Feasibility of routine transradial coronary angiography: a single operator's experience

The aims of this study were to assess the feasibility of routine transradial coronary angiography in a standard population of patients with presumed coronary artery disease over a period of time long enough to allow for technical evolution and evaluation of a single operator's learning curve, and to provide data for a randomized comparison versus the femoral approach. Between June 1994 and March 1997, transradial angiography was attempted in 1,000 patients. Approximately 25% of these patients were excluded because of an abnormal Allen test. Except in the case of acute myocardial infarction, there was no selection based on symptoms, age, sex, weight or size in the absence of double internal mammary artery bypass graft operation or simultaneous right heart catheterization. Symptoms and angiographic results were typical of a standard population. The right radial approach was used in 95% of the cases for ease of handling and comfort of a right-handed operator. Radial artery puncture and catheterization success was obtained in 97.6% of the cases; the left coronary artery was selectively catheterized in 100%, right coronary artery in 98%, left ventricle in 96.9%, mammary artery grafts in 100% and saphenous grafts in 97.2%. Average procedure duration was 18 +/- 9 minutes, and decreased progressively with experience and catheter strategies. The optimal catheter selection would seem to be a single catheter, either left Amplatz or Champ, for both coronary arteries. Two coronary complications and 3 transient neurological complications occurred, but no clinically significant vascular complications requiring surgery or transfusion were reported. Transradial angiography seems to be a routine approach that should now be compared with the femoral approach and supersede the brachial approach whenever possible.     

Coronary physiology in the cath lab: beyond the basics

The adoption of invasive coronary physiologic lesion assessment before percutaneous coronary intervention has become routine in many catheterization laboratories. In the last decade, numerous studies have demonstrated favorable outcomes for revascularization decisions based on in-lab coronary physiology in many patients. The use of coronary physiology in the laboratory has been identified as a class IIa recommendation for patients in whom the clinical presentation and supporting data are too inconclusive to make an objective decision regarding treatment. This article reviews pertinent concepts and studies of the more complex applications of translesional pressure measurements for optimal patient outcomes.     

Ureteroarterial fistula: a rare cause of hematuria managed in the cardiac cath lab

Ureteroarterial fistulae (UAFs) are rare but potentially life-threatening entities that require a high degree of suspicion for diagnosis followed by prompt intervention. This case report describes the successful management of the oldest woman to-date presenting with intermittent hematuria, secondary to a fistula between the ureter and internal iliac artery, which was subsequently resolved by coil embolization. Morbidity and mortality associated with UAFs can be decreased by increasing awareness of this rare but fatal complication. Our review of the medical literature indicates that this is the oldest woman reported to have developed a UAF after radiation therapy and chronic ureteral stent exchange, as well as the first reported management of a UAF by interventional cardiologists.     

Efficiency in the cath lab: Pursuing value-based improvements following a sociotechnical approach

IntroductionCardiac catheterization laboratories (cath labs) are commonly designed to achieve the best clinical outcomes while being efficient. This study develops methods to support healthcare managers in analyzing the added value of improvement measures, following a value-based healthcare (VBHC) framework.MethodsBased on a sociotechnical approach, the applied methods aimed to increase efficiency, reduce duplication of tasks, cut costs, and improve patient care, while creating a more inclusive and trusting decision making process. Within the process of building a multicriteria evaluation model, meetings, interviews, and a decision conference were designed. In parallel, a workflow discrete event simulation model was built to replicate current patient flow and activities and to reproduce the impact of implementing improvement measures and variations in human resources.ResultsFour evaluation criteria were considered for workflow improvement: contribution to the efficiency of the admission process, compliance with schedules, agility among procedures, and human resources training. The designed improvement measures sought to 1) improve the start-up of the day, 2) improve pre-exam assessment, and 3) improve staff training. Results prioritize ‘Measure 2’ and demonstrate that improving human resources allocation increases efficiency and offers significant cost savings.ConclusionsThe proposed solution is in line with VBHC principles, as it improves efficiency and care delivery while optimizing costs. Simulation was an effective tool to replicate and explore possible changes. Multicriteria modeling proved to be a useful approach for a transparent prioritization and redesign of improvements in the healthcare sector.     

X‐ray canary in the cath lab: Posterior cataracts

• Cataract formation in the posterior subcapsular region of the lens is a lesion highly specific to both high‐dose acute radiation exposure and chronic low‐dose exposure.
• Low‐dose radiation may not manifest lens changes for several decades after initial exposure.
• Cardiac catheterization team members need to be educated on, and protected from, this form of radiation injury as its long latency period between exposure and physical damage may acutely reduce the sense of hazard amongst healthcare radiation workers.

     

Arteriovenous access closure in hemodialysis patients with refractory heart failure: a single center experience

Arteriovenous dialysis access may impose a burden on the cardiac system. The objective of this study is to examine the usefulness of access closure in hemodialysis patients with refractory heart failure and to identify possible factors associated with symptomatic improvements. The study population comprised 33 hemodialysis patients with symptomatic heart failure (New York Heart Association [NYHA] class ≥ II), who underwent arteriovenous access closure (30 fistulas and three grafts) between 1991 and 2008. In all patients, heart failure was refractory to all possible medical and surgical treatments, and persisted after optimal dry weight control. First, short-term changes in hemodynamics, clinical symptoms and echocardiographic morphology were examined. Second, clinical and echocardiographic parameters were compared between responders (N=23), who demonstrated NYHA class improvement after access closure, and non-responders (N=10). After access closure, systolic blood pressure rose and the heart rate decreased significantly. Body weight and echocardiographic parameters did not change significantly. Twenty-three patients (70%) demonstrated NYHA class improvement and were designated as responders. In responders, the duration from access creation to closure was significantly shorter and fewer had ischemic heart disease, compared with non-responders. Access flow, cardiac output and ejection fraction were comparable between the two groups. Although the five-year survival was 20.2% in all patients, responders showed better early survival than non-responders. Arteriovenous access closure improved clinical symptoms in 70% of patients with refractory heart failure. This improvement was especially likely to be achieved in patients without ischemic heart disease and those who developed heart failure within a relatively short time after access creation.     

