Catheter-based techniques for closure of coronary fistulae.

This study details different methodologies of percutaneous closure of arteriosystemic and arteriovenous coronary fistula. Seven patients underwent transcatheter intervention of 10 fistulas, with 7 fistulas successfully closed: 6 with embolic coil devices and 1 with a covered stent obstructing the fistula ostium. The major complication encountered was one death as a result of device recoil into a major epicardial vessel. Percutaneous transcatheter closure of coronary fistulas appears to be simple, facile, and effective. However, device recoil into an undesired arterial segment, while irritating in a noncoronary arterial tree, may be catastrophic when occurring in an epicardial coronary artery.

In vivo crushing of an aortic stent enables endovascular repair of a large infrarenal aortic pseudoaneurysm.

PURPOSE: To report an unusual approach to endovascular exclusion of a large aortic pseudoaneurysm. METHODS AND RESULTS: A 63-year-old male had an unsuccessful endovascular repair of an aortic anastomotic pseudoaneurysm that left an expanded, uncovered Palmaz stent lying obliquely within the aorta. After nearly 3 years, the pseudoaneurysm enlarged to 7 cm, and the patient became symptomatic. Repair of the pseudoaneurysm was accomplished by crushing the indwelling stent to allow placement of a stent-graft. CONCLUSIONS: Malpositioned stents that are hindering an endoluminal procedure may be crushed against the arterial wall in vivo to facilitate passage of endovascular instruments or devices.

The prognostic impact of immunosuppression and cellular rejection on cardiac allograft vasculopathy: time for a reappraisal.

BACKGROUND: Our current immunosuppressive strategies have made little impact on the development of cardiac allograft vasculopathy, the leading cause of long-term allograft loss. This study sought to evaluate the relationship of cellular rejection and immunosuppressive therapy with the development of morbid events resulting from cardiac allograft vasculopathy. METHODS: The study population consisted of 163 consecutive patients who received heart transplants between January 1990 and May 1994. Data regarding nonimmunologic risk factors (lipids, obesity indexes, hypertension, donor age and sex, cytomegalovirus infection, diabetes mellitus, time after transplantation, and cold ischemic time), immunologic factors (histocompatibility, episodes of treated rejection, and average first-year biopsy rejection score), and immunosuppressive regimens (cumulative prednisone dose, average daily prednisone dose, mean cyclosporine level, average cyclosporine daily dose, cumulative azathioprine dose, and average daily azathioprine dose) were collected and analyzed in all patients. The diagnosis of cardiac allograft vasculopathy was established in all patients by a combination of necropsy, angiography, and intravascular ultrasound examination of the allograft vasculature. Cardiac events were defined as sudden death, myocardial infarction, and need for revascularization. RESULTS: Of all variables assembled, stepwise logistic regression recognized cumulative prednisone dose > 15 gm (relative risk [RR] 5.7; p = 0.01), donor age > 35 years (RR 3.73; p < 0.05), and average biopsy rejection score > 1 (RR 2.77; p < 0.05) as independent adverse predictors of cardiac events. In distinction, average daily cyclosporine dose > 4.5 mg/kg/day was found to confer a protective effect (RR 0.16; p = 0.03). CONCLUSIONS: The development of cardiac events as a result of cardiac allograft vasculopathy is influenced by the interdependence of allograft rejection and the balance of immunosuppression. The clinical implications of these findings point to the need for a reappraisal of our traditional approach to using corticosteroids (acute and maintenance) and cyclosporine (maintenance) in heart transplantation.

Heterogeneity of cardiac allograft vasculopathy: clinical insights from coronary angioscopy.

OBJECTIVES: With this study, we sought to examine the heterogeneity of cardiac allograft vasculopathy in vivo using coronary angioscopy as an adjunct to intravascular ultrasound, and we evaluated the clinical relations of immunologic and nonimmunologic risk factors with the different forms of cardiac allograft vasculopathy detected angioscopically. BACKGROUND: Intravascular ultrasound detects vascular intimal proliferation accurately but is limited in its ability to delineate morphologic characteristics. Coronary angioscopy can evaluate intimal surface morphology by direct visualization and can differentiate pathologically distinct forms of plaque topography on the basis of color and contour. METHODS: We studied 107 consecutive heart transplant recipients with intravascular ultrasound and angioscopy at the time of their annual angiogram, and we assessed the relation of nonimmunologic and immunologic risk factors to the development of cardiac allograft vasculopathy distinguished angioscopically into a pigmented (yellow) or nonpigmented (white) intimal thickening. We further evaluated the clinical differences in cardiac events among these two forms of angioscopically heterogeneous forms of cardiac allograft vasculopathy. RESULTS: Significant clinical predictors of nonpigmented intimal thickening were advanced donor age and lower mean cyclosporine levels, whereas hyperlipidemia, cumulative prednisone dose and time since transplantation correlated with pigmented intimal hyperplasia. In addition, comparisons between the two angioscopic groups revealed increased intimal thickening, serum cholesterol, low density lipoprotein cholesterol, acute allograft rejection and time since transplantation in the group with pigmented intimal thickening (p < 0.05). With regard to cardiac events, nonpigmented plaque was more frequently found in the sudden death group (53% vs. 20%, p = 0.05), whereas the nonsudden cardiac event group had a significantly higher prevalence of pigmented plaque (80% vs. 47%, p = 0.07). CONCLUSIONS: These findings indicate that cardiac allograft vasculopathy is a heterogeneous disease with varied morphologic expressions with different clinical implications. Furthermore, this investigation provides insight into the cohesive, yet diverse influences of various factors, particularly immunosuppression, in these forms of cardiac allograft vasculopathy.

Vibrio vulnificus sepsis in solid organ transplantation: a medical nemesis.

We report two cases of Vibrio vulnificus wound infection leading to fulminant sepsis syndrome in immunocompromised solid organ transplant recipients. Features of clinical presentation in each of these cases suggest that host immune factors are of great importance in the virulence of this organism and that immunocompromised recipients of solid organ transplants are particularly vulnerable to life-threatening consequences from infection with Vibrio vulnificus. Prompt institution of antibiotic therapy and early consideration for surgical wound debridement are the mainstay of successful management. Heart and other organ transplant recipients should be educated and warned about the hazards associated with raw oysters and shellfish consumption and asked to exercise caution when exposed to a salt water environment.