Percutaneous femoral transluminal angioplasty of a right brachial artery occluded after Sones coronary angiography

A case of percutaneous transluminal angioplasty (PTA) from the groin to a 7-cm right brachial artery occlusion in a 41-year-old man, having previously undergone Sones coronary angiography 2 months earlier, is presented. The post-PTA angiogram shows near-normal reconstitution of the total obstruction, persisting after 6 months with complete loss of collateral circulation. In a case of total obstruction of the brachial artery, femoral PTA should be considered before resorting to surgical treatment.     

Percutaneous radial artery approach for coronary angiography

Percutaneous entry into the distal radial artery and selective coronarography using a French 5 sheath and preshaded catheters were attempted in 100 patients with a normal Allen test. Cannulation of the radial artery was not possible in ten patients, and selective catheterization of the coronary arteries was unsuccessful in two. Manipulation of catheters presented no problem, and arterial spasm was rarely observed, only before the use of a 23-cm-long sheath. Only two complications without symptoms were observed: arterial dissection of the brachial artery in one patient and occlusion of the radial artery in another. With experience, this approach may become as effective and possibly safer than the transbrachial entry.     

Managing the femoral artery in coronary angiography

Vascular access and subsequent methods to obtain haemostasis are commonly overlooked components of coronary angiography, yet most complications related to diagnostic coronary angiography and percutaneous coronary interventions come from groin bleeds. Most of these complications are minor, leading to bruising and patient discomfort. However, major vascular complications such as retroperitoneal bleeding are life threatening. A number of devices are now available to ensure the arteriotomy can be closed immediately at the end of the procedure. These devices have advantages but are in themselves the source of additional complications, which are not seen without them. The mechanisms related to the use of these devices and the potential complications that they may cause should be understood by all cardiologists performing coronary angiography.     

Percutaneous brachial approach using the femoral artery sheath for left heart catheterization and selective coronary angiography

A percutaneous method via the brachial artery for left heart catheterization and selective coronary angiography is described. The technique uses the sheath intended for the femoral artery, continuously infused and introduced following a particular technique. The procedure was performed with minimal complications over 18 months, with multipurpose "Schoonmaker" or preshaped catheters, in all the patients (37) in whom the femoral approach was contraindicated or failed. When a catheterization must be performed from the arm, this method, without cutdown and arteriotomy and allowing a good distal flow during the procedure, appears to have some advantages over the classical Sones technique or the percutaneous arterial axillary approach.     

Referral for coronary artery revascularization procedures after diagnostic coronary angiography: Evidence for gender bias?

Objectives. We sought to determine whether there is a gender bias in the selection of patients for coronary revascularization once the severity of the underlying coronary artery disease has been established with angiography.

Background. It has been suggested that women with coronary artery disease are less likely to be referred for coronary angiography and coronary artery bypass surgery than men. Whether such a referral bias for revascularization procedures, including coronary angioplasty, is present once angiography has been performed is not clear.

Methods. We retrospectively analyzed 22,795 patients with suspected coronary artery disease who underwent coronary angiography between 1981 and 1991 and compared the numbers of women and men who underwent either coronary artery bypass surgery or coronary angioplasty within 30 days of coronary angiography.

Results. Angiography revealed significant (one-vessel or more) disease in 15,455 patients (52% of women, 76% of men). Despite worse symptoms, women had less extensive coronary disease than men as judged by the number of vessels diseased. Women were also more likely to have other co-morbid diseases. An equal proportion of women (54%) and men underwent revascularization procedures. After adjustment for baseline differences and age, differences in the two individual revascularization strategies were very small: More women tended to have coronary angioplasty ([absolute difference ± 1 SD] + 3.3 ± 0.7%, p < 0.0001), but fewer had coronary artery bypass surgery than men (−2.5 ± 0.8%, p = 0.003). When the two revascularization strategies were considered together, there was no significant gender difference in overall adjusted use of revascularization (+0.8 ± 0.9%, p = 0.41).

Conclusions. Once diagnostic coronary angiography had been performed, no major differences in the overall utilization of revascularization procedures were noted for women compared with men.     

