Popliteal artery embolization with the Mynx closure device.

Several different arterial puncture closure devices are available for use after cardiovascular procedures. The main advantages include decrease need of manual compression, reduce patient discomfort, and the time to ambulation. Access site complications are not rare after vascular closure device use. We report a case of popliteal artery embolization after using an extravascular water soluble plug-mediated vascular puncture closure device.

Percutaneous revascularization of occluded renal arteries in the setting of acute renal failure.

We report the case of a 60-year-old patient with acute renal failure and occluded bilateral renal arteries presenting with acute pulmonary edema and non-ST segment elevation myocardial infarction. The patient required renal replacement therapy with hemodialysis and was subsequently successfully treated with bilateral renal artery stent placement. Marked improvement in renal function was noted within 1 week with freedom from the need for renal replacement therapy at 4 months of follow-up.

Percutaneous revascularization of persistent renal artery in-stent restenosis.

Percutaneous renal artery stenting is a common means of treating atherosclerotic renal artery stenosis. However, renal artery restenosis remains a frequent problem. The optimal treatment of restenosis has not been established and may involve percutaneous renal artery angioplasty or deployment of a second stent. Other modalities include cutting balloon angioplasty, repeat stenting with drug-eluting stents or endovascular brachytherapy. Most recently, use of polytetrafluoroethylene (PTFE)-covered stents may offer a new and innovative way to treat recurrent renal artery stenosis. We describe a case in a patient who initially presented with renal insufficiency and multi-drug hypertension in the setting of severe bilateral renal artery stenosis. Her renal artery stenosis was initially successfully treated by percutaneous deployment of bilateral bare metal renal artery stents. After initial improvement of her hypertension and renal insufficiency, both parameters declined and follow-up duplex evaluation confirmed renal artery in-stent restenosis. Owing to other medical co-morbidities she was felt to be a poor surgical candidate and was subsequently treated first with bilateral cutting balloon angioplasty and second with drug-eluting stent deployment. Each procedure was associated with initial improvement of renal function and blood pressure control, which then later deteriorated with the development of further significant in-stent restenosis. It was then decided to treat the restenosis using PTFE-covered stents. At 12 months of follow-up, the blood pressure had remained stable and renal function had normalized. The covered stents remained free of any significant neointimal tissue or obstruction.

Angiographic adverse events during percutaneous coronary intervention fail to predict creatine kinase-MB elevation.

We attempted to determine if aggressive detection of angiographic adverse events during coronary intervention could predict subsequent creatine kinase (CK)-MB elevations. During coronary intervention, both fluoroscopy and cine angiography were used to detect angiographic adverse events. At least one angiographic adverse event occurred in 133/251 (53%) of procedures. CK-MB elevation occurred in 24% of procedures. Slow flow during the procedure (P=0.002) and chest discomfort at the end of the procedure (P=0.007) were the strongest predictors of CK-MB elevation. Among procedures with no angiographic adverse events, CK-MB elevation occurred in 15/121 (12%), accounting for 25% of CK-MB elevations. We conclude that CK-MB elevation occurs after angiographically uncomplicated coronary interventions even when angiographic adverse events are aggressively detected. Routine monitoring of cardiac enzymes is necessary to detect all patients who will experience myocardial injury after coronary intervention.

Angiographic and long-term outcomes of "rescue" stenting versus PTCA in failed thrombolysis in acute myocardial infarction.

Percutaneous transluminal coronary angioplasty (PTCA), when performed early after clinically failed thrombolysis, improves acute infarct-artery patency in up to 90% of cases. Limited data are available regarding the role of rescue stenting in this setting. From January 1995 to December 1999, the authors studied all consecutive patients treated with rescue PTCA or rescue stenting within 12 hours of onset of chest pain and clinically failed thrombolytic therapy at their institution. Baseline demographic characteristics, infarct-related artery location, lesion class, left ventricular function, and incidence of multivessel disease were similar between groups (23 patients in each group). Preprocedural TIMI flow 0 was more common in PTCA patients (p=0.025). Quantitative coronary analysis revealed similar incidence of calcification, thrombus burden, minimal lumen diameter (MLD), and lesion length between groups. Post-procedural TIMI 3 flow was more common in stent patients; however, this was not statistically significant (p=0.18). Greater final MLD (p<0.001), less residual stenosis (p<0.001), and a trend toward larger reference vessel diameter (p=0.13) were observed in favor of stent patients. At 6-month follow-up, there was no difference in the incidence of death, myocardial infarction, or readmission for unstable angina between groups. More stent patients (60% vs 27%, p=0.06) were angina free as compared to PTCA patients. Despite similar in-hospital clinical outcomes, the study suggests better angiographic results and 6-month orbidity with rescue stenting.

Effect of abciximab on angiographic complications during percutaneous coronary stenting in the Evaluation of Platelet IIb/IIIa Inhibition in Stenting Trial (EPISTENT).

In the Evaluation of Platelet IIb/IIIa Inhibition in Stenting Trial (EPISTENT), abciximab reduced ischemic complications of stent implantation at 30 days and 6 months. The responsible mechanisms remain unclear. We sought to determine if abciximab decreases ischemic complications by decreasing the incidence of angiographic complications during coronary stenting. In EPISTENT, patients were randomized to stenting with abciximab (abciximab group), stenting with placebo (placebo group), or balloon angioplasty with abciximab. Angiographic complications (including major or minor dissection, distal embolization, thrombus postprocedure, side branch or other vessel occlusion, residual stenosis >50%, transient coronary occlusion, and Thrombolysis In Myocardial Infarction final flow <3) were recorded prospectively. Creatine kinase (CK)-MB enzyme levels after intervention were measured at 6-hour intervals. We analyzed angiographic complications and CK-MB elevations in the abciximab group (n = 784) and the placebo group (n = 803). Angiographic complications were 29% less frequent in the abciximab group compared with the placebo group (17.0% vs 23.8%; p = 0.001). In patients with angiographic complications, there was a nonsignificant reduction in the incidence of CK-MB elevation >3 times normal with abciximab therapy (19.7% vs 24.5% in placebo group; p = 0.314). Abciximab (compared with placebo) significantly reduced the incidence of CK-MB elevation >3 times normal in those without any angiographic complications (6.5% vs 10.7%; p = 0.007). In summary, abciximab (compared with placebo) significantly reduced angiographic complications during coronary stenting. Abciximab also prevented CK-MB elevations in patients without angiographic complications.