Eric D. Grassman

Use of vascular sealing devices (VasoSeal and Perclose) versus assisted manual compression (Femostop) in transcatheter coronary interventions requiring Abciximab (ReoPro)

Transcatheter coronary interventions requiring abciximab (ReoPro) are associated with vascular access site complications. Several devices have been developed to aid in the closure of the femoral arteriotomy, including collagen plug devices (VasoSeal, Angio‐Seal), percutaneous suture closure (Perclose), and aids to manual compression (Femostop). In 185 patients who received abciximab plus aspirin and heparin for transcatheter coronary interventions, we compared femoral arteriotomy closure by three different methods: VasoSeal, Perclose, and Femostop. A composite endpoint of late complications defined as an access site‐related bleed or hematoma that required blood transfusion or an extended hospital stay, pseudoaneurysm, arteriovenous fistula, arterial or venous thrombosis was compared. VasoSeal was initially successful in 41/52 patients (78.8%). The 11 patients who failed to have adequate hemostasis with VasoSeal required manual compression aided by Femostop, but had no late complications. There was one access site infection and one fatal retroperitoneal hematoma unrelated to the vascular access site (surgically explored). There were no late complications. Perclose was successful in 48/56 patients (85.7%). One Perclose failure required surgical repair for an extensive arteriotomy. The other Perclose failure required manual compression aided by Femostop, but had no late complications. There were no access site infections requiring intravenous antibiotics. There was one retroperitoneal bleed that extended the patients hospital stay and for which a blood transfusion was required. Femostop was successful in 77/77 patients (100%). There were no infections. Late complications occurred in four patients. These included three episodes of bleeding or hematomas requiring blood transfusion, and one pseudoaneurysm. Conclusion: In patients receiving abciximab in addition to aspirin and heparin, VasoSeal and Perclose are at least as safe as Femostop when used to achieve homeostasis after sheath removal. VasoSeal and Perclose have a significantly lower initial rate of successful hemostasis than Femostop. The numbers of late complications between the VasoSeal, Perclose, and Femostop groups were not significantly different. In those patients in whom VasoSeal or Perclose failed, no late complications occurred. Access site infections were no different between VasoSeal, Perclose, and Femostop. Cathet. Cardiovasc. Intervent. 47:143–147, 1999.

Predictors of success and major complications for primary percutaneous transluminal coronary angioplasty in acute myocardial infarction. An analysis of the 1990 to 1994 Society for Cardiac Angiography and Interventions registries.

OBJECTIVES The purpose of this study was to determine predictors of successful coronary angioplasty for acute myocardial infarction (MI) and associated predictors of the major complications of in-hospital mortality and emergency coronary artery bypass graft surgery. BACKGROUND Primary angioplasty is being increasingly used to treat acute MI, but factors affecting the success and major complications have not been well studied. Forty laboratories have been contributing clinical and procedural data to the Society of Cardiac Angiography and Interventions (SCA&I) on primary angioplasty for acute MI. METHODS Univariable and stepwise multivariable logistic regression analysis of clinical and procedural variables was used to calculate predictors of success and major complications. RESULTS There were 4,366 primary angioplasty procedures reported from 1990 through 1994, with an overall success rate of 91.5%, an in-hospital mortality rate of 2.5% and a rate of emergency surgery of 4.3%. Higher laboratory primary angioplasty volume and lower age were predictive of success. An intraaortic balloon pump in place, cardiogenic shock and a moribund condition had negative predictive effects. Unsuccessful angioplasty, cardiogenic shock or a moribund state were predictive of in-hospital death. Unsuccessful angioplasty, the absence of a history of hypertension and the absence of congestive heart failure were predictive of emergency surgery. CONCLUSIONS The rates of success and major complications in the SCA&I Registry are similar to other series. Predictors of success and major complications can be assessed and may be useful for risk stratifying candidates for primary angioplasty in acute MI.

Acute procedural results in the treatment of 30 coronary artery bifurcation lesions with a double-wire atherectomy technique for side-branch protection

Percutaneous treatment of bifurcation lesions has been consistently shown to be associated with lower acute success rates, higher initial complication rates, and an increased rate of restenosis when compared with findings in nonbifurcation lesions. Recent analysis of data from a CAVEAT subgroup suggests that directional atherectomy of bifurcation lesions can improve initial success rates and lower restenosis rates but at the cost of high complication rates. Reports from several angioplasty series document improved success rates and lower complication rates with the use of a two-wire technique to protect side branches when treating bifurcation lesions. Our experience with a two-wire atherectomy technique that uses a nitinol wire to protect important side branches is presented.

New catheter design for cannulation of the anomalous right coronary artery arising from the left sinus of valsalva

Cannulation of an anomalous right coronary artery during coronary angiography and percutaneous intervention poses significant technical difficulties using currently available catheter shapes. We describe a new catheter design and the cannulation technique for application of this catheter. The initial experience with this catheter in cases is reported. Catheter Cardiovasc Interv 2003;60:382–388.

Percutaneous transluminal coronary angioplasty for unstable angina: Predictors of outcome in a multicenter study

Background: Angiographic and clinical studies have demonstrated that coronary artery plaque rupture with thrombus formation, spasm, or both are frequently responsible for the syndrome of unstable angina. Percutaneous transluminal coronary angioplasty (PTCA) is commonly used in the treatment of patients with coronary artery disease and unstable angina. A number of studies have shown, however, that intracoronary thrombus increases the risk of abrupt vessel closure. The purpose of this study was to define preprocedural variables predictive of the outcome of PTCA performed on patients with unstable angina in a prospective multicenter study using a core angiographic laboratory.Methods and Results: A total of 386 patients with unstable angina underwent coronary angioplasty of 487 lesions treated with balloon PTCA at 9 medical centers. Multivessel or left main coronary artery disease was present in 55% and recent myocardial infarction in 22%. Clinical success was achieved in 317 of 386 patients (82.1%), as defined by <50% residual stenosis at every target lesion evaluated in the core angiographic laboratory and no major complication during hospitalization. Major complications (death, Q-wave or non-Q-wave myocardial infarction, or emergency coronary artery bypass surgery) occurred in 36 patients (9.3%), and abrupt vessel closure occurred in 50 (13.0%). Logistic regression analysis identified preprocedural variables that were predictive of outcome of angioplasty. Strong predictors of any complication (major complication or abrupt vessel closure) included age [odds ratio (OR)=1.04; 95% confidence interval [CI] 1.02, 1.07]) for each additional year of age; p < 0.001), number of diseased vessels (OR=1.58; 95% CI=1.16, 2.15 per additional vessel; p=0.012), the number of lesions treated at angioplasty (OR =1.72; 95% CI=1.11, 2.66; p=0.014), and angiographic evidence of filling defect preceding angioplasty (OR=3.30; 95% CI=1.11, 9.75; p < 0.001).Conclusions: The outcome of PTCA performed for unstable angina is influenced by a combination of clinical, angiographic, and procedural variables. This study suggests that PTCA performed on lesions associated with filling defects or on more than one lesion at the time of the procedure carries an increased risk of complication. The outcome of PTCA for unstable angina may be improved by identifying new strategies for the treatment of lesions associated with filling defects and by using more accurate methods to identify and treat the culprit lesion responsible for unstable angina.