32 ± 2.29 vs. 4.83 ± 2.23 hr; P = 0.004). There was significantly higher incidence of radial artery occlusion in patients with smaller wrist circumference, the patients who experienced radial artery spasm during the procedure, and patients with no heparin administration during the procedure. Conclusions : We have shown in a randomized comparison of Radistop and TR band that both devices are safe and effective as hemostatic compression devices following transradial procedures. However, more patients felt discomfort with the Radistop device and the time taken to achieve hemostasis was longer with TR band. © 2010 Wiley‐Liss, Inc.     

Transradial approach for noncoronary angiography and interventions.

PURPOSE: The purpose of this study was to retrospectively evaluate the feasibility and safety of a transradial approach for non-coronary angiography and interventions. BACKGROUND: Generally, the transradial approach is used for coronary angiography and intervention around the world, and experiences have been widely reported. However, few large studies have examined the transradial approach for vessels other than the coronary or cerebral artery. METHODS: Subjects comprised 329 patients who underwent a total of 400 procedures (285 abdomens, 68 pelvises, and 47 lower limbs) with transradial angiography and interventions between January 1999 and June 2006. Normal Allen test results were confirmed before all procedures. A 130- or 150-cm long 4F catheter modified to our own design was used for angiography and interventions such as transarterial embolization or transarterial chemotherapy. RESULTS: Radial artery access was unachievable in 19 of the 400 procedures (4.8%). The radial artery was injured during 1 procedure (0.2%). In the remaining 380 procedures, sufficient angiography was obtained to grasp the condition of indispensable vessels for diagnosis and interventions scheduled in advance succeeded. Total transradial technical success rate in the series was 95%. Frequency of complications such as radial injury or radial spasm was 1.8%. No cases of local hematoma, hand ischemia, or cerebral infarction were encountered. CONCLUSION: The transradial approach was useful for non-coronary angiography and interventions and offers the advantages of low risk and reduced stress on patients.     

Day procedure intervention is safe and complication free in higher risk patients undergoing transradial angioplasty and stenting. The discharge study.

OBJECTIVES: To assess the timeframe of postprocedural complications following transradial percutaneous intervention in selected nonlow-risk risk patients as a feasibility study for same day discharge. BACKGROUND: Percutaneous coronary intervention (PCI) is traditionally performed as an inpatient procedure. Transradial access with its lower complication rate facilitates safe and same day discharge. We hypothesize that with current standards of pharmacotherapy and intervention, complications post transradial percutaneous coronary angioplasty even in a nonlow-risk patient cohort will be evident within 6 hr or occur more than 24 hr post procedure. Under these circumstances, overnight stay results in no improvement in patient safety. METHODS: 2,189 patients underwent transradial PCI at our institution between January 2005 and June 2006. Of these 1,174 were assessed as intermediate or high risk and admitted postprocedure. The remaining 1,015 were assessed as low risk and discharged the day of procedure. All 1,174 inpatients were entered into our study database. Information was collected on patient demographics, angiographic characteristics, post procedural complications, and timing of post procedural events. RESULTS: 1,543 ACC type B2 or C lesions were treated in 1,174 patients. All post-procedural complications were identified within 6 hr of the intervention or occurred more than 24 hr later when patients would have been discharged according to overnight admission protocols. CONCLUSIONS: Day case transradial percutaneous intervention with a 6-hr period of post procedure observation is a safe and feasible practice. The presence of higher-risk features should not be considered an absolute indication for overnight admission in patients considered clinically appropriate for discharge.     

Re‐access complication with a starclose device

Diagnostic cardiac catheterizations are predominantly performed using access through the femoral artery. To improve patient comfort and early mobilization, a number of percutaneous closure devices have been developed. One such device using the nitinol clip was developed by Abbott Vascular Devices and was approved for use on the basis of the results of the Clip Closure In Percutaneous Procedures (CLIP) study. The safety of repuncture through a previously deployed device has not been established in humans. We present the case of a patient who had an arterial line placed for post‐operative monitoring after cardiac surgery at the site of a previous arteriotomy closed with the Starclose device. The catheter traversed through the central portion, tethered to the periphery of the ninitol clip, and required surgery for extraction. © 2009 Wiley‐Liss, Inc.     

The CAPTURE registry: predictors of outcomes in carotid artery stenting with embolic protection for high surgical risk patients in the early post-approval setting.

