Institutional Variability in Patient Radiation Doses ≥5 Gy During Percutaneous Coronary Intervention.

OBJECTIVES: The aim of this study was to evaluate institutional variability in high radiation doses during percutaneous coronary intervention (PCI). BACKGROUND: It is unknown whether radiation safety practices are optimally applied across institutions performing PCI. METHODS: Using data from a large statewide registry, PCI discharges between July 1, 2016, and March 31, 2018, with a procedural air kerma (AK) recorded were analyzed. PCI procedures were grouped by the performing hospital, and institutional frequency of procedural AK ≥5 Gy was calculated. Fitted hierarchical Bayesian modeling was performed to identify variables independently associated with an AK ≥5 Gy. The performing hospital was included as a random effect in the hierarchical model. RESULTS: Among 36,201 PCI procedures at 28 hospitals, procedural AK was ≥5 Gy in 1,477 cases (4.1%), ≥10 Gy in 185 (0.5%), and ≥15 Gy in 105 (0.3%). The institutional frequency of procedural AK ≥5 Gy ranged from 0.0% to 10.9%. Bayesian modeling identified body mass index, dyslipidemia, diabetes, prior coronary bypass surgery, use of mechanical circulatory support, and the performing hospital as independent predictors of an AK ≥5 Gy. The median odds ratio for the performing hospital, representing an estimate of the contribution of interhospital variability in determining the odds of having a procedural AK ≥5 Gy, was 3.08 (95% confidence interval: 3.01 to 3.16). CONCLUSIONS: Wide variability exists in the institutional frequency of procedural AK ≥5 Gy during PCI. After accounting for patient characteristics and procedural variables, the performing hospital appears to be a major factor in determining patient radiation dose in contemporary PCI.

Acute Hand Ischemia and Digital Amputation After Transradial Coronary Intervention in a Patient With CREST Syndrome.

The radial artery approach for coronary angiography and intervention is rapidly replacing the femoral artery approach, largely because it reduces bleeding and vascular access site complications. However, complications associated with transradial access warrant attention, notably radial artery occlusion. This report focuses on a case of radial artery occlusion after percutaneous coronary intervention in a 46-year-old woman with CREST (calcinosis, Raynaud phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome, which ultimately led to acute hand ischemia necessitating amputation of her middle and index fingers.

Trends in major entry site complications from percutaneous coronary intervention (from the Dynamic Registry).

Several factors contribute to the risk of percutaneous coronary intervention-related major entry site (MES) complications. We sought to examine the trends in MES among unselected patients during the stent era. Data from the Dynamic Registry including 5 distinct recruitment waves from 1997 to 2006 (n = 10,932) were used to assess baseline characteristics and MES among consecutive patients undergoing percutaneous coronary intervention. MES was defined as bleeding requiring transfusion, pseudoaneurysm, arterial thrombosis or dissection, vascular complication requiring surgery, or retroperitoneal bleed. Uncomplicated hematomas were not included. Several trends were observed in baseline characteristics including an increase from wave 1 to wave 5 in body mass index >30 kg/m(2) (30.2% to 40.4%), renal disease (3.5% to 9.1%), diabetes (28.0% to 34.1%), and hypertension (59.4% to 78%; ptrend <0.001 for all). The use of a thienopyridine increased significantly from wave 1 (49.7%) to wave 5 (84%), whereas glycoprotein IIb/IIIa inhibitor use peaked in wave 3 (53.1%) and then decreased (p <0.001). Access site was predominately femoral, but radial access increased over time (0.3% wave 1, 6.6% wave 5, p ≤0.0001). The rates of MES (2.8% to 2.2%, ptrend = 0.01) and MES requiring transfusion (2.0% to 0.74%, ptrend <0.001) were low and decreased with time. The trend in less risk for MES in later time periods remained after adjustment. In conclusion, MES has decreased over time; however, opportunity for bleeding avoidance strategies still exists.

The spectrum of aortic pathology in alport syndrome: a case report and review of the literature.

Alport syndrome is an inherited disorder of type IV collagen most commonly leading to glomerulonephritis and kidney failure. Various extrarenal manifestations have been reported, including a spectrum of aortic and aortic valve diseases. We report a case of a 34-year-old man with Alport syndrome presenting with chest pain. Work-up showed a dilated aortic root, bicuspid aortic valve, aortic insufficiency, and small ascending aortic dissection necessitating surgical repair. We provide a review of the literature describing aortic pathology in Alport syndrome and suggest that clinicians caring for patients with Alport syndrome have a high index of suspicion for such entities in patients presenting with symptoms of chest pain.

Direct stenting compared to balloon predilation in drug-eluting stents: one-year outcomes from the DEScover Registry.

OBJECTIVES: We sought to examine the determinants and outcomes of direct stenting (DS) compared to predilation with drug-eluting stents (DES). BACKGROUND: Limited data suggest that DS with DES is feasible and may reduce restenosis compared to predilation. Whether DS improves clinical outcomes in unselected patients treated with DES is unknown. METHODS: DEScover is a prospective, multicenter, observational study of percutaneous coronary intervention that enrolled patients in 2005. The analysis cohort included 4,210 patients who received a DES and had a single lesion treated with DS (n = 1,651) or predilation (n = 2,559) at the discretion of the operator. Multivariable analysis was performed for 1-year outcomes. RESULTS: DS was performed in 39.2% of patients. The direct stent patients were younger, less often male, and had a lesser extent of CAD. DS was performed less often in patients presenting with an acute myocardial infarction (MI) and more often in stable angina and elective procedures. Lesion characteristics differed with DS performed less often for calcified lesions, high-grade stenoses (>90%), and bifurcation lesions. Lesion postdilation was less common in direct stent patients (42.1% vs. 50.7%, P = 0.0001). Complete procedural success was similar (99.8% vs. predilation 99.7%, P = 0.46). At 1 year, there was no difference in the adjusted hazard ratios of death (0.67, 0.44-1.04, P = 0.08), MI (1.05, 0.66-1.67, P = 0.83), stent thrombosis (0.38, 0.13-1.14, P = 0.08), TLR (0.75, 0.48-1.17, P = 0.21), TVR (0.89, 0.64-1.23, P = 0.47), and major adverse coronary event (0.88, 0.71-1.09, P = 0.24). CONCLUSIONS: DS with DES is commonly performed in clinical practice and results in similar long-term outcomes as predilation.

Type A Aortic Dissection Presenting with Acute Lower Extremity Vascular Insufficiency in the Absence of Chest Pain.

We report a case of a 53 year-old man with a history of hypertension presenting with acute left lower extremity parasthesias and pulselessness initially presumed to be secondary to arterial thrombosis or embolism. Work-up included a transthoracic echocardiogram which revealed an aortic dissection at the level of the aortic root extending to the visualized portions of the descending aorta. Type A aortic dissections are relatively rare, with the vast majority of patients presenting with chest pain. Timely diagnosis of Type A aortic dissections are critical as to facilitate rapid surgical repair. To our knowledge, this is the first report of a painless Type A aortic dissection presenting with isolated lower extremity vascular insufficiency and demonstrates the potential role of transthoracic echocardiography as a rapid, non-invasive bedside modality in visualizing Type A aortic dissections.