Non-surgical management of iatrogenic arterial pseudoaneurysms-ultrasound-guided manual compression, an Indian experience.

OBJECTIVE: To evaluate the efficacy of ultrasound-guided manual compression of arterial pseudoaneurysms formed as a result of various procedures. METHODS: Ultrasound-guided manual compression was performed in 444 patients with ultrasound-diagnosed pseudoaneurysm. These patients were evaluated for number of locules in pseudoaneurysm, size of pseudoaneurysm, total time of compression, number of sittings, success/failure of the procedure, and possible complications. RESULTS: Out of 444 patients, 231 (52%) were on post-coronary angiography (3 via brachial route and rest via femoral route), 212 (47.7%) had post-coronary angioplasty and 1 (0.22%) was post-nailing of fracture of right tibia (pseudoaneurysm of right anterior tibial artery). Out of 444 patients, 132 (29.7%) had hypertension, 45 (10.1%) had diabetes mellitus, 117 (26.3%) had both hypertension and diabetes, and 90 (20.2%) were obese. 384 (86.5%) had unilocular, 51 (11.5%) had bilocular, 6 (1.3%) had trilocular and 3 (0.67%) had tetralocular pseudoaneurysm. Size of pseudoaneurysm varied between 0.8 cm and 8.1 cm (mean 3.3 cm). 342 (77%), 48 (10.8%), 54 (12.1%) required 1, 2 and 3 sittings, respectively for complete closure. The compression time was between 15 and 120 minutes (mean 40 minutes). Successful compression was achieved in 423 (95.3%). There were 21 (4.7%) failures, 12 out of which required surgical repair, 6 had spontaneous closure between 12 and 24 weeks and 3 were lost to follow up at 1 year. Out of 212 post-coronary intervention patients, 9 were on low molecular weight heparin (LMWH). In 7 of these 9 patients, LMWH was stopped 48 hours before compression and in remaining 2, compression was done during the course of LMWH therapy. The compression was successful in all 9 patients. Only 2 patients had a transient vasovagal attack. CONCLUSIONS: USG manual compression is safe, inexpensive, reliable and effective outpatient procedure for non-surgical management of arterial pseudoaneurysm.

Coronary calcium and coronary artery disease: an Indian perspective.

BACKGROUND: Coronary artery calcification is a part of the development of atherosclerosis. It occurs exclusively in atherosclerotic arteries and can be used as a noninvasive marker of coronary atherosclerosis. As there is no large-scale study on coronary calcium score reported in the Indian population till date, this study was undertaken for calculating the score in Indians at intermediate-to-high risk of coronary artery disease, and to correlate it with angiographically proven coronary artery disease. METHODS AND RESULTS: A total of 388 consecutive patients who underwent coronary calcium scoring and coronary angiography were included in the study. Calcium scoring was performed based on a modification of the Agatston Score using a high-speed computed tomography scanner (GE CT/i scanner). Coronary calcium scores were correlated with the presence or absence of significant coronary artery disease (defined as > or = 70% stenosis of at least one major epicardial coronary artery) on angiography. Out of 388 patients who underwent coronary angiography, 298 were found to have significant coronary artery disease. Mean coronary calcium score was significantly higher in patients with angiographically proven coronary artery disease (226.7+/-65.2) as compared to those who had normal angiograms (20.29+/-56.7; p value<0.0001). All the 72 patients who had a score > 400 had an abnormal angiogram (sensitivity 23.1%, specificity 100%, positive predictive value 100%, and negative predictive value 24.1%). On the other hand, among the patients who had a score > 0, 298 were found to have abnormal angiograms, while 16 had normal angiograms (sensitivity 95.5%, specificity 78.9%, positive predictive value 94.9%, and negative predictive value 81.1%). CONCLUSIONS: Detection of coronary calcium score by a helical computed tomography scanner is a useful tool for predicting the presence of significant coronary artery disease in intermediate-to-high risk patients. An absolute score of 0 has a high negative predictive value for the presence of coronary artery disease, and may obviate the need to perform coronary angiogram in intermediate-risk patients. On the other extreme, score > 400 is highly predictive of the presence of coronary artery disease, and virtually confirms the presence of significant coronary artery disease in intermediate-to-high risk patients.

Minimally invasive mitral valve surgery.

BACKGROUND: To reduce surgical trauma and the drawbacks associated with sternotomy, we performed robotically controlled, video-assisted mitral valve surgery, using either the port-access or the transthoracic clamp technique. METHODS AND RESULTS: Between September 1997 and September 2000, 221 patients (78 males, 143 females) underwent mitral valve surgery through a small right minithoracotomy using the port-access endovascular cardiopulmonary bypass system. Mitral valve exposure was facilitated with an endoscope attached to a voice-controlled robotic arm (AESOP 3000) allowing stabilization and voice-activated camera positioning. Twenty-six patients underwent mitral valve repair and 195 had valve replacement. In 197 patients, mitral valve surgery was the primary operation, while 24 were redo cases. Skin-to-skin mean operating time was 3.5 +/- 1.2 hours and aortic cross-clamp time was 58 +/- 16 min, mean intensive care unit stay was 22 +/- 7 hours and hospital stay 6.4 +/- 1.2 days. There was no re-exploration for bleeding. There was no late death or re-operation on mean follow-up of 16.4 +/- 12.2 months. Patients showed improvement in their NYHA functional class from 2.6 +/- 0.5 to 1.4 +/- 0.8 postoperatively. Outcomes were compared with those of our previous 220 patients who underwent mitral valve surgery with the median sternotomy approach. CONCLUSIONS: The use of video and robotic assistance in port-access mitral valve surgery not only minimizes the length of the incision, but also gives full visualization of the entire mitral valve apparatus. This approach provides comparable results with the sternotomy approach, as well as marked advantages of reduced intensive care unit stay. ,ower blood transfusion requirement, better cosmesis and earlier hospital discharge.