Vascular injury following cardiac catheterization, coronary angiography, and coronary angioplasty

All vascular injuries occurring at this hospital departmentover a 5-year period (1987–91) as a result of cardiaccatheterization, coronary angiography, or coronary angioplasty(PTCA) and requiring transfusion, surgical consultation, orrepair, are reviewed. Such complications may occur late and,to detect cases not apparent from the protocol accompanyingevery examination, a questionnaire was sent to all surgicalclinics in the region asking for details of vascular surgicalintervention after angiography. The present review of 4879 examinationsdisclosed 18 patients with 19 vascular injuries (0·39%),four of them were detected by the questionnaire. The types ofinjury were: pseudoaneurysm (12), thrombembolic episode (4),and excessive bleeding (3). Of the patients with a vascularcomplication 11 (61%) were receiving anticoagulation treatment,compared to 10% n the whole series; two others suffered froma coagulopathic state. Catheterization was difficult or severeatherosclerosis was present in three, inadvertent mobilizationoccurred in one, and unintentional puncture distal to the commonfemoral artery occurred in two patients. With the increasinguse of invasive diagnostic and interventional procedures incardiovascular diseases, knowledge of the type and frequencyof possible complications is important, especially of thosethat may occur late. In the present study anticoagulation, coagulationdisorders, and cardiac catheterization combined with brachialpuncture and angiography all predisposed to a vascular complication.     

Percutaneous transluminal coronary angioplasty of aorta ostial, non-aorta ostial, and branch ostial stenoses: acute and long-term outcome

The acute and long-term outcome of 198 patients who underwentcoronary angioplasty of ostial stenoses was evaluated. Proceduralsuccess was achieved in 85% of aorta ostial stenoses, 90% ofnon-aorta ostial stenoses, and 87% of branch ostial stenoses(P=0–84). A major complication occurred in 5.9%, 6.3%,and 6–9% of patients who underwent aorta ostial, non-aortaostial, and branch ostial stenosis angioplasty, respectively(P=0.97). A greater residual stenosis (P=0.005) resulted fromangioplasty of aorta ostial lesions despite a greater inflationfrequency (P<0.001), inflation pressure (P<0.001), andtotal inflation duration (P<0.001). The restenosis rate washigher for aorta ostial lesions (71%) when compared to non-aortaostial (60%) and branch ostial lesions (32%) (P=0.01). However,since the denominator included only the 49% who returned forrepeat coronary angiography, the exact angiographic restenosisrate cannot be determined. The cumulative probability of survivalwas 99% at 1 year and 93% at 3 years. The 1 and 3 year freedomfrom death, myocardial infarction, bypass surgery, and repeatangioplasty was 70% and 57%, respectively. At census, 57% wereasymptomatic, and only 9% suffered severe angina. Coronary angioplastyof ostial stenoses can be carried out with an acceptable successand complication rate, and provides good symptomatic reliefand favourable long-term outcome. Randomized trials to comparenew angioplasty technology with balloon angioplasty will benecessary to select the best device therapy for ostial lesions.     

Initial experience with excimer laser angioplasty for coronary ostial stenoses.

The excimer laser has several potential advantages over conventional balloon angioplasty in the management of stenoses of the native coronary arteries and of the ostia of saphenous vein grafts. Its use in nine patients, eight of whom were classed as high risk, is described. Four lesions involved the ostia of saphenous vein grafts, three of protected left main stems, and two of native right coronary arteries. Stand alone laser was used in seven cases and laser with additional balloon angioplasty was used in two vein graft stenoses. Acute laser success was achieved in all cases, with a mean reduction of stenosis from 82% to 34% after laser alone and to 28% when balloon angioplasty was used as well. One patient died during laser angioplasty to a non-ostial lesion (procedural success rate 89%) and a second died ten weeks after the procedure. In one patient recurrent angina developed (clinical recurrence rate 25%) and restenosis was confirmed on angiography. Follow up angiography was also performed on the other six surviving patients, all of whom were symptom free and none of whom showed evidence of significant restenosis (restenosis rate 14%). With a mean follow up of 19.7 months the overall success rate was 67%.     

Isolated bilateral coronary ostial stenosis--an uncommon presentation of aortoarteritis

Cardiac fibromas are benign tumours, often diagnosed in childhood, but rarely they may be diagnosed in adults or the elderly. We present an interesting case of a middle-aged lady presenting with exertional chest pain and breathlessness, who was found to have a heavily calcified mass within the myocardium. With a previous history of chest trauma, a calcified myocardial haematoma was initially suspected. Complete surgical excision led to a total resolution of symptoms. Histological examination confirmed the diagnosis of a cardiac fibroma. Complete excision of cardiac fibromas, where possible, is advised and is associated with excellent survival.     

