Michael A. Ricci

Vascular complications of cardiac catheterization

Peripheral vascular complications after cardiac catheterization constitute an increasing portion of traumatic vascular injuries. To determine the incidence of these complications and the sequelae of their treatment, we reviewed 7,690 catheterizations performed over a 40-month period. One hundred eleven vascular complications were detected (1%), 41 of which required surgical repair (0.5%). Pseudoaneurysm (10), arteriovenous fistula (4), thromboembolism (9), infection (5), and other bleeding complications (83) were all found. Significantly more complications occurred in patients who were older than 60 years of age or female (P < 0.0009). In addition, the likelihood of a vascular injury after coronary angioplasty was significantly higher than after angiography alone (3% versus 1%, P < 0.00001). Secondary local and systemic complications after surgical repair were more frequent compared with those injuries that were managed nonoperatively (32% versus 11%; P = 0.015). Vascular complications continue to be a significant problem after cardiac catheterization, especially when coronary angioplasty is performed. The sequelae of surgical repair are significant, adding to their morbidity. Periodic review of these complications may identify factors that might be modified to reduce complications.

Prophylactic Vena Cava Filter Insertion In Severely Injured Trauma Patients: Indications And Preliminary Results

Pulmonary embolism (PE) remains a significant problem in trauma patients. A 5-year review at this institution revealed 25 PEs (seven fatal) in 2525 admitted trauma patients (1% incidence). Three groups of high-risk patients were identified: (1) those with severe head injury and coma; (2) those with spinal cord injuries with neurologic deficit; and (3) those with pelvic and long bone fractures. The relative risk of PE in these high-risk patients was 21 to 54 times that of the general trauma population. Beginning in July 1991, as prophylaxis against PE, vena cava filters (VCF) were inserted in patients whose injuries placed them in a high-risk group. Thirty-four patients had VCFs inserted percutaneously in the radiology suite without complications. On follow-up examination, 17.6% developed documented lower extremity deep vein thrombosis. There were no PEs. Overall, the incidence of PE in the general trauma population was significantly decreased from 1% to 0.25% (p < 0.05; chi 2). We conclude that insertion of VCFs in high-risk trauma patients is safe and efficacious in decreasing the incidence of PE.

Abdominal aortic aneurysm expansion rate: effect of size and beta-adrenergic blockade.

PURPOSE The purpose of this study was to investigate the hypothesis that abdominal aortic aneurysm (AAA) expansion may be slowed by beta-adrenergic antagonists. METHODS One hundred twenty-one patients with infrarenal AAA were monitored with serial aortic ultrasound examinations. Eighty-three patients received no beta-blockers (group I), and 38 patients received beta-blockers (group II). Values are expressed as mean +/- SD. RESULTS The mean follow-up was 43 +/- 29 months with 5.5 +/- 3.4 ultrasound examinations per patient. The expansion rate among all AAA was 0.38 +/- 0.44 cm/yr. Large aneurysms (> or = 5 cm) expanded significantly faster than small aneurysms (p = 0.02) in patients not treated with beta-blockers. Among patients with large AAA, those receiving beta-blockers had a significantly reduced mean expansion rate; 0.36 +/- 0.20 versus 0.68 +/- 0.64 cm/yr, (p < 0.05). Although rupture rates were lower in group I (5%) versus group II (13%), this difference was not statistically significant. Thirty-four patients in a poor-risk category with AAA were monitored greater than 5 cm in diameter. Ten of these AAA ruptured. The mean expansion rate was significantly greater in those patients with ruptured AAA versus those patients with AAA that did not rupture; 0.82 +/- 0.74 versus 0.42 +/- 0.41 cm/yr (p = 0.04). CONCLUSIONS In patients not undergoing beta-blocker therapy, large AAA expand at a significantly greater rate than smaller AAA. Large aneurysms that rupture show more rapid expansion than those AAA that do not rupture. We have demonstrated a significantly reduced rate of expansion of large AAA in patients receiving beta-blockade.

