Vladimir Lakhter

Impact of Institutional Volume on Outcomes of Catheter Directed Thrombolysis in the Treatment of Acute Proximal Deep Vein Thrombosis A 6-Year US Experience (2005–2010)

Background— The use of catheter-directed thrombolysis (CDT) in the treatment of acute proximal lower-extremity deep vein thrombosis is increasing in the United States and has been linked to higher bleeding rates. Whether this relationship is interrelated with institution volume of CDT is unknown. Methods and Results— The Nationwide Inpatient Sample database was used to identify all patients admitted with a principal diagnosis of proximal or inferior vena caval deep vein thrombosis and treated with CDT from 2005 to 2010. Institutions were divided into high-volume (≥6 procedures a year) and low-volume (<6 procedures a year) centers. Propensity score matching was used to create 2 matched groups for comparative analysis. A total of 90 618 patients were hospitalized for proximal lower-extremity deep vein thrombosis, and 3649 patients (4.1%) underwent CDT. In-hospital mortality was significantly lower at high-volume centers (0.6% versus 1.5%; P=0.04) with a trend toward lower intracranial hemorrhage rates compared with low-volume centers (0.4% versus 1%; P=0.07). No significant difference was seen with blood transfusion (10.4% versus 10.8%; P=0.70), gastrointestinal bleeding (1.4% versus 1.8%; P=0.35), or pulmonary embolism rates (18.4% versus 17.9%; P=0.72). Median length of stay was similar (6 days) and hospital charges were higher (

Intermediate term hemodynamic effects of single inferior vena cava valve implant for the treatment of severe tricuspid regurgitation: IVC Valve Implant In Tricuspid Regurgitation

65 500 versus

Multimodality imaging in the diagnosis and management of cardiac sarcoidosis

75 870) at high-volume centers. Conclusions— In this observational study, we found that an increase in institutional volume of CDT was associated with lower in-hospital mortality and lower intracranial hemorrhage rates. Further studies are needed to assess whether standardization of CDT protocols across all institutions in the United States improves outcomes.

Under-pressure: Right Ventricular Infarction

Severe tricuspid regurgitation (TR) remains a vastly undertreated disease, with sustained elevation of right atrial (RA) pressure directly resulting in chronic end‐organ damage. Recently, bi‐caval valve implantation has been shown to improve symptoms in patients with symptomatic TR who are at high risk for surgery. We present the first report of intermediate term hemodynamic effects of single inferior vena cava (IVC) valve implantation (CAVI) for treatment of severe TR. We performed CAVI on a 66‐year‐old female with severe TR, who suffered from repeat hospitalizations for treatment refractory NYHA class III–IV heart failure symptoms and had prohibitive operative risk. Pre‐implantation right heart catheterization (RHC) revealed a mean RA pressure of 12 mm Hg, an IVC mean pressure of 13 mm Hg, with V‐waves to 16 and 18 mm Hg in the RA and IVC respectively, and a cardiac output (CO) of 3.5 liters per minute (LPM). Postprocedure, mean IVC and RA pressures decreased to 11 and 10 mm Hg, respectively, with CO increasing to 5.1 LPM. At one month, symptoms improved to NYHA class II. At 9 months, mean RA pressure was 5 mm Hg with V‐waves to 7 mm Hg and an improvement in CO to 6.3 LPM. CAVI appears to result in similar decreases in RA pressure at intermediate follow‐up as compared to bi‐caval valve implantation. The favorable hemodynamic effects were likely mediated by redirection of regurgitant blood flow away from the IVC thereby resulting in sustained reduction in right‐sided pressures as well as an increase in CO.

Therapeutic Options for In-Stent Restenosis

Sarcoidosis is a multisystem disorder that is characterized histologically by non-caseating, non-necrotic granulomas. Although it most commonly manifests in the lungs or with lymphadenopathy, it can affect any organ. Cardiac Sarcoidosis (CS) occurs with an incidence of 5%-39% depending on detection method, and has a wide range of clinical manifestations, from no symptoms to sudden cardiac death. CS is considered to be the second leading cause of death by sarcoidosis in the United States, making diagnosis and monitoring the progression of disease of utmost importance. Guidelines of the Japanese Ministry of Health and Welfare (JMHWG) from 2006 have gained wide acceptance as a reference standard for diagnosing CS. They outline diagnostic criteria that include histologic confirmation of CS by myocardial biopsy or clinical confirmation based on a combination of major and minor criteria, which include Gallium-67 uptake as a major criteria. Gallium-67 has since been shown to be inferior in its sensitivity and diagnostic accuracy for CS as compared to Fluorine-18-fluorodeoxyglucose Positron Emission Tomography (FDG-PET), which is not mentioned in the criteria. Additionally, diagnosing CS via myocardial biopsy is unreliable due to the characteristic skip lesions of CS and sampling error. Multiple studies have evaluated the use of FDGPET and Cardiac Magnetic Resonance (CMR) in diagnosing CS and predicting adverse outcomes. However, a diagnostic gold standard has yet to be identified. Given the multimodality imaging landscape, it is important to understand the underlying imaging concepts and capabilities of each modality.