Double- vs. single-balloon enteroscopy: single center experience with emphasis on procedural performance

Purpose

This study aims to compare double- (DBE) and single-balloon enteroscopy (SBE) in small bowel disorders with respect to procedural performance and clinical impact.

Methods

This retrospective analysis at a tertial referral center included 1,052 DBEs and 515 SBEs performed in 904 patients over 7 years. Procedural and patients' characteristics were precisely analyzed.

Results

Significantly more patients with anemia and gastrointestinal bleeding were investigated by DBE (P?<?0.01). Oral insertion depth and length of investigated small bowel in the combined approach were significantly higher in the DBE compared to the SBE group (245?±?65.3 vs. 218?±?62.6 and 355?±?101.9 vs. 319?±?91.2, respectively; P?<?0.001, each). By analyzing only recent years of enteroscopy (2008–2011), no difference in small bowel visualization could be observed. The anal insertion depths and complete enteroscopy rates (CER) were comparable. Procedure times were significantly shorter within the SBE procedure (oral: 50 vs. 40 min; anal: 55 vs. 46 min, P?<?0.001) and the usage of sedation was significantly less (propofol: P?<?0.001; pethidine: P?<?0.05). Diagnostic yield was significantly higher in the SBE, compared to the DBE group (61.7 vs. 48.2 %; P?<?0.001). The rate of severe adverse events was close to zero.

Conclusion

Both enteroscopy techniques are safe diagnostic tools and proved to be indispensable in the daily gastroenterological practice. The lower insertion depths, but higher diagnostic yield, of SBE may reflect the more focused selection of patients scheduled for small bowel diagnostics in recent years.     

Adjunctive therapies in the cath lab. Intracoronary tirofiban infusion in a case with massive intracoronary thrombus

By inhibiting platelet aggregation, glycoprotein IIb/IIIa inhibitors prevent arterial occlusion and reduce ischemic complications in the setting of acute ischemic coronary syndromes associated with intracoronary thrombus. There are also accumulating data in the literature regarding the local use of these agents for thrombus dissolution. We report a case with massive right coronary artery thrombus in which the thrombus was successfully dissolved with intracoronary tirofiban infusion. To the best of our knowledge, this is the first case of this kind.     

Hemophilia in the cath lab: Balancing the need to clot with the treatment of thrombosis

• Hemophilia is a rare genetic disorder that inherently results in bleeding risks that can be successfully managed in the cardiac catheterization laboratory.
• Standard of care options such as drug‐coated stents should not be denied hemophiliacs solely on the basis of their genetic defect.
• Successful care of hemophilia requires a close collaboration with a specialist in these bleeding disorders to optimize care.

     

Transradial access in an occluded radial artery: new technique

Radial access is considered clearly impossible in patients who develop radial artery occlusion after a transradial procedure. Radial artery occlusion also prohibits an ipsilateral transulnar approach. For patient subsets such as those with dialysis access in the other upper extremity or an occluded left radial artery with left internal mammary artery bypass grafts, switching to the transfemoral approach becomes inevitable. In some instances, the femoral access is also not an option due to severe aortoiliac disease. We describe a technique that allows the operator to access the proximal circulation from the occluded radial artery.     

Iatrogenic aortic haematoma during primary PTCA: diagnostic value of transesophageal echocardiography in cath lab.

A 60-year-old woman with severe chest pain and ECG diagnostic for acute transmural ischemia was transferred to cath lab for primary PTCA. After procedure, transesophageal echocardiography (TEE) views revealed an intramural haematoma extending from the ostium of the RCA throughout the sino-tubular junction. These findings and the stable clinical conditions of patient guided us to a conservative therapeutic approach. A TEE study, performed 5 days after admission, showed a complete resolution of intramural haematoma. A waiting strategy can be a valid therapeutic option in selected patients with iatrogenic haematoma and TEE is a useful diagnostic tool for clinical decision making.     

How to prevent unnecessary coronary interventions: identifying lesions responsible for ischemia in the cath lab

PURPOSE OF REVIEW: Coronary angiography is limited by the inability to identify intermediate coronary lesions responsible for ischemia. In the catheterization laboratory three techniques can be used for the evaluation of the physiologic significance of intermediate or borderline significant coronary stenoses: (1) pressure wire-derived coronary fractional flow reserve (FFR), (2) Doppler wire-derived measurement of coronary flow reserve (CFR), and (3) intravascular ultrasound (IVUS). RECENT FINDINGS: All of these techniques have been validated for assessing the functional significance of intermediate stenoses, but also have inherent limitations. SUMMARY: Overall, measurement of FFR appears to be the best method for interrogating intermediate coronary lesions. This review discusses the strengths and limitations of each of these techniques.