Isolated bilateral ostial coronary stenosis with proximal right coronary artery occlusion

The incidence of coronary ostial stenosis in patients undergoing coronary arteriography has been found to range between 0.07 and 0.25%. A slightly higher incidence has been observed in patients with angiographically confirmed coronary artery disease: between 0.13 and 2.7%. Bilateral ostial stenosis is even less common. longer a prominent condition, it must be considered in the differential diagnosis since it carries a very high risk (50%) of cardiovascular complications if left untreated. Ostial coronary stenosis occurs in 26% of patients with syphilitic aortitis. This paper reports on a 41-yearold Wasserman (WR)-positive woman with progressive angina caused by bilateral ostial coronary stenosis. (Int J Cardiovasc Although cardiovascular syphilis is no Intervent 2000; 3:47–49)     

Interpretation of the serum enzyme changes following cardiac catheterization and coronary angiography

The changes in the serum enzymes following cardiac catheterization and coronary angiography remain the subject of controversy and their value in the diagnosis of complicating acute myocardial infarction (AMI) has been questioned. In order to evaluate this problem serum glutamic oxaloacetic transminase (SGOT), creatine phosphokinase (CPK), and lactic dehydrogenase (LDH) were determined before (PRE-) and 24 hours after (POST-) 70 uncomplicated studies. Intramuscular premedications were used in 50 (Group I) and 20 had oral premedications or none (Group II). The changes in SGOT and LDH were trivial, and the POST values remained within the normal range. The CPK increased significantly in 68 per cent of patients in Group I, while in Group II it increased insignificantly within the normal range. The mean enzyme values from 20 patients admitted to the Coronary Care Unit with straightforward AMI 24 hours after the chest pain were clearly and significantly higher than all the mean POST values; however, there was considerable overlap of the individual CPK values with those of Group I. With this understanding the serum enzymes remain a valuable adjunct to the diagnosis of AMI complicating coronary arteriography.     

Outpatient cardiac catheterization and coronary angiography

The cost of and hospitalization required for cardiac catheterization led us to evaluate this procedure in 308 adult outpatients. Patients were scheduled on the basis of stability of symptoms. Two hundred eighty-eight underwent left heart catheterizations and coronary arteriography. Ninety-five percent of the procedures were performed by the percutaneous technique. Fifty patients had normal studies and 30 patients had congenital or valvular disease. Two hundred twenty-eight patients had significant coronary artery disease, 85 patients had triple vessel disease, and 45 patients had left main coronary artery disease. There were six significant complications: one death; two myocardial infarctions; one air embolism, and two patients with hematomas. Three of the complications were in patients with left main disease. Only two of the complications can be ascribed to the outpatient nature of the procedure. The complication rate is comparable to that reported in the literature. Fifteen hundred subsequent cases were studied as outpatients, with a very low mortality and morbidity. It is concluded that cardiac catheterization can be performed on an outpatient basis with safety comparable to inpatient studies, and at a great economic savings.     

"Y" graft bypass for bilateral coronary ostial aortoarteritis

A case of bilateral coronary ostial aortoarteritis, which presented with angina pectoris, is reported. Emergency total arterial revascularization was performed using the bilateral mammary artery and radial artery, and the radial artery was hanged "Y" on the left internal mammary artery. The patient was discharged on low-dose steroid. He was asymptomatic at 1-year follow-up.     

Severe syphilitic aortic regurgitation with bilateral critical coronary ostial stenosis

A forty-year-old male with syphilitic severe aortic regurgitation and critical bilateral coronary ostial stenosis, proved by cardiac catheterization and angiocardiography, is presented. He underwent successful aortic valve replacement and coronary artery bypass grafting with gratifying results.     

Bilateral coronary ostial stenoses post-Bentall procedure: management options in the DES era

The Bentall procedure for aortic root and valve replacement with coronary reimplantation was initially described in 1968. This procedure is considered the "gold standard" for treatment of combined valve and ascending aortic pathology. The procedure is performed most commonly in patients with degenerative aortic disease, including atherosclerotic disease, ectasia and poststenotic aortic dilatation. The complication of single coronary ostial stenosis following reimplantation is extremely rare in this procedure, occurring in less than 2% of patients. We describe the first case of bilateral coronary ostial stenoses following the Bentall procedure in a patient with documented heparin-induced thrombocytopenia (HIT) that was successfully treated with percutaneous coronary intervention (PCI).     

