Lorenza Makke

Optimizing Radiation Safety in the Cardiac Catheterization Laboratory: A Practical Approach.

Reducing radiation exposure during cardiovascular catheterization is of paramount importance for both patient and staff safety. Over the years, advances in equipment and application of radiation safety protocols have significantly reduced patient dose and operator exposure. This review examines the current status of radiation protection in the cardiac and vascular catheterization laboratory and summarizes best practices for minimizing radiation exposure.

Effect of a Real-Time Radiation Monitoring Device on Operator Radiation Exposure During Cardiac Catheterization The Radiation Reduction During Cardiac Catheterization Using Real-Time Monitoring Study

Background—The Radiation Reduction During Cardiac Catheterization Using Real-Time Monitoring study sought to examine the effect of a radiation detection device that provides real-time operator dose reporting through auditory feedback (Bleeper Sv; Vertec Scientific Ltd; Berkshire, UK) on patient dose and operator exposure during cardiac catheterization. Methods and Results—Between January 2012 and May 2014, 505 patients undergoing coronary angiography, percutaneous coronary intervention, or both were randomized to use (n=253) or no use (n=252) of the Bleeper Sv radiation monitor. Operator radiation exposure was measured in both groups using a second, silent radiation exposure monitoring device. Mean patient age was 65±8 years, most patients (99%) were men, and 30% had prior coronary artery bypass graft surgery. Baseline clinical characteristics were similar in the 2 study groups. Radial access was used in 18% and chronic total occlusion percutaneous coronary intervention constituted 7% of the total procedures. Median procedure time was 17 (12–27) minutes for diagnostic angiography, 42 (28–70) minutes for percutaneous coronary intervention, and 27 (14–51) minutes in the overall study population, with similar distribution between the study groups. First (9 [4–17] versus 14 [7–25] &mgr;Sv; P<0.001) and second (5 [2–10] versus 7 [4–14] &mgr;Sv; P<0.001) operator radiation exposure was significantly lower in the Bleeper Sv group. Use of the device did not result in a significant reduction in patient radiation dose. The effect of the Bleeper Sv device on operator radiation exposure was consistent among various study subgroups. Conclusions—Use of a real-time radiation monitoring device that provides auditory feedback can significantly reduce operator radiation exposure during cardiac catheterization. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01510353.

Association of coronary lipid core plaque with intrastent thrombus formation: A Near-Infrared Spectroscopy and Optical Coherence Tomography Study

Background: Optical coherence tomography (OCT) and near‐infrared spectroscopy (NIRS) allow assessment of the anatomy (OCT) and composition (NIRS) of coronary lesions. We sought to examine the association between pre‐stenting lipid core plaque (LCP), as assessed by NIRS and post‐stenting thrombus formation, as assessed by OCT. Methods: We reviewed the angiograms of nine patients who underwent coronary stenting in association with NIRS and OCT imaging. A large LCP by NIRS was defined as at least three 2‐mm yellow blocks on the NIRS block chemogram with >200° angular extent. Intracoronary thrombus was defined as a mass of medium reflectivity protruding into the vessel lumen, discontinuous from the surface of the vessel wall. Results: Mean age was 67 ± 7 years, and all patients were men, presenting with stable angina (56%), unstable angina (11%), or acute myocardial infarction (33%). The mean vessel lipid core burden index (LCBI) was 120 ± 45, and the mean highest 6‐mm LCBI was 386 ± 190. Three patients had a large LCP and two of them (66%) developed intrastent thrombus after stent implantation compared to none of six patients without large LCPs (0%, P = 0.02). The thrombus resolved after intracoronary glycoprotein IIb/IIIa administration and balloon postdilation. Postprocedural myocardial infarction occurred in 33% versus 17% of patients with and without large LCP, respectively (P = 0.57). Conclusion: Stenting of large LCPs may be associated with intrastent thrombus formation, suggesting that more intensive anticoagulant and/or antiplatelet therapy may be beneficial in such lesions.

Prevalence and outcomes of intermediate saphenous vein graft lesions: Findings from the stenting of saphenous vein grafts randomized-controlled trial

BACKGROUND We sought to examine the prevalence and progression rate of intermediate saphenous vein graft (SVG) lesions in the Stenting Of Saphenous vein grafts (SOS) trial. METHODS The baseline and follow-up angiograms of 80 patients participating in the SOS trial were analyzed to determine the prevalence of intermediate (30-60% angiographic diameter stenosis) SVG lesions and their progression rate. RESULTS At least one intermediate SVG lesion was present in 31 of 143 (22%) SVGs in 27 of 80 (34%) patients. Most intermediate lesions were present in the SOS stented SVGs (20 grafts in 19 patients). During a median follow-up of 35 months, angiographic follow-up was available for 28 grafts in 25 patients. Progression (defined as percent diameter stenosis ≥ 70% but <100% at follow-up angiography) was seen in 11 of 28 SVGs (39%) in 11 of 25 patients (44%). Progression rate at 12, 24 and 36 months was 28% and 47% and 84%, respectively. Seven of 11 patients (64%) with intermediate SVG lesion progression presented with an acute coronary syndrome and 8 (73%) underwent PCI. Four of the 28 grafts with intermediate lesions at baseline were 100% occluded at follow-up; all of those SVGs had received a stent in another location in the SVG as part of the SOS trial. CONCLUSIONS Intermediate SVG lesions are common in patients undergoing SVG stenting, have high rates of progression and frequently present with an acute coronary syndrome. Further study of pharmacologic and mechanical treatments to prevent progression of these lesions is needed.

