Renato M. Santos

Progression of renal artery stenosis in patients undergoing cardiac catheterization

BACKGROUND Renal artery stenosis is potentially correctable by either revascularization surgery or percutaneous methods. However, appropriate use of these techniques has been hampered by a lack of data on the natural history of this disease. This study assesses the prevalence, risk factors for progression, and effect on renal function of angiographically demonstrated renal artery disease in patients undergoing cardiac catheterization. METHODS The severity of renal artery stenosis was quantified in all patients who underwent abdominal aortography as part of a diagnostic cardiac catheterization study at Duke University Medical Center between January 1989 and February 1996. RESULTS There were 14,152 patients in the study (mean age 61+/-12 years, 62% male). Normal renal arteries were identified in 12,543 (88.7%) patients, insignificant disease (<50% stenosis) in 1 or more vessels in 726 patients (5.1 %), and significant stenosis in 883 patients (6.3%). Significant bilateral renal artery stenosis was present in 178 patients (1.3%). By multivariate logistic regression, elevated serum creatinine level, coronary artery disease, peripheral vascular disease, hypertension, cerebrovascular disease, older age, female sex, and family history of coronary artery disease were identified as independent predictors of significant renal arterial disease. Disease progression was assessed in 1189 patients. Mean time between cardiac catheterizations was 2.6+/-1.6 years. Significant disease progression occurred in 133 patients (11.1 %). Independent predictors of disease progression were female sex, age, coronary artery disease at baseline, and time between baseline and follow-up. At follow-up, serum creatinine level was significantly higher in patients who demonstrated > or =75% stenosis in 1 or more vessels (mean creatinine level 141+114 micromol/L compared with those with insignificant disease (mean creatinine level 97+/-44 micromol/L (P= .01). CONCLUSIONS Renal artery disease is frequently progressive in patients who undergo cardiac catheterization for investigation of coronary artery disease. Significant stenotic disease may develop over a short period despite evidence of normal renal arteries at prior catheterization.

Trends in Vascular Complications After Diagnostic Cardiac Catheterization and Percutaneous Coronary Intervention Via the Femoral Artery, 1998 to 2007

OBJECTIVES This study sought to evaluate trends in vascular complications after diagnostic cardiac catheterization (CATH) and percutaneous coronary intervention (PCI) from the femoral artery from 1998 to 2007. BACKGROUND Vascular complications have been recognized as an important factor in morbidity after CATH and PCI. Whether strategies to reduce vascular complications performed from the femoral artery in the past decade have improved the safety of these procedures, however, is uncertain. METHODS A total of 35,016 consecutive diagnostic cardiac catheterization (n = 20,777) and percutaneous coronary intervention procedures (n = 14,239) performed via a femoral access at a single site (Wake Forest University Baptist Medical Center) between 1998 and 2007 were evaluated. Annual rates of vascular complications were evaluated. Covariate effects on the risk of vascular complications were evaluated by logistic regression and risk-adjusted trend analysis. RESULTS Overall, the incidence of any vascular complication decreased significantly for CATH, 1.7% versus 0.2%, and PCI, 3.1% versus 1.0%, from 1998 to 2007, both p < 0.001 for trend. Favorable trends in procedural covariates affecting vascular complications were mainly responsible for the decrease in the incidence of vascular complications, including fewer closure device failures and use of smaller sheath sizes. CONCLUSIONS In this large, single-center, contemporary observational study, the safety of CATH and PCI performed from the femoral artery improved significantly from 1998 to 2007. Reductions in the prevalence of adverse procedural factors contributed to the decrease in the incidence of vascular complications, suggesting that strategies to reduce vascular complications can be effective in improving the safety of these procedures.

Propensity score analysis of vascular complications after diagnostic cardiac catheterization and percutaneous coronary intervention 1998–2003

Objectives: To evaluate the adjusted risk of vascular complications after manual compression and vascular closure devices for femoral artery access site management in a large contemporary cohort, using propensity score analysis. Background: Vascular closure devices (VCD) allow early ambulation after cardiac procedures involving femoral artery access, but whether the benefit of use of vascular closure devices (VCD) is offset by reduced safety in contemporary practice remains uncertain. Methods: Twenty one thousand eight hundred and forty one consecutive diagnostic cardiac catheterization (n = 13,124) and percutaneous coronary intervention procedures (n = 8,717) performed via a femoral access at a single site (WFUBMC) between 1998 and 2003 were evaluated. VCDs were used based on operator preference. Propensity to receive a vascular closure device (VCD) was calculated. The relative incidence of vascular complications was evaluated by logistic regression models, using the propensity score as a covariate. Results: Overall, the unadjusted incidence of any vascular complication was 1.3% for VCD use and 1.4% for manual compression, p = NS. The propensity score‐adjusted odds ratio for any vascular complication comparing VCD (n = 8,707) to manual compression (n = 13,034) was 0.86 (0.67–1.11) for all procedures, 0.80 (0.53–1.21) for diagnostic procedure, and 0.90 (0.65–1.26) for interventional procedures. Conclusions: In this large single‐center, contemporary observational study, the risk‐adjusted occurrence of vascular complications following VCD use for femoral artery access management is not increased by VCD use. Thus, in the current era, the benefit of VCD use is not offset by reduced safety.

Late outcomes of drug-eluting versus bare metal stents in saphenous vein grafts: Propensity score analysis.