Ultrasound guided percutaneous thrombin injection of iatrogenic femoral artery pseudoaneurysms after coronary angiography and intervention

Ultrasound guided percutaneous thrombin injection has recently been described for the treatment of iatrogenic femoral pseudoaneurysms. Patient selection and technical aspects of this technique are still evolving and safety data, particularly after coronary intervention, remains limited. The percutaneous thrombin injection of femoral artery pseudoaneurysms in 13 consecutive patients, most of whom were receiving antiplatelet/anticoagulant treatment (aspirin 11, heparin 4, clopidogrel 6), is reported. Thrombin (1000 U/ml) was injected over several seconds until Doppler colour flow within the cavity ceased. The median dose of thrombin injected was 800 U (range 200-1000 U) and the treatment was successful in all cases without complication. In one case, thrombus was visualised within the arterial lumen immediately after thrombin injection, but this dissolved spontaneously within five minutes without evidence of embolisation. In contrast to ultrasound guided compression, percutaneous thrombin injection of femoral pseudoaneurysms is a rapid, well tolerated, and successful technique even in patients receiving antiplatelet/anticoagulant treatment.


Keywords: ultrasound guided percutaneous thrombin injection; iatrogenic femoral artery pseudoaneurysm     

Internal mammary artery angiography should be a routine component of diagnostic coronary angiography

Left internal mammary artery (LIMA) angiography was performed with diagnostic coronary angiography in 130 cases for which the coronary findings made use of the LIMA as a bypass graft a consideration. In 98% of the cases the approach to LIMA angiography was femoral with a 5F LIMA catheter first directed into the proximal subclavian and then advanced over a guidewire placed into the distal subclavian well beyond the origin of the LIMA. After withdrawing the wire the catheter was brought proximally to selectively can-nulate and visualize the LIMA with nonionic contrast media. The only complication was a single transient occipital visual field loss. LIMA caliber too narrow to permit use as a graft was found twice, LIMA occlusion unrelated to prior surgery was found once, and LIMA occlusion related to prior surgery was found twice. Subclavian and/or vertebral stenosis was present five times. Large proximal branches of the LIMA best identified prior to surgery were present 12 times. Based on this experience, LIMA angiography (1) can be performed safely with a high degree of success, (2) demonstrates significant findings in 15% of cases, and 3) should therefore be performed whenever coronary angiographic findings make it appropriate to consider LIMA to coronary artery bypass grafting.     

Percutaneous transulnar artery approach for diagnostic and therapeutic coronary intervention

While the transradial approach is now a well-established alternative to the conventional femoral approach for cardiac catheterization, the ulnar artery is rarely used. The objective of this prospective study was to evaluate the feasibility and safety of transulnar catheterization for routine diagnostic and therapeutic coronary interventions. Among 210 consecutive patients referred for diagnostic coronary angiography and or angioplasty and screened for appropriateness of the ulnar approach, 172 (172 of 210, 82%) underwent attempted ulnar artery catheterization, which was successful in 158 (158 of 172, 91%). The 173 procedures successfully performed via the ulnar approach included 122 diagnostic coronary angiographies, 38 coronary angiographies followed by angioplasty, and 13 elective angioplasties. Access site complications consisted of one case each of silent ulnar artery thrombosis, pseudoaneurysm, and hematoma due to ulnar artery wall rupture during an unsuccessful catheterization attempt. No cardiac or systemic complications were recorded. The transulnar approach appears feasible and safe for routine coronary diagnostic and therapeutic interventions.     

冠状动脉多层螺旋CT成像及冠脉造影对冠脉搭桥术后桥血管的评价

目的观察冠状动脉多层螺旋CT成像及冠脉造影对冠脉搭桥手术后桥血管的评价作用。方法33例冠脉搭桥手术患者,术前常规冠脉造影检查,手术行不停跳冠脉搭桥术,手术后1 a行冠状动脉多层螺旋CT成像,并于冠状动脉多层螺旋CT成像复查后1周内行冠脉造影检查。结果33例患者共行冠脉搭桥101支,冠状动脉多层螺旋CT成像能够成功显示99支,显示率为98.02%。冠状动脉多层螺旋CT成像与冠脉造影结果对比,其对冠脉搭桥手术后桥血管狭窄和阻塞评价敏感度达100%。结论应用冠状动脉多层螺旋CT成像对冠脉搭桥术后桥血管评价简便、无创,具有较好的可信性和可行性。     