The effect of peripheral vascular disease on in-hospital mortality rates with coronary artery bypass surgery

PURPOSE The purpose of this study was to examine the effect of peripheral vascular disease (PVD) on in-hospital mortality rates after coronary artery bypass grafting (CABG). METHODS We performed a regional cohort study of 3003 patients undergoing CABG between 1987 and 1989 at five tertiary care centers in Maine, New Hampshire, and Vermont. Data reflecting patient characteristics, severity of heart disease, comorbidity, and in-hospital mortality rates were collected prospectively; the presence of clinical and subclinical indicators of PVD was determined retrospectively. RESULTS Observed in-hospital mortality rates with CABG were 2.4-fold higher in the 796 patients with indicators of PVD (7.7%) than in the 2207 patients without PVD (3.2%) (crude odds ratio [OR] 2.42 [95% confidence interval (CI) 1.73-3.37]). After adjusting for their higher comorbidity scores, more advanced heart disease, and age, patients with PVD remained 73% more likely to die in hospital after CABG (adjusted OR 1.73 [CI 1.19-2.51]). The excess risk of in-hospital death associated with PVD was attributable largely to lower extremity occlusive disease (adjusted OR 2.03 [CI 1.34-3.07]). Subclinical lower extremity occlusive disease (asymptomatic absence of pedal pulses) had the same effect as clinically overt disease. Cerebrovascular disease had a small and statistically nonsignificant effect on CABG-related deaths (adjusted OR 1.13 [CI 0.73-1.74]). Excess mortality rates in patients with PVD were primarily due to increased risk of death from heart failure and dysrhythmias, but not to cerebrovascular accidents or peripheral arterial complications. CONCLUSIONS The presence of lower extremity arterial occlusive disease is an important, independent predictor of in-hospital mortality rates for patients undergoing CABG. Controlled studies of the long-term effects of CABG in patients with PVD are needed to determine the optimal role of myocardial revascularization in this population.

Prophylactic vena cava filter insertion in patients with traumatic spinal cord injury: preliminary results.

Pulmonary embolism (PE) is a devastating complication in patients with traumatic spinal cord injury (SCI). Prophylactic measures such as venous compression hose or low-dose heparin are only partially protective in reducing the risk of venous thromboembolism and are contraindicated in some patients. Because of extended perturbations in fibrinolytic activity, catecholamine effects on platelet aggregation, increased activity of complement and acute phase reactants, abnormally high factor VIII concentrations, and persistent venous stasis with ongoing endothelial damage, the patient with an SCI remains at prolonged risk for venous thromboembolism. A retrospective 5-year review at the Medical Center Hospital of Vermont revealed seven patients with eight documented PEs (three fatal; 2.7%) in 111 SCI patients (6.3%). Six PEs (75%) occurred after discharge from the acute care facility. Median time to PE after injury was 78 days (range, 9-5993). Although comprising only 4% of all trauma admissions, SCI accounted for 31% of all PEs in the total trauma population (2525 patients). Beginning in July 1991, a new prophylaxis protocol was instituted, which included the percutaneous insertion of vena cava filters under local anesthesia in all SCI patients with paraplegia or quadriplegia. Fifteen patients have undergone the insertion of titanium filters. Impedance plethysmography was performed weekly to detect deep venous thrombosis. No complications were associated with vena cava filter insertion. No patients developed deep venous thrombosis during their acute hospitalization (median, 22 d), and no patients have developed PE after filter insertion.(ABSTRACT TRUNCATED AT 250 WORDS)

Benefits of a Telepsychiatry Consultation Service for Rural Nursing Home Residents

Psychiatric care for nursing home residents is difficult to obtain, especially in rural areas, and this deficiency may lead to significant morbidity or death. Providing this service by videoconference may be a helpful, cost-effective, and acceptable alternative to face-to-face treatment. We analyzed data for 278 telepsychiatry encounters for 106 nursing home residents to estimate potential cost and time savings associated with this modality compared to in-person care. A total of 843.5 hours (105.4 8-hour work days) of travel time was saved compared to in-person consultation for each of the 278 encounters if they had occurred separately. If four resident visits were possible for each trip, the time saved would decrease to 26.4 workdays. Travel distance saved was 43,000 miles; 10,750 miles if four visits per trip occurred. More than

Evaluating chronic venous disease with a new venous severity scoring system

3,700 would be spent on gasoline for 278 separate encounters; decreased to

Changes in Arterial Expression of Fibrinolytic System Proteins in Atherogenesis

925 for four visits per roundtrip. Personnel cost savings estimates ranged from

Anti-CD 18 monoclonal antibody slows experimental aortic aneurysm expansion☆☆☆★★★

33,739 to

Dependence of Augmentation of Arterial Endothelial Cell Expression of Plasminogen Activator Inhibitor Type 1 by Insulin on Soluble Factors Released From Vascular Smooth Muscle Cells

67,477. Physician costs associated with additional travel time ranged from