Characteristics and outcomes of surgically ineligible patients with multivessel disease treated with percutaneous coronary intervention.

OBJECTIVES: In this study we evaluated the clinical characteristics and outcomes of surgically ineligible patients with coronary artery disease (CAD) who underwent multivessel percutaneous coronary intervention (PCI). BACKGROUND: Patients with multivessel CAD who are surgically ineligible and undergo PCI are not well represented in large trials. METHODS: Out of 1,061 consecutive patients who underwent a non-emergent PCI for unprotected left main or multivessel CAD at the University of Virginia Medical Center, 137 patients were determined to be surgically ineligible for coronary artery bypass graft (CABG) surgery by a heart team. The clinical characteristics and reasons for surgical ineligibility were collected. The coronary angiograms were reviewed and the SYNTAX score calculated. The Society of Thoracic Surgeons (STS) score was calculated. Outcomes were determined at 30 days and 1-year. RESULTS: The mean age of the cohort was 71 and 59% were women. Hypertension, hyperlipidemia, tobacco abuse, and diabetes were common comorbidities. The average SYNTAX score was 22. The most commonly cited reasons for surgical ineligibility were advanced age, frailty, severe lung disease, ejection fraction ≤ 30% and STS score ≥ 8%. Outcomes at 30 days were excellent and better than those predicted by STS for surgery. Frailty and STS score predicted one-year outcomes. CONCLUSIONS: Patients undergoing PCI for multivessel disease who are surgically ineligible have multiple risk factors and comorbidities. Frailty, lung disease, poor left ventricular function, and high STS score represent common reasons for surgical ineligibility. Frailty and the STS score better predict one-year outcomes after PCI compared to the SYNTAX score.

Intentional removal of erroneously deployed coronary stents: A case series and review of the literature.

Most reports of stent retrieval involve undeployed, embolized stents. While the retrieval of fully deployed stents has been sporadically reported, most of these were not intentional. The feasibility and safety of intentional retrieval of fully deployed, but erroneously placed stents have not been well described. We report four cases of successful, intentional stent retrieval for stents placed erroneously in an aorto-ostial position. The stents were retrieved at varying times after deployment, ranging from immediately to up to 5 years. In all cases, stents were retrieved successfully with no complication. We conclude that the intentional retrieval of fully deployed, but erroneously placed stents is feasible and safe when stenting involved an aorto-ostial location.

Association between circulating fibrocytes and angiographic coronary collaterals in patients with obstructive coronary artery disease.

Circulating fibrocytes are a population of bone marrow-derived progenitor cells that have been implicated in neovascularization. The recruitment of coronary artery collaterals, a form of neovascularization, is associated with improved outcomes in coronary artery disease. In this study, we tested the hypothesis that, in subjects with stable chronic coronary artery disease, the blood concentration of fibrocytes is associated with the presence of angiographic coronary collaterals. A total of 58 subjects with at least one epicardial coronary artery with ≥ 90% luminal stenosis were enrolled, among whom 26 (45%) had angiographic evidence of coronary collaterals. Subjects with collaterals had significantly elevated circulating concentrations of all examined subsets of activated fibrocytes, suggesting that there is a relationship between fibrocytes and coronary collateral recruitment.

Insertion of balloon retained gastrostomy buttons: a 5-year retrospective review of 260 patients.

PURPOSE: Radiologically inserted gastrostomy (RIG) is an established way of maintaining enteral nutrition in patients who cannot maintain nutrition orally. The purpose of this study was to evaluate the safety and efficacy of primary placement of a wide bore button gastrostomy in a large, varied patient population through retrospective review. METHODS: All patients who underwent gastrostomy placement from January 1, 2004 to January 1, 2009 were identified. 18-Fr gastrostomy buttons (MIC-Key G) were inserted in the majority. Follow-up ranged from 6 months to 4.5 years. RESULTS: A total of 260 patients (M:F 140:120, average age 59.2 years) underwent gastrostomy during the study period. Overall success rate for RIG placement was 99.6 %, with success rate of 95.3 % for primary button insertion. Indications included neurological disorders (70 %), esophageal/head and neck malignancy (21 %), and other indications (9 %). Major and minor complication rates were 1.2 and 12.8 %, respectively. Thirty-day mortality rate was 6.8 %. One third of patients underwent gastrostomy reinsertion during the study period, the main indication for which was inadvertent catheter removal. Patency rate was high at 99.5 %. The maximum number of procedures in any patient was 8 (n = 2), and the average tube dwell time was 125 days. CONCLUSIONS: Primary radiological insertion of a wide bore button gastrostomy is a safe technique, with high success rate, high patency rate, and low major complication rate. We believe that it is feasible to attempt button gastrostomy placement in all patients, once tract length is within limits of tube length. If difficulty is encountered, then a standard tube may simply be placed instead.