Objective: To compare late outcomes with the routine use of drug‐eluting stents (DES) compared with bare‐metal stents (BMS) during percutaneous intervention (PCI) of saphenous vein grafts (SVGs). Background: Safety concerns >1 year from stent implantation have been raised about DES used for PCI of SVGs in a small randomized clinical trial. However, there are few studies comparing late outcomes of DES and BMS in routine clinical practice. Methods: Clinical outcomes (nonfatal MI, cardiac mortality) were assessed in 74 consecutive patients who received BMS and 74 consecutive propensity score matched patients that received DES for PCI of SVGs. Clinical follow‐up was censored at 2 years ± 30 days for both stent groups. Results: At 2 years, the hazard ratio for DES compared with BMS for PCI of SVGs for target vessel revascularization was 0.54 (0.21–1.36), nonfatal MI or cardiac death was 0.68 (0.27–1.68), cardiac mortality 1.19 (0.32–4.45), and stent thrombosis 0.49 (0.09–2.66). Similar outcomes were observed stratified by propensity score quintile. Conclusions: The routine clinical use of DES for PCI of SVGs was associated with a safety profile that was similar to that of bare metal stents with a clear trend toward a less frequent need for reinterventions.

Incidence of Coronary Stent Thrombosis Based on Academic Research Consortium Definitions

Stent thrombosis occurs infrequently after drug-eluting stent (DES) placement, but concerns have surfaced that identification of stent thrombosis based solely on angiography may underestimate the true incidence of this complication. The purpose of this study was to compare rates of stent thrombosis using Academic Research Consortium (ARC) definitions. From April 2002 to February 2005, bare-metal stents (BMSs) and DESs were placed at Wake Forest University Baptist Medical Center. Rates of ARC definite, probable, and possible stent thrombosis were evaluated. Overall, definite stent thrombosis occurred in 1.4% of BMSs and 1.1% of DESs (p = 0.47); probable stent thrombosis, in 1.0% of BMSs and 0.9% of DESs (p = 0.81); definite plus probable stent thrombosis, in 2.3% of BMSs and 1.9% of DESs (p = 0.48); and possible stent thrombosis, in 6.8% of BMSs and 3.5% of DESs (p <0.001). Rates of definite late (31 days to 1 year) and very late (>1 year) stent thrombosis were 0.9% for BMSs and 0.06% for DESs (p <0.001) and 0.16% for BMSs and 0.56% for DESs, respectively (p = 0.13). Rates of definite plus probable and late and very late stent thrombosis were 1.1% for BMSs and 0.19% for DESs (p <0.001) and 0.40% for BMSs and 0.68% for DESs, respectively (p = 0.31). Rates of possible stent thrombosis increased significantly for each thrombosis interval. In conclusion, rates of stent thrombosis using the proposed ARC definition differed by stent type, definition of stent thrombosis, and thrombosis interval. Use of the ARC probable stent thrombosis paralleled rates of definite stent thrombosis alone, but partially masked the occurrence of late (>1 year) stent thrombosis in DESs compared with BMSs.

Chronic kidney disease and dipstick proteinuria are risk factors for stent thrombosis in patients with myocardial infarction.

BACKGROUND Kidney failure (stage 5 chronic kidney disease [CKD]) is an independent risk factor for stent thrombosis (ST). Moderate (stage 3-4) CKD and proteinuria are both associated with adverse cardiovascular events, including worse outcomes after myocardial infarction (MI). Whether moderate CKD and proteinuria increase the risk of ST after MI is not known. This study evaluated the risk of ST associated with moderate CKD and dipstick proteinuria. METHODS We retrospectively analyzed clinical and laboratory data from 956 non-stage 5 CKD patients who were admitted with MI and received intracoronary stenting. Clinical follow-up was collected at 1 year for definite or probable ST, as well as for all-cause mortality, nonfatal MI or death, and target vessel revascularization or coronary artery bypass graft surgery. RESULTS After adjustment for multiple clinical and biochemical covariates, patients with both estimated glomerular filtration rate (GFR) of 15 to 59 mL min(-1) 1.73 m(-2) and > or =30 mg/dL dipstick proteinuria had increased cumulative incidence of ST (hazard rate [HR] 3.69, 95% CI 1.54-8.89), all-cause mortality (HR 2.68, 95% CI 1.34-5.37), and nonfatal MI or death (HR 3.20, 95% CI 1.77-5.81) at 1 year. In addition, estimated GFR of 15 to 59 mL min(-1) 1.73 m(-2) was a significant independent predictor of ST (HR 2.61, 95% CI 1.33-5.10). Dipstick proteinuria > or =30 mg/dL was associated with a trend toward increased risk for all outcomes. CONCLUSIONS In an acute MI population, moderate CKD was identified as a novel prognostic marker for ST. In addition, patients with both decreased GFR and proteinuria had higher incidences of all-cause mortality and nonfatal MI or death than patients with either condition alone.

Cost-Effectiveness of Drug-Eluting Stents Versus Bare Metal Stents in Clinical Practice

Background—Drug-eluting stents (DES) reduce the need for repeat target revascularization (TVR) compared with bare metal stents (BMS) but are more costly. The objective was to evaluate the cost-effectiveness of DES versus BMS. Methods and Results—We evaluated clinical outcomes and costs of care over 3 years in 1147 undergoing BMS before the availability of DES and 1247 DES patients at Wake Forest University Baptist Medical Center from 2002 to 2005. Costs for index stenting, TVR, and clopidogrel use were assessed. The 2 groups were well matched for baseline characteristics. Index stenting costs were

Prognostic implications of vascular complications following PCI

1846 higher per patient for DES versus BMS (

Transitioning to the radial artery as the preferred access site for cardiac catheterization: An academic medical center experience

1737 more to

Effect of Length and Diameter of Drug-Eluting Stents Versus Bare-Metal Stents on Late Outcomes

1950 more). At 3 years, absolute TVR rates were 15.2 per 100 DES patients and 24.1 per 100 BMS patients, and as a result, cumulative TVR-related costs were