Incidence and Treatment of Arterial Access Dissections Occurring during Cardiac Catheterization

BACKGROUND Arterial access dissections may complicate cardiac catheterization and can often be treated percutaneously. The goal of this study was to examine the incidence, consequences, and the treatment of arterial access dissections at a tertiary referral hospital with an active training program. METHODS Patients experiencing arterial access dissection during coronary angiography or intervention at our institution between October 1, 2004, and January 31, 2007, were identified and their records were retrospectively reviewed. RESULTS Thirteen of the 3,062 consecutive patients (0.42%) had arterial access dissection during the study period. The location of the dissection was in the common femoral artery (CFA) (n = 6), the external iliac artery (EIA) (n = 6), or in an aortobifemoral graft (n = 1). Three of the six patients with CFA dissection were diagnosed during coronary angiography, and because of significant comorbidities were treated with self-expanding stents. After a mean follow-up of 7 months, they experienced no stent fracture or other complication. Six patients had EIA dissections. In one such patient, the dissection was not flow limiting and was treated conservatively. The remaining five patients underwent successful implantation of self-expanding stents, and during a mean follow-up of 9.6 months, no patient had any symptoms or events related to lower extremity ischemia. Finally, one patient had an aortobifemoral graft dissection. Due to the patients critical condition, secondary to sepsis, his family elected to withdraw care, and he subsequently expired. CONCLUSIONS Arterial access dissections occur infrequently during cardiac catheterization. Routine femoral artery angiography may help identify vascular access complications, often allowing simultaneous endovascular treatment, with excellent short-term outcomes.

Role of embolic protection devices in ostial saphenous vein graft lesions.

Although embolic protection devices (EPDs) have been shown to be beneficial in saphenous vein graft (SVG) lesions, their role in the subgroup of ostial SVG lesions has received limited study.

Determinants of operator and patient radiation exposure during cardiac catheterization: Insights from the RadiCure (RADIation reduction during cardiac catheterization using real-timE monitoring) trial

In the RadiCure study 505 catheterization procedures were 1:1 randomized to use or no use of real‐time radiation monitoring. Use of the Bleeper Sv monitor resulted in a significant reduction in operator radiation exposure.

Procedural outcomes with use of the flash ostial system in aorto‐coronary ostial lesions

The Flash Ostial system (Ostial Corporation, Sunnyvale, CA) was designed to optimize implantation of aorto‐ostial coronary stents by flaring the proximal stent struts against the aortic wall.

THE ‘ANGIOGRAPHIC EVALUATION OF THE EVEROLIMUS-ELUTING STENT IN CHRONIC TOTAL OCCLUSIONS’ (ACE-CTO) STUDY

BACKGROUND There are limited data on outcomes after implantation of second-generation drug-eluting stents in coronary chronic total occlusions (CTOs). We aimed to evaluate the frequency of angiographic restenosis and clinical outcomes after implantation of the everolimus-eluting stent (EES) in coronary CTOs. METHODS One hundred patients undergoing successful CTO percutaneous coronary intervention using EES at our institution between 2009 and 2012 were enrolled. The primary study endpoint was binary in-segment restenosis at 8-month follow-up quantitative coronary angiography. Secondary endpoints included death, myocardial infarction, target-lesion and target-vessel revascularization, and symptom improvement. RESULTS Mean age was 64 ± 7 years and 99% of the patients were men. The successful crossing technique was antegrade wiring in 51 patients, antegrade dissection/reentry in 24 patients, and retrograde in 25 patients. Binary angiographic restenosis occurred in 46% of the patients (95% confidence interval [CI], 35%-57%). The pattern of restenosis was focal, proliferative, and total occlusion in 19 lesions (46%), 14 lesions (34%), and 8 lesions (20%), respectively. At 12 months, the incidences of death, myocardial infarction, target-lesion revascularization, and target-vessel revascularization were 2%, 2%, 37%, and 39%, respectively. At 12 months, symptoms were improved, unchanged, or worse compared with baseline in 89 patients, 8 patients, and 1 patient, respectively (2 patients died before the 12-month follow-up). On multivariable analysis, smaller stent diameter was associated with higher risk for binary angiographic restenosis. CONCLUSION High rates of angiographic restenosis and repeat revascularization were observed among patients receiving EES in coronary CTOs, but most had significant symptom improvement.