BACKGROUND: The use of carotid artery stenting with embolic protection has been practiced for over a decade in the United States, and increasingly so since carotid stenting received FDA approval in 2004. While there have been attempts at establishing predictors of outcomes in carotid artery stenting, they have generally been limited to single center experiences and/or multicenter retrospective surveys. This report examines predictors of outcomes in carotid stenting in the earliest and largest prospective multicenter neurologist-adjudicated experience in the United States post device approval. METHODS: The Carotid Acculink/Accunet Post-Approval Trial to Uncover Unanticipated or Rare Events (CAPTURE) is a prospective, multi-center registry conducted to assess outcomes of carotid artery stenting (CAS) in the noninvestigational setting following device approval for high surgical risk patients (symptomatic with > or =50% stenosis; asymptomatic > or =80% stenosis). A neurologist examined the patients before the procedure, at 24 hr and 30-days post-procedure. The primary endpoint was a composite of death, any stroke, or myocardial infarction within 30-days post-procedure. Strokes and neurological events suspected to be strokes were adjudicated by an independent Clinical Events Adjudication Committee (CEAC) using prespecified definitions. Logistic regression analysis was performed to determine clinical, procedural, and anatomic predictors of endpoint outcomes. RESULTS: Three thousand five hundred patients were enrolled at 144 sites by 353 physicians of varying specialty backgrounds and CAS experience. The 30-day primary endpoint event rate of death, stroke and MI was 6.3% [95% CI: 5.5-7.1%], and the rate of major stroke and death 2.9% [95% CI: 2.4-3.5]. Predictors of adverse outcomes included age, symptomatic patients, predilation prior to embolic protection device placement, time from symptoms to CAS procedure, and the use of multiple stents. CONCLUSIONS: In general, carotid stenting is performed safely in patients with severe stenosis at high surgical risk, with best outcomes in younger asymptomatic patients. However, there are certain patient and procedural characteristics that are associated with poorer outcomes. In these patients, the risk of stenting should be considered vis-à-vis both the anticipated benefit as well as the alternative surgical and medical options.     

Prevention of radial artery occlusion—Patent hemostasis evaluation trial (PROPHET study): A randomized comparison of traditional versus patency documented hemostasis after transradial catheterization

Objective: The objective of this study was to evaluate the efficacy of hemostasis with patency in avoiding radial artery occlusion after transradial catheterization. Background: Radial artery occlusion is an infrequent but discouraging complication of transradial access. It is related to factors such as sheath to artery ratio and is less common in patients receiving heparin. Despite being clinically silent in most cases, it limits future transradial access. Patients and Methods: Four hundred thirty‐six consecutive patients undergoing transradial catheterization were prospectively enrolled in the study. Two hundred nineteen patients were randomized to group I, and underwent conventional pressure application for hemostasis. Two hundred seventeen patients were randomized to group II and underwent pressure application confirming radial artery patency using Barbeau's test. Radial artery patency was studied at 24 hr and 30 days using Barbeau's test. Results: Thirty‐eight patients had evidence of radial artery occlusion at 24 hr. Twenty patients had persistent evidence of radial artery occlusion at 1 month. Group II, with documented patency during hemostatic compression, had a statistically and clinically lower incidence of radial artery occlusion (59% decrease at 24 hr and 75% decrease at 30 days, P < 0.05), compared with patients in group I. Low body weight patients were at significantly higher risk of radial artery occlusion. No procedural variables were found to be associated with radial artery occlusion. Conclusion: Patent hemostasis is highly effective in reducing radial artery occlusion after radial access and guided compression should be performed to maintain radial artery patency at the time of hemostasis, to prevent future radial artery occlusion. © 2008 Wiley‐Liss, Inc.     

Unintentional embolization of a guide wire in the inferior vena cava during central venous catheter insertion successfully retrieved percutaneously 9 months later

Central venous catheters are routinely positioned for hemodynamic monitoring and fluid administration in patients undergoing cardiac surgery, and many well‐known complications associated with this manoeuver have been described. Metalic guide wire embolization is a rare complication potentially associated with nonmechanical and mechanical adverse events. The case we report is peculiar as an almost fully endothelialized guide wire was successfully retrieved 9 months after its unintentional embolization in the inferior vena cava. © 2013 Wiley Periodicals, Inc.