Female gender and mortality after percutaneous coronary intervention: Results from a large registry

Objectives : To investigate if previously reported gender‐based outcome disparities following percutaneous coronary intervention (PCI) are applicable in a large and racially‐diverse cohort in the drug eluting stent (DES) era. Background : It is generally believed that women suffer inferior outcomes compared to men after PCI. However, various strategies have evolved that may have mitigated this imbalance, including improved medical therapy, attention to risk‐factors, and procedural advances of PCI including DES. Methods : We identified 13,752 patients (4,761 female, 34.6%) with complete follow‐up data who underwent de novo lesion PCI from 04/2003 to 04/2009. Relevant data were extracted from an IRB‐approved registry. Results : Compared to males, females were significantly older (69.0 vs. 64.8 years) and more frequently from a minority or non‐Caucasian background. Females smoked less, but more were hypertensive and/or diabetic. Women had higher HDL, but also higher LDL cholesterol levels. More women presented with an unstable coronary syndrome and required left anterior descending artery PCI. While unadjusted post‐PCI mortality rates were higher in females versus males (30 days, 1.3 vs. 0.8%, P = 0.009; 1 year, 6.1 vs. 4.8%, P = 0.001; 3 year, 10.4 vs. 8.4%, P < 0.0001), multivariable regression analyses failed to identify female gender as an independent predictor of mortality. Propensity‐adjusted modeling confirmed that females were not at intrinsically higher risk for mortality after PCI. Conclusions : Females undergoing PCI exhibit more comorbidities and adverse prognostic factors than males. However, risk‐adjusted analyses identified that gender is not an independent predictor of mortality after PCI in the DES era. © 2011 Wiley Periodicals, Inc.     

Repeat percutaneous coronary revascularization: Indications and outcomes in a “Real World” cohort

Objectives : To investigate rates of and reasons for second and subsequent stent procedures in an unselected, “real‐world” population. Background : Repeat stenting is the primary difference reported in clinical trials of alternative revascularization strategies. The incidence, indication, and outcome for repeat stenting in contemporary practice outside the more selective populations of trials and registries has not been described. Method : All patients undergoing a first percutaneous coronary intervention (PCI) procedure with stenting from January 2001 to August 2009 (10,509) from a large UK tertiary referral and district general hospital were identified. Mortality and the incidence, timing, and indication for repeat revascularization in this population were investigated from patient records. Results : Of 10,509 patients undergoing a first PCI and stent implant 23.5% underwent repeat angiography of which 11.2% required repeat PCI and 2% coronary artery bypass grafting (median follow‐up of 3.8 years). A total of 1.3% went on to a third PCI. The commonest indication for repeat stenting was disease progression remote from the original stent (46%) and planned staged PCI (23%); 21% had a stent‐related indication. Functional assessment before repeat stenting was used in one‐third of stable patients. Mortality was 2.5% per annum. Conclusions : In contemporary practice, patients undergoing a first stenting procedure have a low subsequent mortality, and the substantial majority (86.4%) requires no further revascularization over a median 3.8 year follow‐up. For those who do require repeat stenting, this is most commonly at a site remote from the first stent. © 2012 Wiley Periodicals, Inc.     

Novel use of the Mguard™ mesh‐covered stent to treat coronary arterial perforations

Covered stents seem to be an effective tool to seal severe perforations that have persisted despite prolonged balloon inflation. However, the high profile and low flexibility of previous covered stents compromise the deliverability of these devices, particularly in emergency situations. The Mguard? stent (InspireMD, Tel Aviv, Israel) is a novel mesh‐covered stent that has been designed to prevent distal embolization in thrombotic lesions. We herein report two cases that describe a new potential use of the Mguard stent for sealing perforations in coronary circulation. © 2012 Wiley Periodicals, Inc.     

