Riyaz Bashir

Renal fractional flow reserve: A hemodynamic evaluation of moderate renal artery stenoses

The objective of this study was to perform a hemodynamic evaluation of moderate (50–90%) renal artery stenosis (RAS) under conditions of rest and maximum hyperemia. Identifying patients with RAS who have hemodynamically significant stenoses and are most likely to benefit from revascularization is clinically important. Current methods used to evaluate RAS, including angiography, have limitations. Physiologic evaluation of RAS may have a role in identifying patients with hemodynamically significant stenosis. Patients with suspected renovascular hypertension due to aorto‐ostial RAS were included in the study. Hyperemia was induced by administration of intrarenal papavarine. Translesional pressure gradients were measured and renal fractional flow reserve (FFR) was calculated using a 0.014″ pressure guidewire. Thirteen patients and 14 arteries with moderately severe (50–90%) RAS were studied. The mean translesional pressure gradient rose from a baseline of 6.3 ± 3.9 to 17.5 ± 10.8 mm Hg with maximal hyperemia. The renal FFR ranged from 0.58 to 0.95. There was a poor correlation between angiographic stenosis measurement and the renal FFR (r = −0.18; P = 0.54) and the hyperemic translesional mean pressure gradient (r = 0.22; P = 0.44). There was an excellent correlation between renal FFR and the resting mean translesional pressure gradient (r = −0.76; P = 0.0016) and the hyperemic mean translesional pressure gradient (r = −0.94; P < 0.0001). Selective renal arterial papavarine administration induces maximum hyperemia, permitting the calculation of renal FFR in renal arteries with aorto‐ostial stenoses. The renal FFR correlates well with other hemodynamic parameters of lesion severity, but poorly with angiographic measures of lesion severity. Catheter Cardiovasc Interv 2005;64:480–486.

Comparative Outcomes of Catheter-Directed Thrombolysis Plus Anticoagulation vs Anticoagulation Alone to Treat Lower-Extremity Proximal Deep Vein Thrombosis

IMPORTANCE The role of catheter-directed thrombolysis (CDT) in the treatment of acute proximal deep vein thrombosis (DVT) is controversial, and the nationwide safety outcomes are unknown. OBJECTIVES The primary objective was to compare in-hospital outcomes of CDT plus anticoagulation with those of anticoagulation alone. The secondary objective was to evaluate the temporal trends in the utilization and outcomes of CDT in the treatment of proximal DVT. DESIGN, SETTING, AND PARTICIPANTS Observational study of patients with a principal discharge diagnosis of proximal or caval DVT from 2005 to 2010 in the Nationwide Inpatient Sample (NIS) database. We compared patients treated with CDT plus anticoagulation with the patients treated with anticoagulation alone. We used propensity scores to construct 2 matched groups of 3594 patients in each group for comparative outcomes analysis. MAIN OUTCOMES AND MEASURES The primary study outcome was in-hospital mortality. The secondary outcomes included bleeding complications, length of stay, and hospital charges. RESULTS Among a total of 90,618 patients hospitalized for DVT (national estimate of 449,200 hospitalizations), 3649 (4.1%) underwent CDT. The CDT utilization rates increased from 2.3% in 2005 to 5.9% in 2010. Based on the propensity-matched comparison, the in-hospital mortality was not significantly different between the CDT and the anticoagulation groups (1.2% vs 0.9%) (OR, 1.40 [95% CI, 0.88-2.25]) (P = .15). The rates of blood transfusion (11.1% vs 6.5%) (OR, 1.85 [95% CI, 1.57-2.20]) (P < .001), pulmonary embolism (17.9% vs 11.4%) (OR, 1.69 [95% CI, 1.49-1.94]) (P < .001), intracranial hemorrhage (0.9% vs 0.3%) (OR, 2.72 [95% CI, 1.40-5.30]) (P = .03), and vena cava filter placement (34.8% vs 15.6%) (OR, 2.89 [95% CI, 2.58-3.23]) (P < .001) were significantly higher in the CDT group. The CDT group had longer mean (SD) length of stay (7.2 [5.8] vs 5.0 [4.7] days) (OR, 2.27 [95% CI, 1.49-1.94]) (P < .001) and higher hospital charges (

Endovascular therapy for acute ischaemic stroke: a systematic review and meta-analysis of randomized trials

85,094 [

Inferior Vena Cava Thrombosis.

69,121] vs

Trends, predictors, and outcomes of cerebrovascular events related to percutaneous coronary intervention: A 16-year single-center experience

28,164 [

Inferior vena cava filters in the United States: Less is more

42,067]) (P < .001) compared with the anticoagulation group. CONCLUSIONS AND RELEVANCE In this study, we did not find any difference in the mortality between the CDT and the anticoagulation groups, but evidence of higher adverse events was noted in the CDT group. In the context of this observational data and continued improvements in technology, a randomized trial with outcomes such as mortality and postthrombotic syndrome is needed to definitively address this comparative effectiveness.