冠状动脉造影后即刻PTCA与择期PTCA的比较

目的　研究冠状动脉造影后即刻冠状动脉成形术的成功率及并发症率进而探讨其临床应用价值。方法　对冠状动脉造影后即刻冠脉成形术及靶病变特点与其相似的择期冠脉成形术各７０ 例进行对比分析。结果　Ａ 和Ｂ型病变的成功率和并发症率两组间差异无显著性,Ｃ型病变的成功率即刻组低于择期组（５７．１４％ 对９２．８６％ ,Ｐ＜ ０．０５）而并发症率高于择期组（５７．１４％ 对１４．２９％ ,Ｐ＜ ０．０１）,闭塞性病变的成功率及并发症率两组间差异无显著性。结论　Ｃ型病变不宜于造影后即刻行冠脉成形术。闭塞性病变可于造影后即刻试行冠脉成形以避免次全闭塞进展为完全闭塞后才进行手术。造影后即刻冠脉成形有一定的临床应用价值     

Comparison of femoral bleeding complications after coronary angiography versus percutaneous coronary intervention

Vascular complications arising after coronary angiography (CA) and percutaneous coronary intervention (PCI) may be under-reported. Access site complications were studied after consecutive CA and PCI in the investigators' center (an urban university hospital) from October to December 2002. Three hundred eleven consecutive procedures (237 CA studies and 74 PCIs) were included, of which 309 (99%) involved femoral arterial access. Seventy percent of all arterial punctures were closed by manual pressure, 28% by C-pressure clamps, and 2% with closure devices. Femoral hematomas occurred in 22% and 41% of CA studies and PCIs, respectively. Hematoma >5 cm occurred in 6% and 11% of CA studies and PCIs, respectively. Nineteen patients (23%) with access site complications had prolonged hospital admission. Increased body mass index and hematoma development within the catheter laboratory were predictors of prolonged admission.     

Internal mammary artery angiography should be a routine component of diagnostic coronary angiography.

Left internal mammary artery (LIMA) angiography was performed with diagnostic coronary angiography in 130 cases for which the coronary findings made use of the LIMA as a bypass graft a consideration. In 98% of the cases the approach to LIMA angiography was femoral with a 5F LIMA catheter first directed into the proximal subclavian and then advanced over a guidewire placed into the distal subclavian well beyond the origin of the LIMA. After withdrawing the wire the catheter was brought proximally to selectively cannulate and visualize the LIMA with nonionic contrast media. The only complication was a single transient occipital visual field loss. LIMA caliber too narrow to permit use as a graft was found twice, LIMA occlusion unrelated to prior surgery was found once, and LIMA occlusion related to prior surgery was found twice. Subclavian and/or vertebral stenosis was present five times. Large proximal branches of the LIMA best identified prior to surgery were present 12 times. Based on this experience, LIMA angiography 1) can be performed safely with a high degree of success, 2) demonstrates significant findings in 15% of cases, and 3) should therefore be performed whenever coronary angiographic findings make it appropriate to consider LIMA to coronary artery bypass grafting.     

无肝素冠脉造影术后股动脉止血方法的探讨

目的：评价无肝素股动脉冠状动脉造影术（CAG）后股动脉穿刺部位应用改良加压包扎法止血的效果和安全性。方法：经股动脉途径行CAG的120例患者,分为两组,A组术后采用Angio—seal．装置止血,B组采用改良加压包扎法止血,两组抗血小板治疗相同。比较两组止血时间、止血成功率、开始活动时间、并发症和患者的舒适度。结果：①两组止血的成功率（均为100％）,制动时间[A组为（3．6±0．7）h,B组（3．8±0．5）h]．舒适度均无显著差异（P〉0．05）;②止血时间[A组（2．1±0．8）min．B组（7．5±2．8）min],加压包扎时间[A组0h,B组为（10．2±2．3）h],A组显著短于B组（P〈0．05）;③主要并发症：血肿发生率A组（11．7％）显著多于13组（3．3％）．P〈0．05。结论：无肝素股动脉冠状动脉造影术后股动脉穿刺部位应用改良加压包扎法止血效果好．价格低廉。并发症少,值得临床推广。     

Percutaneous transluminal coronary angioplasty after previous coronary artery bypass surgery