Arterial access and door‐to‐balloon times for primary percutaneous coronary intervention in patients presenting with acute ST‐elevation myocardial infarction

Objectives: This study compares the transradial versus the transfemoral approach for time to intervention for patients presenting with ST elevation myocardial infarction (STEMI). Background: Survival following STEMI is associated with reperfusion times (door‐to‐balloon; D2B). For patients undergoing primary PCI for acute STEMI, potential effects of transradial approach (r‐PCI) as compared with the femoral artery approach (f‐PCI) on D2B times have not been extensively studied. Methods: Consecutive patients presenting with STEMI at a tertiary care medical center were enrolled in a comprehensive—Heart Alert program (HA) and included in this analysis. Time parameters measured included: door‐to‐ECG, ECG‐to‐HA activation, HA activation‐to‐cath lab team arrival, patient arrival in cath lab to arterial access, and arterial access‐to‐balloon inflation. Results: Of 240 total patients, 205 underwent successful PCI (n = 124 r‐PCI; n = 116 f‐PCI). No significant difference was observed in the pre‐cath lab times. Mean case start times for r‐PCI took significantly longer (12.5 ± 5.4 min vs. 10.5 ± 5.7 min, P = 0.005) due to patient preparation. Once arterial access was obtained, balloon inflation occurred faster in the r‐PCI group (18.3 vs. 24.1 min; P < 0.001). Total time from patient arrival to the cardiac cath lab to PCI was reduced in the r‐PCI as compared to the f‐PCI group (28.4 vs. 32.7 min, P = 0.01). There was a small but statistical difference in D2B time (r‐PCI 76.4 min vs. f‐PCI 86.5 min P = 0.008). Conclusions: Patients presenting with STEMI can undergo successful PCI via radial artery approach without compromise in D2B times as compared to femoral artery approach. © 2009 Wiley‐Liss, Inc.     

Long term clinical outcomes after deployment of femoral vascular closure devices in coronary angiography and percutaneous coronary intervention

Background: We evaluated the long term clinical outcomes of femoral vascular closure devices following its deployment in coronary angiography and percutaneous coronary intervention (PCI) procedures. Methods: From June 2000 to September 2004, 265 patients who received femoral vascular closure devices after coronary angiography and PCIs were enrolled into the study. Patients' medical records were reviewed and vascular complications within 1 year of follow‐up period were recorded. Rutherford's categories of claudication were used to quantify different degrees of claudication and leg ischaemia. Duplex ultrasonography of both femoral arteries (using the nonaccessed site as control) was performed at 1 year after deployment of vascular closure devices. Vessel diameter and flow velocities for both common femoral arteries were obtained. Results: There was no occurrence of late vascular complications like arteriovenous fistula, pseudoaneurysm, surgical repair of access site complications, late groin bleeding and infection. By Rutherford categories of claudication, 99.2% of patients had grade 0 claudication while the remaining 0.8% was in grade 1. By arterial Duplex ultrasonography, the peak systolic velocity of the accessed femoral artery (predominantly right side) was nonsignificantly higher, 94.9 ± 26.0 cm/s when compared to 91.5 ± 24.8 cm/s in the control site (P = 0.12). As for vessel diameter, no significant difference was found in the mean end‐diastolic vessel diameter 8.8 ± 1.3 mm (puncture site) versus 8.7 ± 4.4 mm (control site) (P = 0.72). Conclusion: We found that the use of femoral closure devices was safe and it was not associated with any adverse long term vascular complications. © 2009 Wiley‐Liss, Inc.     

Longitudinal compression of the platinum‐chromium everolimus‐eluting stent during coronary implantation: Predisposing mechanical properties,incidence, and predictors in a large patient cohort

Objectives: To assess the longitudinal compression behavior of platinum‐chromium everolimus‐eluting stents, evaluate frequency of inadvertent longitudinal compression during percutaneous intervention, and define patient‐ and lesion‐related predictors of this complication. Background: Platinum‐chromium stents of Element family have unique design features to improve flexibility that may, however, impair longitudinal stability. Incidence of longitudinal stent compression during implantation and predictors for this complication are not well understood. Methods : Five contemporary stent platforms were longitudinally compressed in a bench test experiment, and spring constant, yield force, and ultimate strength were calculated from force‐strain curves. We also evaluated all coronary cases treated with an Element stent from January 1, 2010, to October 31, 2011, for documented longitudinal compression. We compared baseline characteristics and periprocedural data between patients with and without longitudinal stent compression and assessed predictors for this event by multiple logistic regression models. Results : Yield force and ultimate strength were significantly lower for the Element compared with all other tested stents. In 20 patients (1.4%) and 20 lesions (0.7%) from 1,392 cases with 2,839 atherosclerotic lesions longitudinal stent compression was reported. Ostial segments, number of stents, and the presence of a bifurcation were significant predictors (adjusted odds ratios [95% confidence intervals]: 8.33 [3.30–21.28], 1.57 [1.01–2.45], 3.57 [1.36–9.35], respectively). Conclusion : The Element stent exhibits the lowest overall longitudinal strength compared with four contemporary platforms. Longitudinal compression of the Element stent is a rare complication and occurs more frequently in ostial or bifurcation lesions and with multiple stents. © 2012 Wiley Periodicals, Inc.     

