[Reducing the risk of vascular complications during percutaneous aortic valve replacement]. / Comment réduire le risque de complication vasculaire lors des procédures de remplacement valvulaire percutané (TAVI) réalisées par voie fémorale ?

The percutaneous aortic valve replacement (TAVI) is the most recent and promising procedure in the area of interventional cardiology with a rapidly growing number of interventions worldwide. The transfemoral approach being less invasive, it has become the predominant access for the device delivery. The prevention of vascular complications by an optimal risk stratification using appropriate imaging techniques (vascular CT scan and angiography), optimised techniques for femoral puncture (active control of the arterial punction, crossover...) and skilled teams for peripheral angioplasty and percutaneous arterial closure devices (Prostar) has become mandatory given the fragile target population for TAVI. Vascular complications remain indeed one of the most frequent complication although the trend toward reduced sheeths size led to significant reduction This is mandatory regarding the needed size of the vascular arterial access - itself with constant improvement by minimising the initial 24 French with mandatory real chirurgical closure to the actual 18-19 French and soon 16 French. The improvement of the implanted devices is due to the recent evidence of the promising future of this technique and the important technological effort realised by the industry not only on the implanted aortic prosthesis but also on their delivering catheters.

[Saphenous graft angioplasty]. / Angioplastie des pontages veineux.

In our daily practice the rate of saphenous graft angioplasty is less than 5%. This kind of angioplasty is more complex with a higher rate of complications in known fragile patients. Some technical trips and tricks are necessary to easily perform these angioplasties. Main difficulties are the extension of saphenous graft lesions, the risk of distal embolism, coronary slow or no flow and the high rate of restenosis. Pharmacological treatment is disappointing with no efficacy of the Gp IIb-IIa blockers. Otherwhise the use of protection devices is clearly effective and must be used when it is technically possible. With the use of bare metal stents in saphenous graft angioplasty the rate of restenosis is very high. There are some encouraging results with drug eluting stents. But we are still now not allowed to use them in this indication in our daily practice.

[Rotational coronary angiography]. / Angiographie coronaire rotationnelle.

CONTEXT: Rotational angiography (RA) is a radiological technique that provides multiple views of a vessel for a single injection of contrast. Its significance in the field of coronary angiography is poorly known at present. This study aimed to compare the radiation dose as well as the volume of contrast used during RA compared to standard angiography (SA), and to evaluate its diagnostic precision. METHOD: 78 patients sent for diagnostic coronary angiography were explored using the radial approach. The patients were randomised between RA (3 acquisitions for the left coronary and 1 for the right coronary) or SA. Once a decision to undertake angioplasty had been made following the angiography (RA or SA), the initial study was complemented using the alternative technique (SA or RA) before the angioplasty procedure was performed at a later stage. The severity of the lesions as shown by RA and SA was compared by four experienced coronary angiography operators. RESULTS: 65 patients (mean age 61+/-10 years--mean BMI 26+/-4 Kg/m2) underwent complete RA+SA investigation. The total x-ray dose used during ciné-angiography, the dose received by the patient, and the volume of contrast were significantly reduced in the RA group compared to the SA group (-25%; -36%; -33% respectively). An evaluation of the severity of the stenoses was performed on 168 arterial segments. There was a significant correlation between the two techniques (R=0.95--p<0.001) and the intra-observer variability was non significant (3.7+/-6.8%--p=NS). CONCLUSIONS: Rotational angiography allows the radiation dose and the volume of contrast to be reduced, while retaining a diagnostic precision similar to that of standard angiography.

Procedural characteristics of primary coronary angioplasty in diabetic patients with acute anterior myocardial infarction.

BACKGROUND: Mortality and morbidity rates are higher in diabetics compared to non-diabetics after acute myocardial infarction (AMI). Previous angiographic studies regarding primary angioplasty for the treatment of AMI found that angioplasty was similarly successful in diabetics and non-diabetics. However, it is noteworthy that patients of "real life" are often far from the population randomised in prospective protocols. The aim of this study was to examine the procedural characteristics of consecutive diabetic patients hospitalised for anterior AMI and treated with primary angioplasty as compared to non-diabetics. METHOD: We analysed 28 consecutive diabetics and 74 non-diabetics who underwent primary angioplasty for anterior AMI (< 12 h from the onset of symptoms) during 15 consecutive months between 2000 and 2001 in our institution, depending on the presence or absence of diabetes. RESULTS: Among analysed data, we found that in diabetics compared to non diabetics: (i) the delay before arrival in the cath-lab was significantly longer (5.5 +/- 2.7 vs 4.2 +/- 2.8 h); (ii) there was a less important collateral flow coming from the non-culprit arteries towards the culprit artery; (iii) there was a less important rate of recovery of a normal flow (TIMI 3) in the culprit artery after coronary angioplasty (67% vs 91%). CONCLUSION: Our study demonstrates that several procedural characteristics could explain the poorer prognosis of AMI treated by primary angioplasty in the diabetic population. The longer delay found in diabetics before arrival in hospital could probably be improved.