To improve symptomatic status and avoid repeat coronary artery bypass graft surgery (CABG), 115 lesions were approached for transluminal coronary angioplasty (PTCA) in 94 patients (82 men, 12 women) with angina pectoris and prior CABG at a mean of 60 months (range 4 to 192) after CABG. Fifteen patients were in Canadian Cardiovascular Society functional class I, 32 were in class II, 31 were in class III, and 16 were in class IV. Patients were 37 to 76 years old (mean 57). PTCA was successful (at least a 40% reduction in stenosis diameter and improvement in symptomatic status) in 83 patients (88%) and 103 (90%) lesions. Mean stenosis was reduced from 80 +/- 14% to 20 +/- 16% (mean +/- standard deviation) and mean pressure gradient from 41 +/- 7 mm Hg to 14 +/- 6 mm Hg. Seven patients had lesions that could not be crossed for technical reasons and these patients underwent non-emergency CABG. Four patients required emergency CABG after PTCA; 1 patient subsequently died and 2 survived acute myocardial infarction. One patient had a femoral artery laceration, which required surgical repair. At a mean follow-up of 8 +/- 4 months, 63 patients (76%) with initially successful results were free of angina or in improved condition. Of the remaining 20 patients, 18 consented to repeat coronary angiography. Four patients did not have restenosis. Of the 14 patients with documented restenosis, 5 underwent successful repeat PTCA, 5 had repeat CABG, and 4 were treated medically. Thus, when coronary anatomy is suitable, PTCA is an effective alternative to reoperation in symptomatic patients with prior CABG.     

冠状动脉造影与经皮冠状动脉介入治疗术后股动脉假性动脉瘤临床分析

目的　对经皮冠状动脉介入治疗 (PCI)后出现的股动脉假性动脉瘤 (FAP)的患者进行回顾性分析 ,了解PCI后FAP的发生及临床处理情况。方法　入选 10 5例PCI后FAP的患者 ,并与同期无血管并发症的患者进行对照 ,分析FAP的临床特点和处理方法。结果　本组病例冠状动脉造影的FAP发生率为 0 8% ,PCI的FAP发生率为 1 6 % ,logistic回归分析显示女性 (P =0 0 4 7)、动脉鞘管型号≥ 7F(P =0 0 0 7)、介入术中平均压水平 (P <0 0 0 1)和围术期应用低分子肝素 (P <0 0 0 1)与FAP的发生显著相关。弹力绷带加压包扎修复的成功率为 6 3% ,超声指导下压迫修复的成功率为 85 %。结论　女性、鞘管直径、介入术中血压水平以及围术期应用低分子肝素是发生FAP的危险因素。FAP超声指导下压迫修复成功率高。     

Bail-Out stenting for left main coronary artery occlusion following diagnostic angiography

We report a case of acute left main coronary artery occlusion treated with stenting of the left main artery. The patient had a severe ostial left main stenosis and after diagnostic coronary angiography developed a total occlusion of the left main artery with life threatening hemodynamic consequences. Stenting of the unprotected left main coronary artery was successfully performed as a salvage procedure.     

Percutaneous left heart catheterization and coronary arteriography using a femoral artery sheath

Percutaneous left heart catheterization and coronary arteriography with a standard angiographic catheter introduced through a femoral artery sheath has been performed in over 200 patients during the past 12 months. The use of the sheath for catheter introduction and manipulation offers several advantages, including the capability of monitoring two arterial pressures with only one arterial puncture, the minimization of time in which the guidewire is intravascular, the capability of using all types of catheters from a femoral artery percutaneous approach, and, most importantly, the complete elimination of patient discomfort during catheter changes. The disadvantages of the sheath technique are relatively minor. Thus, percutaneous left heart catheterization and coronary arteriography through a femoral artery sheath can be performed safely and with relatively little trauma to the femoral artery.     

Catastrophic left main coronary artery occlusion following diagnostic coronary angiography: salvage by emergency left main coronary artery stenting

Acute occlusion of left main coronary artery after diagnostic angiography can be rapidly fatal. We describe two patients with left main disease that developed cardiac arrest shortly after diagnostic coronary angiography. They were both successfully treated with emergency left main stenting while cardiopulmonary resuscitation was being performed. Patients with left main disease should be carefully monitored after diagnostic angiography to allow prompt recognition of acute occlusion. Emergency stenting may be required for salvaging the patients.     

Catastrophic left main coronary artery occlusion following diagnostic coronary angiography: Salvage by emergency left main coronary artery stenting

Acute occlusion of left main coronary artery after diagnostic angiography can be rapidly fatal. We describe two patients with left main disease that developed cardiac arrest shortly after diagnostic coronary angiography. They were both successfully treated with emergency left main stenting while cardiopulmonary resuscitation was being performed. Patients with left main disease should be carefully monitored after diagnostic angiography to allow prompt recognition of acute occlusion. Emergency stenting may be required for salvaging the patients.