Pseudoaneurysm after transradial cardiac catheterization: Case series and review of the literature

Introduction : Radial artery access for diagnostic and therapeutic procedures offers clear advantages in terms of vascular complications. While radial artery occlusion may occasionally complicate radial artery access, new methods of hemostasis are now utilized to avoid this complication. In contrast, pseudoaneurysm following radial artery access is an extremely uncommon complication. Methods : We describe a series of patients who developed radial artery pseudoaneurysm after their procedure. Results : Five patients developed radial pseudoaneurysm after diagnostic and interventional procedures, likely reflecting inadequate hemostasis following the procedure and delayed bleeding complicating systemic anticoagulation. Conclusions : While uncommon, radial artery pseudoaneurysm may complicate cardiac catheterization procedures, with anticoagulation an important contributor. The clinical presentation, likely precipitating mechanisms and treatment options are discussed. © 2011 Wiley Periodicals, Inc.     

Coil embolization of left coronary artery pseudoaneurysms arising as a complication of percutaneous coronary intervention

Coronary aneurysms and pseudoaneurysms have been described as rare complications following percutaneous coronary intervention (PCI). There is limited data available on the optimal treatment strategy for these conditions. Use of noninvasive techniques including covered stents has been described as a potential therapeutic strategy. We report a case of percutaneous coil embolization of two enlarging left anterior descending pseudoaneurysms arising as a complication of PCI. © 2012 Wiley Periodicals, Inc.     

Fistula between right coronary artery vein graft and right atrium as an immediate complication of percutaneous coronary intervention

Fistula between saphenous vein graft (SVG) and a cardiac chamber or structure is a rare complication after coronary artery bypass grafting (CABG). We report the first case of a fistula between SVG and the right atrium (RA) as an immediate complication after a percutaneous coronary intervention (PCI) in an 86-year-old female. She presented with inferior ST-elevation myocardial infarction (STEMI) and was treated with thrombolytic therapy in a peripheral hospital, which was unsuccessful. PCI to SVG to the right coronary (RCA) was complicated by a fistula to RA. Cardiac magnetic resonance (CMR) confirmed the site of the fistula and also presence of a significant arteriovenous (AV) shunt. Reversal of anticoagulation had no effect on fistula closure. Therefore, a covered stent was deployed for closure of the fistula to avoid long-term complications of the significant AV shunt. In summary, the diagnosis and appropriate management of this rare complication is challenging, but excellent result can be achieved by the use of appropriate percutaneous techniques.     

Treatment of right ventricular perforation during percutaneous coronary intervention

Percutaneous coronary intervention (PCI) is widely used to treat stenotic coronary arteries caused by coronary heart disease. Coronary artery perforation is a rare but dreaded complication of PCI. Here, we report the successful treatment of a patient with coronary perforation of the right ventricular cavity. To our knowledge, this is the first report of its kind.The patient was a 69-year-old woman with intermittent chest tightness and chest pain of about five years’ duration who was hospitalised for severe chest tightness and pain persisting for three days. She had a history of hypertension and hyperlipidaemia; routine admission examination showed no other abnormalities. Results of routine blood, urine and stool tests, liver and kidney function, clotting time, electrocardiogram, chest radiography and echocardiography were normal.Although coil embolisation rather than balloon is safe and effective for treating coronary artery perforation, it may be not the best choice overall. If the perforation breaks through into the right ventricle, we may just monitor closely rather than treat. That course may be beneficial for patients in that it reduces the risk of myocardial cell necrosis. This case provides useful information for the treatment of such patients in the future.     

