Neeraj Tandon

Atherectomy devices: technology update.

Atherectomy is a procedure which is performed to remove atherosclerotic plaque from diseased arteries. Atherosclerotic plaques are localized in either coronary or peripheral arterial vasculature and may have different characteristics depending on the texture of the plaque. Atherectomy has been used effectively in treatment of both coronary and peripheral arterial disease. Atherectomy devices are designed differently to either cut, shave, sand, or vaporize these plaques and have different indications. In this article, current atherectomy devices are reviewed.

Comparison of manual compression and vascular hemostasis devices after coronary angiography or percutaneous coronary intervention through femoral artery access: A meta-analysis of randomized controlled trials☆☆☆

OBJECTIVES To compare the efficacy and safety of manual compression (MC) with vascular hemostasis devices (VHD) in patients undergoing coronary angiography (CA) or percutaneous coronary intervention (PCI) through femoral artery access. INTRODUCTION The use of femoral artery access for coronary procedures may result in access-related complications, prolonged immobility and discomfort for the patients. MC results in longer time-to-hemostasis (TTH) and time-to-ambulation (TTA) compared to VHDs but its role in access-related complications remains unclear in patients undergoing coronary procedures. METHODS We searched MEDLINE, EMBASE, Cochrane CENTRAL and relevant references for English language randomized controlled trials (RCT) from inception through September 30, 2016. We performed the meta-analysis using random effects model. The outcomes were time-to-hemostasis, time-to-ambulation, major bleeding, large hematoma >5cm, pseudoaneurysm and other adverse events. RESULTS The electronic database search resulted in a total of 44 RCTs with a total of 18,802 patients for analysis. MC, compared to VHD resulted in longer TTH [mean difference (MD): 11.21min; 95% confidence interval (CI) 8.13-14.29; P<0.00001] and TTA [standardized mean difference: 1.2 (0.79-1.62); P<0.00001] along with excess risk of hematoma >5cm formation [risk ratio (RR): 1.38 (1.15-1.67); P=0.0008]. MC resulted in similar risk of major bleeding [1.01 (0.64-1.60); P=0.95] pseudoaneurysm [0.99 (0.75-1.29); P=0.92], infections [0.52 (0.25-1.10); P=0.09], need of surgery [0.60 (0.29-1.22); P=0.16), AV fistula [0.93 (0.68-1.27); P=0.63] and ipsilateral leg ischemia [0.95 (0.57-1.60); P=0.86] compared to VHD. CONCLUSION Manual compression increase time-to-hemostasis, time-to-ambulation and risk of hematoma formation compared vascular hemostasis devices.

Using 7.5 frames per second reduces radiation exposure in lower extremity peripheral vascular interventions.

Background Peripheral vascular interventions can be associated with significant radiation exposure to the patient and the operator. Objective In this study, we sought to compare the radiation dose between peripheral vascular interventions using fluoroscopy frame rate of 7.5 frames per second (fps) and those performed at the standard 15 fps and procedural outcomes. Methods We retrospectively collected data from consecutive 87 peripheral vascular interventions performed during 2011 and 2012 from two medical centers. The patients were divided into two groups based on fluoroscopy frame rate; 7.5 fps (group A, n = 44) and 15 fps (group B, n = 43). We compared the demographic, clinical, procedural characteristics/outcomes, and radiation dose between the two groups. Radiation dose was measured as dose area product in micro Gray per meter square. Results Median dose area product was significantly lower in group A (3358, interquartile range (IQR) 2052–7394) when compared to group B (8812, IQR 4944–17,370), p < 0.001 with no change in median fluoroscopy time in minutes (18.7, IQR 11.1–31.5 vs. 15.7, IQR 10.1–24.1), p = 0.156 or success rate (93.2% vs. 95.3%), p > 0.999. Conclusion Using fluoroscopy at the rate of 7.5 fps during peripheral vascular interventions is associated with lower radiation dose compared to the standard 15 fps with comparable success rate without associated increase in the fluoroscopy time or the amount of the contrast used. Therefore, using fluoroscopy at the rate of 7.5 fps should be considered in peripheral vascular interventions.