Effect of compression stockings on post thrombotic syndrome in patients with deep vein thrombosis: a meta-analysis of randomised controlled trials

AIMS Evidence from randomized controlled trials (RCTs) evaluating possible benefits of endovascular therapy (EVT) for acute ischaemic stroke has shown conflicting results. The purpose of this meta-analysis was to systematically examine clinical outcomes in RCTs comparing the use of intravenous (IV) fibrinolysis alone to IV fibrinolysis plus EVT, for the treatment of acute ischaemic stroke. METHODS AND RESULTS We selected English language RCTs, comparing EVT plus IV tissue-type plasminogen activator (tPA) (if eligible) with IV tPA alone in eligible patients for the treatment of acute ischaemic stroke. The primary endpoint was good functional outcome [modified Rankin Scale (mRS) of 0-2]. Other major endpoints of interest were all-cause mortality and symptomatic intracerebral haemorrhage (sICH). The meta-analysis included 8 RCTs that randomized 2423 patients with large-vessel, anterior-circulation stroke. EVT significantly improved the rate of functional independence (90-day mRS of 0-2) when compared with IV fibrinolysis [odds ratio (OR) 1.73, 95% confidence interval (CI) 1.18-2.53, number needed to treat (NNT) = 9.3]. The all-cause mortality was lower with EVT compared with the control group; however, the result did not reach statistical significance (OR 0.89, 95% CI 0.68-1.15). The rate of sICH was not higher with EVT (OR 1.07, 95% CI 0.73-1.56). Analyses from only the recent trials (reported in 2014-15) showed further benefit (OR of mRS 0-2: 2.42, 95% CI 1.91-3.08, NNT = 5) with similar safety results. CONCLUSION In centres with advanced systems of stroke care, EVT significantly improved functional outcomes (without compromising safety) in patients with acute ischaemic stroke due to anterior circulation, large artery occlusion, compared with standard therapy.

Study design and rationale of the heterotopic implantation of the Edwards-Sapien XT transcatheter valve in the inferior VEna cava for the treatment of severe tricuspid regurgitation (HOVER) trial.

Thrombosis of the inferior vena cava (IVC) is an under-recognized entity that is associated with significant short- and long-term morbidity and mortality. In absence of a congenital anomaly, the most common cause of IVC thrombosis is the presence of an unretrieved IVC filter. Due to the substantial increase in the number of IVC filters placed in the United States and the very low filter retrieval rates, clinicians are faced with a very large population of patients at risk for developing IVC thrombosis. Nevertheless, there is a paucity of data and societal guidelines with regards to the diagnosis and management of IVC thrombosis. This paper aims to enhance the awareness of this uncommon, but morbid, condition by providing a concise, yet comprehensive, review of the etiology, diagnostic approaches, and treatment strategies in patients with IVC thrombosis.

Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score

OBJECTIVES We sought to determine trends, predictors, in-hospital and long-term outcomes of cerebrovascular events (CVE) related to percutaneous coronary intervention (PCI) over a 16-year period. BACKGROUND Despite a temporal increase in patient risk profile and procedural complexity, rates of PCI-related mortality and myocardial infarction have decreased. Temporal trends, characterization, and outcomes after PCI-related CVE in the contemporary era remain unknown. METHODS We performed a retrospective study of 24,126 PCI hospitalizations in 19,165 unique patients, between January 1, 1994, and December 31, 2009, and compared those who suffered an in-hospital PCI-CVE with the remaining control population who did not. RESULTS The incidence of CVE was 0.37% (n = 89), of which 22% were transient ischemic attacks. Temporal analysis showed no significant trend in incidence over 16 years (p = 0.47). Multiple clinical and angiographic predictors of PCI-CVE were identified. Multivariate logistic regression analyses revealed age, female sex, myocardial infarction within 7 days before PCI, and history of prior CVE as independent predictors of PCI-CVE, with a 19-fold increase in incidence in patients over 80 with a prior CVE history. In-hospital mortality was 19% after PCI-CVE versus 2% in controls (p < 0.001). Those who survived PCI-CVE exhibited a markedly higher risk of mortality over the subsequent 10 years (p < 0.001). CONCLUSIONS The incidence of PCI-related CVE has remained steady over a 16-year period, despite an increase in the baseline risk profile. Age and prior history of CVE were the strongest independent demographic predictors. PCI-CVE had a markedly adverse impact on early and late outcomes.

Comparative Outcomes of Catheter-Directed Thrombolysis Plus Anticoagulation Versus Anticoagulation Alone in the Treatment of Inferior Vena Caval Thrombosis

Despite the widespread use of Inferior vena cava (IVC) filters, there is no quality evidence to demonstrate their efficacy for routine use, nor there is a consensus on their appropriate indications among major medical societies. The introduction of retrievable filters led to further increase in the utilization of these devices. However, several studies have shown that retrievable filters are rarely retrieved. The implant rates of IVC filters are many folds higher in the United States than in Europe, yet the retrieval rates are much lower. The U.S. Food and Drug Administration has recently issued a safety alert advocating for consideration of filter retrieval when the protection offered by the filter is no longer needed. The controversies surrounding IVC filter placement and retrieval, however, will likely to continue in the absence of good evidence on their efficacy and side effects. Time has come for initiatives to conduct well designed trials based on agreed-upon criteria to settle this debate.