Coronary perforation during percutaneous coronary intervention in the era of abciximab platelet glycoprotein IIb/IIIa blockade: an algorithm for percutaneous management.

Coronary perforation is an uncommon but potentially life-threatening complication of percutaneous coronary intervention. The use of both atheroablative technologies for coronary intervention and adjunctive platelet glycoprotein blockade pharmacology may increase the incidence of or risk for life-threatening bleeding complications following the occurrence of coronary artery perforation. The interventional database for 6,214 percutaneous coronary interventions performed between January 1995 and June 1999 was analyzed. Hospital charts and cine angiograms for all patients identified in the database as having had coronary perforation were reviewed. Coronary perforation complicated 0.58% of all procedures and was more commonly observed in patients with a history of congestive heart failure and following use of atheroablative interventional technologies (2.8%). There was no association of abciximab therapy with either the incidence of or classification for coronary perforation. Adverse clinical outcomes (death, emergency surgical exploration) were related to the angiographic classification of perforation and were more frequently observed in patients who experienced a class 3 coronary perforation. These data suggest that specific clinical and procedural demographic factors are associated with the occurrence and severity of angiographic coronary perforation. An angiographic perforation class-specific algorithm for treatment of coronary perforation is proposed.     

Perforation of the sinus of Valsalva by guiding catheter during the percutaneous coronary intervention via the right transradial approach: A very unusual complication

Iatrogenic dissection of the sinus of Valsalva or of the ascending aorta is a rare but potentially fatal event, during the percuteneous coronary intervention (PCI). We reported a case of perforation of the sinus of Valsalva by guiding catheter during PCI via the right transradial approach (TRA) successfully managed and sealed without any sequelae. The choice of guiding catheter into the right TRA should be done carefully and its manipulation should be performed with caution in the coronary artery and in the sinus of Valsalva. © 2011 Wiley Periodicals, Inc.     

Long‐term outcomes of drug‐eluting stents versus bare‐metal stents in saphenous vein graft disease: Results from the Prairie “Real World” Stent Registry

Objectives:

This study was designed to compare long‐term clinical outcomes of drug‐eluting stents (DES) versus bare metal stents (BMS) in patients with saphenous vein graft (SVG) disease in the “real world.”

Background:

The safety and efficacy of DES versus BMS in SVG remains uncertain due to contradictory reports of either lower revascularization rates with DES; or clinical equivalence to BMS; or even an excess of clinical events associated with DES use.

Methods:

We identified consecutive patients who underwent stent placement within a de novo SVG lesion between May 1, 2003 and July 31, 2007. Follow‐up was obtained at regular intervals. The Kaplan–Meier method was used to produce actuarial survival estimates. Cox regression analysis was used to predict the risk associated with stent type, and propensity scores were generated to risk‐adjust the results.

Results:

The study group included 379 stent recipients (284 DES; 95 BMS) with 410 stented lesions. BMS were placed more frequently in current smokers, acute myocardial infarctions, larger vessels, and longer lesions. In‐hospital mortality was higher in BMS recipients than in their DES counterparts (3.2% vs. 0, respectively; P = 0.015). At 3 years, there was no significant difference in clinical adverse event rates between DES and BMS recipients, even after risk adjustment.

Conclusions:

Three‐year adverse event rates are similar among patients treated with DES or BMS in SVG lesions. Therefore, while DES are safe, they do not appear to offer an advantage in terms of long‐term graft patency. © 2009 Wiley‐Liss, Inc.     

Failed pericardiocentesis for acute cardiac tamponade: Two cases associated with bivalirudin administration during PCI

Successful management of acute cardiac tamponade secondary to coronary artery perforation during percutaneous coronary intervention (PCI) includes sealing off the site of perforation and pericardiocentesis. We report two cases of acute cardiac tamponade during PCI associated with the administration of bivalirudin, in which attempts at percutaneous pericardiocentesis failed, due to the present of thrombus, rather blood, in the pericardium. © 2009 Wiley‐Liss, Inc.