Sex differences in utilization and outcomes of catheter-directed thrombolysis in patients with proximal lower extremity deep venous thrombosis – Insights from the Nationwide Inpatient Sample:

PRESENTATION When a 60-year-old woman’s electrocardiogram (ECG) indicated both anterior and inferior ST-segment elevation myocardial infarction, it was unclear which artery was blocked until treatment with nitroglycerin and morphine rendered her hypotensive. The patient, who had a history of type 2 diabetes mellitus and hypertension, arrived at the emergency department 30 minutes after acute onset of diaphoresis and shortness of breath. The ECG (Figure 1) showed atrial fibrillation, ST-segment elevations in the inferior leads, and reciprocal ST depressions in leads I and aVL. Marked ST-segment elevations were also visible in the anterior leads, V3 and V4. She had a heart rate of 119 beats per minute and a blood pressure of 116/56 mmHg. On physical examination, the patient was in mild distress and diaphoretic. Her cardiovascular examination was significant for tachycardia with an irregularly irregular heartbeat. She was treated immediately with aspirin, clopidogrel, and heparin. A few minutes later, she was given sublingual nitroglycerin and a bolus dose of intravenous morphine. Shortly after receiving the nitroglycerin and morphine, her blood pressure dropped to 72/49 mmHg. She was hydrated aggressively and taken to the cardiac catheterization laboratory for coronary angiography.

Case of Percutaneous Extracorporeal Femoro-Femoral Bypass for Acute Limb Ischemia From Large Bore Access

Purpose of ReviewIn-stent restenosis (ISR) is a complex disease process that became apparent shortly after the introduction of stents into clinical practice. This review seeks to define in-stent restenosis (ISR) as well as to summarize the major treatment options that have been developed and studied over the past two decades.Recent FindingsRecent developments in drug-coated balloons and bioresorbable vascular scaffolds have added new potential treatments for ISR. Two recent network meta-analyses performed a head-to-head comparison of all the various treatment modalities in order to identify the best approach to management of ISR.SummaryCurrent data suggests that repeat stenting with second-generation drug-eluting stents is most likely to lead to the best angiographic and clinical outcomes. In situations where repeat stenting is not preferable, drug-coated balloon therapy seems to be a reasonably effective alternative.

Current Status and Outcomes of Iliac Artery Endovascular Intervention

Catheter-directed thrombolysis (CDT) is being increasingly used for the treatment of proximal lower extremity (LE) deep venous thrombosis (DVT). However, sex differences in utilization and safety outcomes of CDT in these patients are unknown. The Nationwide Inpatient Sample (NIS) database was used to identify all patients with a principal discharge diagnosis of proximal LE or caval DVT who underwent CDT between January 2005 and December 2011 in the United States. We evaluated the comparative safety outcomes of CDT among a propensity-matched group of 1731 men versus 1731 women. Among 108,243 patients with proximal LE or caval DVT, 4826 patients (4.5%) underwent CDT. Overall, women underwent CDT less often compared to men (4.1% vs 4.9%, p<0.01, respectively). The rates of CDT increased between 2005 and 2011 for both women (2.1% to 5.9%, p<0.01) and men (2.5% to 7.5%, p<0.01). There was no significant difference in in-hospital mortality (1.2% vs 1.3%, p=0.76). Women were noted to have higher rates of blood transfusions (11.7% vs 8.8%, p<0.01), but lower rates of intracranial hemorrhage (0.5% vs 1.2%, p=0.03) and gastrointestinal bleeding (0.9% vs 2.2%, p<0.01) compared with men. Women were more likely to undergo inferior vena cava filter placement (37.0% vs 32.1%, p<0.01). In this large nationwide cohort, women with proximal DVT were less likely to receive CDT compared to men. Although mortality rates were similar, women were noted to have higher blood transfusion rates while men had more episodes of intracranial and gastrointestinal bleeding.

SEX DIFFERENCES IN THE USE OF INFERIOR VENA CAVA FILTERS IN PATIENTS WITH PROXIMAL LOWER EXTREMITY DEEP VEIN THROMBOSIS IN THE UNITED STATES

An 80-year-old man presented with acute inferior ST-segment elevation myocardial infarction and cardiogenic shock. Cardiac catheterization revealed 99% stenosis in the mid-right coronary artery, a 95% focal severe stenosis in mid-left anterior descending coronary artery and a 60% to 70% stenosis in

NATIONWIDE CONTEMPORARY TRENDS IN ADJUNCTIVE ANGIOPLASTY AND STENTING AT THE TIME OF CATHETER DIRECTED THROMBOLYSIS IN PATIENTS WITH PROXIMAL LOWER EXTREMITY DEEP VEIN THROMBOSIS

Aortoiliac occlusive disease (AIOD) is widely prevalent and leads to significant limitations in patient quality of life. All patients with aortoiliac occlusive disease should be managed with approved medical therapies in addition to a supervised exercise program. Persistence of significant symptoms despite noninvasive therapy should prompt further management with endovascular revascularization. Although patients with the most complex cases of AIOD anatomy may ultimately require surgery, advances in endovascular techniques have made it possible to treat most of these patients with AIOD using an endovascular-first approach.