Manjunath Raju

Coronary artery fistula: A case series with review of the literature

Coronary artery fistula (CAF) is an anomalous connection between a coronary artery and a major vessel or cardiac chamber. Most of the coronary fistulas are discovered incidentally during angiographic evaluation for coronary vascular disorder. The management of CAF is complicated and recommendations are based on anecdotal cases or very small retrospective series. We present three cases of CAF, two of which were symptomatic due to hemodynamically significant coronary steal phenomenon. They underwent successful transcatheter coil embolization, leading to resolution of their symptoms. Percutaneous closure offers a safe and effective way for the management of symptomatic patients. CAFs are rare cardiac anomalies but can give rise to a variety of symptoms because of their hemodynamic consequences or complications. They should be part of cardiac differential diagnosis particularly in patients without other risk factors. Correction of CAF is indicated if the patients are symptomatic or if other secondary complications develop.

Statin therapy in the reduction of cardiovascular events in patients undergoing intermediate-risk noncardiac, nonvascular surgery

Hydroxymethylglutaryl‐coenzyme A reductase inhibitors (statins) reduce perioperative cardiac events in high‐risk patients undergoing cardiovascular surgery. However, there is paucity of data on the role of statins in patients undergoing intermediate‐risk noncardiac, nonvascular surgery (NCNVS).

Bivalirudin for the treatment of patients with confirmed or suspected heparin-induced thrombocytopenia

Heparin‐induced thrombocytopenia (HIT) is an adverse immune‐mediated response to unfractionated heparin and, less commonly, low molecular weight heparin. It is associated with a high thrombotic risk and the potential for limb and life‐threatening complications. Argatroban is the only approved and currently available anticoagulant for HIT treatment in the USA.

External validation of the HIT Expert Probability (HEP) score

The diagnosis of heparin-induced thrombocytopenia (HIT) can be challenging. The HIT Expert Probability (HEP) Score has recently been proposed to aid in the diagnosis of HIT. We sought to externally and prospectively validate the HEP score. We prospectively assessed pre-test probability of HIT for 51 consecutive patients referred to our Consultative Service for evaluation of possible HIT between August 1, 2012 and February 1, 2013. Two Vascular Medicine fellows independently applied the 4T and HEP scores for each patient. Two independent HIT expert adjudicators rendered a diagnosis of HIT likely or unlikely. The median (interquartile range) of 4T and HEP scores were 4.5 (3.0, 6.0) and 5 (3.0, 8.5), respectively. There were no significant differences between area under receiver-operating characteristic curves of 4T and HEP scores against the gold standard, confirmed HIT [defined as positive serotonin release assay and positive anti-PF4/heparin ELISA] (0.74 vs 0.73, p = 0.97). HEP score ≥ 2 was 100 % sensitive and 16 % specific for determining the presence of confirmed HIT while a 4T score > 3 was 93 % sensitive and 35 % specific. In conclusion, the HEP and 4T scores are excellent screening pre-test probability models for HIT, however, in this prospective validation study, test characteristics for the diagnosis of HIT based on confirmatory laboratory testing and expert opinion are similar. Given the complexity of the HEP scoring model compared to that of the 4T score, further validation of the HEP score is warranted prior to widespread clinical acceptance.

Renal Artery Stent Fracture in Patients With Fibromuscular Dysplasia A Cautionary Tale

Fibromuscular dysplasia (FMD) is a nonatherosclerotic vascular disease that most commonly affects the renal, carotid, and vertebral arteries.1 Renal FMD is associated with renovascular hypertension, and patients may be referred for revascularization, generally with balloon angioplasty. We report a series of 2 patients with renal artery FMD who developed stent fracture. A 16-year-old girl was seen for a second opinion on renal FMD. Hypertension was diagnosed at the age of 13 years and initially treated medically; however, bilateral renal artery angioplasty was subsequently performed for poorly controlled blood pressure. She subsequently underwent placement of a drug eluting stent in the right renal artery for restenosis. Although she initially improved, there was gradual worsening of her blood pressure control. Noninvasive testing was consistent with severe restenosis of the right renal artery stent. Renal arteriography revealed a severe stenosis estimated at 80% in the right renal artery (Figure 1). There was severe narrowing noted at the ostium, resulting in a 70 mm Hg gradient across the lesion. …

BIVALIRUDIN FOR THE TREATMENT OF HEPARIN-INDUCED THROMBOCYTOPENIA: A 9 YEAR, 461 PATIENT EXPERIENCE

Heparin-induced thrombocytopenia (HIT) is an adverse immune-mediated response to unfractionated heparin and less commonly low molecular weight heparin. It is associated with a high risk for thrombotic events and potential for limb and life-threatening complications. The only approved and currently