Ali E. Denktas

Incidence, correlates, management, and clinical outcome of coronary perforation: analysis of 16,298 procedures

BACKGROUNDnCoronary perforation is a serious but uncommon complication of percutaneous coronary intervention (PCI) and is associated with significant morbidity and mortality.nnnMETHODSnWe performed an analysis of the Mayo Clinic PCI database. Clinical records, procedural reports, and angiographic studies were reviewed. Multiple logistic regression analysis was performed to identify clinical, procedural, anatomic, and angiographic correlates of coronary perforation.nnnRESULTSnA total of 16,298 PCI procedures were performed between January 1990 and December 2001. We identified 95 coronary perforations (0.58%; 95% CI, 0.47-0.71). The incidence of coronary perforation varied with time. Correlates of coronary perforation included the use of an atheroablative device and female sex. Twelve patients (12.6%) sustained an acute myocardial infarction, and cardiac tamponade developed in 11 patients (11.6%). Management strategies included reversal of heparin, pericardiocentesis, placement of a covered stent, and surgical repair. Seven patients died (7.4%).nnnCONCLUSIONSnCoronary perforation during PCI is rare, but is associated with significant morbidity and mortality. The variable frequency of perforation may be explained by temporal variations in the use of atheroablative devices.

Comparison of combination therapy of adenosine and nitroprusside with adenosine alone in the treatment of angiographic no-reflow phenomenon.

We sought to compare the combination therapy of adenosine and nitroprusside in no‐reflow phenomenon during percutaneous coronary intervention. Improvement in coronary flow from no‐reflow to postdrug state was evaluated. Patients who received adenosine (n = 21) were compared to ones who received the combination of adenosine and nitroprusside (n = 20) for treatment. Improvement of TIMI flow grades was higher in the group that received combined therapy (1.5 ± 1.0 vs. 0.8 ± 0.6; P < 0.05). Combination therapy of adenosine and nitroprusside is safe and provides better improvement in coronary flow compared to intracoronary adenosine alone in case of impaired flow during coronary interventions. Catheter Cardiovasc Interv 2004;61:484–491.

Distal protection devices during percutaneous coronary and carotid interventions

Distal embolization of particulate matter complicates percutaneous coronary and peripheral interventions more often than had been recognized until recently. A number of distal protection devices are under development. The PercuSurge GuardWire™ is a balloon occlusion thrombectomy device approved by the United States Food and Drug Administration for saphenous vein graft intervention. A number of filter devices utilize an expandable filter mounted on the angioplasty guidewire to facilitate entrapment of particles and safe removal. The Parodi Anti-Emboli System™ is an example of a catheter occlusion device that establishes protection by reversing blood flow in the target vessel.

Cutting balloon angioplasty vs. conventional balloon angioplasty in patients receiving intracoronary brachytherapy for the treatment of in-stent restenosis

The objective of this study was to evaluate the safety and efficacy of cutting balloon angioplasty (CBA) for the treatment of in‐stent restenosis prior to intracoronary brachytherapy (ICB). Cutting balloon angioplasty may reduce the incidence of uncontrolled dissection requiring adjunctive stenting and may limit “melon seeding” and geographic miss in patients with in‐stent restenosis who are subsequently treated with ICB. We performed a retrospective case‐control analysis of 134 consecutive patients with in‐stent restenosis who were treated with ICB preceded by either CBA or conventional balloon angioplasty. We identified 44 patients who underwent CBA and ICB, and 90 control patients who underwent conventional percutaneous transluminal coronary angioplasty (PTCA) and ICB for the treatment of in‐stent restenosis. Adjunctive coronary stenting was performed in 13 patients (29.5%) in the CBA/ICB group and 41 patients (45.6%; P < 0.001) in the PTCA/ICB group. There was no difference in the injury length or active treatment (ICB) length. The procedural and angiographic success rates were similar in both groups. There were no statistically significant differences in the incidence of death, myocardial infarction, recurrent angina pectoris, subsequent target lumen revascularization, or the composite endpoint of all four clinical outcomes (P > 0.05). Despite sound theoretical reasons why CBA may be better than conventional balloon angioplasty for treatment of in‐stent restenosis with ICB, and despite a reduction in the need for adjunctive coronary stenting, we were unable to identify differences in clinical outcome. Catheter Cardiovasc Interv 2004;63:152–157.

New approaches to the pharmacological treatment of angina

The treatment of angina is changing, with many new agents being added to those existing agents that have been used for many years. New data regarding the use of glycoprotein IIb/IIIa inhibitors now exist and low molecular weight heparins are used more frequently with greater efficacy than unfractionated heparin. New thrombin inhibitors are also receiving a fresh look. An expert panel has recently published guidelines for the treatment of unstable angina.

75-Year-Old Man With Fever, Weight Loss, and Diarrhea

75-year-old retired farmer came to our institution because of anorexia, fever, weight loss, diarrhea, and occasional right upper quadrant pain. Three months earxad lier, the patient had noticed decreased appetite and energy. A month later, coughing and expectoration of yellowish sputum were treated with an orally administered macrolide antibiotic. Despite completion of the course of antibiotic, fever (temperatures up to 38.9°C) developed, occurring primarily at night. One month before admission, the paxad tient had diarrhea, with production of up to seven brown liquid stools per day without hematochezia or mucus; these bouts resolved spontaneously in 3 to 4 days. At that time, he was admitted to another hospital with the diagnosis of right lower lobe pneumonia, for which he received ceftriaxone, 1 g intravenously every 24 hours, and erythroxad mycin, 500 mg intravenously four times a day, for 8 days, after which he was dismissed with a 10-day oral regimen of antibiotics. Two days after completion of the antibiotic therapy, another episode of diarrhea occurred, with up to seven brown liquid stools per day, again without mucus or hematochezia. Four days later, he was admitted to our institution with the diagnosis of dehydration. Throughout this period, the patient continued to have nightly fevers (temperatures up to 40°C) with occasional drenching night sweats. The patient had a history of a monoclonal gammopathy of undetermined significance (MGUS) for at least 9 years, with low levels ofIgA, IgG, and IgM and an M peak in yof 0.8 g/dL (IgG K type). He had hypothyroidism and had also undergone a coronary artery bypass grafting procedure 2 years earlier. He had a history of farmers lung and chronic obstructive pulmonary disease, with frequent use of antibixad otics during the past few years for recurrent upper respiraxad tory tract infections. Additionally, he had a history of paroxysmal atrial fibrillation, for which he was receiving