Bilateral isolated coronary ostial stenosis following mediastinal irradiation

Isolated coronary ostial narrowing is rare and may represent a separate disease entity from atherosclerotic coronary artery disease. The case of a 41-year-old female with no coronary risk factors who developed severe bilateral isolated coronary ostial stenosis following mantle radiotherapy for Hodgkin's disease is described. She underwent urgent coronary artery bypass grafting and has remained well for 3 years.     

Update on cardiac catheterization and coronary arteriography

Indications for cardiac catheterization--including coronary angiography--have substantially broadened with the advent of nonsurgical therapeutic interventions performed in the catheterization laboratory. Consequently, the increasing number of facilities performing these procedures require clear and unmistakable guidelines regarding the indications for and the safety and ethical aspects of the procedure. Technical developments in image acquisition and evaluation, such as quantitative analysis, allow the exact, reproducible assessment of minute changes in cardiac morphology and function, the evaluation of which becomes increasingly important in prognosis-related clinical trials.     

Success,complications, and restenosis following rotational and transluminal extraction atherectomy of ostial stenoses

Our objectives were to determine procedural success, clinical complications, and follow-up restenosis rates after rotational burr and transluminal extraction atherectomy of coronary artery and saphenous vein graft ostial stenoses. Balloon angioplasty of ostial lesions has been associated with low rates of success and high rates of clinical complications and restenosis compared to nonostial lesions. Atherectomy, due to its ability to excise (extraction atherectomy) or pulverize (rotational atherectomy) atheroma and the internal elastic lamina, may result in improved procedural outcome. We retrospectively studied 101 patients with ostial stenoses treated by rotational burr and transluminal extraction atherectomy over a 3-yr period. Quantitative angiography and clinical follow-up were reviewed to determine success, complication, and restenosis rates. Rotational burr (n = 29) and transluminal extraction (n = 72) atherectomy were associated with high procedural success (93% and 90%, respectively) and a low incidence of complications (6.9% and 4.2%, respectively). Postatherectomy angiographic success was low (52% and 69%, respectively) and required adjunctive balloon angioplasty in 85% of patients overall. This lower success rate likely reflects device undersizing as the overall postatherectomy artery to device ratio was near unity (0.95). The rates of angiographic ostial restenosis remain high (39.1% and 65.9%, respectively, P < 0.05). The high rate of restenosis after transluminal extraction atherectomy was due to the higher rate of restenosis in saphenous vein grafts (80%) compared to TEC treated coronary arteries (59%). When only coronary artery lesions were compared, there was no significant difference between atherectomy device groups with respect to restenosis rates or late loss. Rotational or transluminal extraction atherectomy of ostial stenoses is associated with high procedural success rates and a low incidence of complications; however, the rates of restenosis in these lesions remain high.     

Filmless multimedia display following cardiac catheterization

In traditional cardiac catheterization laboratories, anatomic images are acquired onto 35-mm cine film and presented in series with related information days, weeks, or months later to an audience of decision-makers. These data are projected onto a convenient light-colored wall or silver screen, while echocardiograms and electrophysiologic data are displayed using small single-user computer monitors. This presentation format is not ideal, because full audience participation is not fostered, image quality may be degraded, and small computer screens can be adequately visualized only by those individuals immediately in front of them. Modern video multimedia systems now make an ideal data presentation format practical, in which all types of media including digitally acquired angiograms can be displayed in parallel with full annotation, using large diagonal multisync color monitors. This communication discusses how to design a multimedia conference center in which remotely acquired filmless digital images can be displayed and processed together with all other pertinent cardiac multimedia to a large audience. Cathet. Cardiovasc. Diagn. 41:456–466, 1997. © 1997 Wiley-Liss, Inc.     

Subacute left main coronary stenosis following percutaneous transluminal coronary angioplasty

Subacute left main coronary stenosis following percutaneous transluminal coronary angioplasty (PTCA) is an uncommon but recognized complication of the procedure. This report describes a case of left main coronary stenosis, which occurred 6 months following PTCA of an angulated, eccentric, proximal (adjacent to the left main stem) left anterior descending artery stenosis. Angiographically demonstrated morphology of complicated coronary stenosis adjacent to the left main coronary artery may represent a risk factor threatening major complications of PTCA. Detailed evaluation of angiographic coronary anatomy may improve patient selection and reduce the likelihood of such complications.