Protected carotid artery stenting in patients at high risk for carotid endarterectomy.

Objectives: To compare the 30-day, six-month, and one-year outcomes of carotid artery stenting (CAS) and carotid endarterectomy (CEA) in male veterans, and to identify any predictors of adverse outcomes. CAS has been shown to be non-inferior to CEA in patients at high-risk for CEA. The outcome of CAS compared to low-risk CEA is less clear. Methods: Retrospective analysis of 96 consecutive patients who underwent CAS (N = 31) or CEA (N = 65). The cumulative 30-day, six-month, and one-year incidence of ipsilateral transient ischemic attack (TIA) or stroke, restenosis or reocclusion, need for target vessel revascularization, non-fatal myocardial infarction (MI), and death were compared. Results: All patients in the CAS group were at high risk for CEA. Among the CEA group, 50 (76.9%) were at high risk and the remaining 15 (23.1%) were considered to be at low risk. The cumulative incidence of adverse outcomes with CAS and CEA, respectively, at 30 days (3.2% vs 9.2%, P = ns), six months (3.2 vs 18.5%, P = 0.047), and one year (9.7% vs 18.5%, P = ns) favored CAS. This difference was primarily due to adverse events in the high-risk CEA patients. There was no significant difference in outcome between the CAS and low-risk CEA groups. The independent significant predictors for adverse outcomes within six months were the group (P = 0.047) and number of risk factors (P = 0.01). Interestingly, the use of angiotensin-converting enzyme inhibitors (ACE-I) predicted adverse outcomes within one year (P = 0.01). Conclusion: CAS may be superior to high-risk CEA with better six-month outcomes. The outcomes with CAS were not significantly different compared to low-risk CEA, suggesting that CAS may be non-inferior to low-risk CEA.

STANDARD VERSUS LOW-DOSE HEPARIN USE ON ACCESS-RELATED COMPLICATIONS AFTER CORONARY ANGIOGRAPHY THROUGH RADIAL ACCESS: A META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

Background: Transradial access (TRA), compared to femoral access, is preferred for coronary procedures due to reduced access-related bleeding and mortality. Radial artery occlusion (RAO) is a known complication of TRA, and precludes its use as a future access site, conduit for CABG or for

A comparison of standard versus low dose heparin on access-related complications after coronary angiography through radial access: A meta-analysis of randomized controlled trials

BACKGROUND Transradial access (TRA) is preferred for coronary angiography (CA) or percutaneous coronary intervention due to reduced access-related complications, and mortality especially for patients with ST elevation myocardial infarction. Radial artery occlusion (RAO) is a known complication of TRA, and precludes its use as a future access site, conduit for coronary artery bypass grafting or for hemodialysis fistula placement. Although a standard dose (SD) heparin of 5000 Units is used during TRA, the risks of RAO and hematoma compared to lower dose (LD) remain unclear. To compare the risks of RAO and hematoma using SD vs. LD heparin after CA through TRA, we performed a meta-analysis of randomized controlled trials (RCT). METHODS We searched PubMed, EMBASE, CINAHL and CENTRAL for RCTs since inception through 06/30/2017 and used random effects model for analysis. The outcomes analyzed were RAO, hematoma formation and radial artery compression time (RACT). RESULTS We identified a total of 6 RCTs with a total of 2239 patients. SD heparin resulted in a trend toward a lower risk of RAO [4.2% vs. 10.7%; risk ratio (RR): 0.40, 95% confidence interval (CI): 0.16-1.0; P=0.05], a trend toward increased risk of hematoma [2.2% vs. 1.1%; 1.83 (0.91-3.66); P=0.09], and a longer duration of RACT [mean difference: 9.64min (4.01-15.28); P=0.0008] compared to LD. CONCLUSIONS The current meta-analysis showed a trend towards reduction in the risk of RAO with the use of standard dose heparin. Larger randomized trials should explore the appropriate dosing of heparin to prevent radial artery occlusion.