Usefulness of coronary stenting for cardiogenic shock.

Coronary stenting was performed in 15 selected patients with cardiogenic shock, with favorable clinical and angiographic outcomes. This experience suggests that coronary stenting may play an important adjunctive role in the management of cardiogenic shock and may improve outcome beyond that achieved with balloon angioplasty alone.

Initial experience using Prostar: a new device for percutaneous suture-mediated closure of arterial puncture sites.

A new device that enables closure of the femoral artery puncture site by percutaneous placement of two nonabsorbable sutures (Prostar) was evaluated. Our initial experience included 32 insertion attempts at 29 femoral arterial puncture sites and one femoral venous puncture site. The device was applied at arterial puncture sites that had been used to carry out 12 balloon angioplasties (41%), seven intracoronary stent placements (24%), five intraaortic balloon pump insertions (17%), four diagnostic angiographies (14%), and one rotational ablation (3%). The venous access site closed was in a patient who had undergone balloon angioplasty and intracoronary thrombolysis. Most patients were anticoagulated with an average activated clotting time (ACT) of 306 +/- 123 sec (12 patients) or an average PTT of 68 +/- 29 sec (14 patients). There were four failures to achieve hemostasis using the device due to: inability to place the device because of peripheral vascular disease, entrapment of cutaneous tissue in the suture, a suture break that prevented hemostasis from being achieved, and avulsion of the sutures from the needles. Although three other suture breaks occurred, these did not prevent hemostasis from being achieved. Thus, 88% (28/32) of attempted uses were successful, and by using a second device in two of the failed attempts, 94% (30/32) of the puncture sites were successfully closed using the device. There was one late rebleed that required 1 hr of groin clamp pressure in an angioplasty patient who had received intracoronary urokinase. An ooze of blood occurred in 4 patients, but in only 2 was this more than trivial, resulting in discontinuation of heparin in one patient and a small hematoma in the other. We conclude that this device can be used safely and effectively, even in fully anticoagulated patients who have undergone complex procedures. The ultimate role of the device will require further experience and appropriate randomized studies.

Collagen plug hemostatic closure of femoral arterial puncture sites following implantation of intracoronary stents.

Recently a new adjunct to achieving arterial hemostasis has been developed. The device consists of a purified bovine collagen plug which when inserted adjacent to the arterial wall induces the formation of a hemostatic cap directly over the arterial puncture. We have utilized collagen plug hemostasis in 32 patients on 35 occasions undergoing implantation of intracoronary stents while attempting to maintain continuous full anticoagulation. Initial hemostasis was successfully achieved in all patients. Moderate sized (5 to 10 cm) hematomas were noted in 4 patients and large hematomas (> 10 cm) in 3, of whom 2 required vascular repair and transfusion. One patient developed a purulent discharge from the puncture site which resolved with a brief course of antibiotics. No patient suffered femoral arterial occlusion, distal embolization, or venous thrombosis. There were no long term access site problems at a mean follow up of 6 months. Repeat catheterization utilizing the same femoral artery was performed in 16 patients without difficulty. In five of these patients angiography was performed early after stent implantation without discontinuation of full anticoagulation and collagen closure was utilized a second time. Collagen plug hemostasis is feasible after coronary stenting, may allow more aggressive anticoagulation than might otherwise be achieved, and may facilitate angiographic restudy early after stenting without the need to discontinue anticoagulation.

'Salvage atherectomy' for discrete arterial dissections resulting from balloon angioplasty.

OBJECTIVE: To review the outcome of attempted salvage atherectomy performed following failed balloon angioplasty at a single centre. DESIGN: Retrospective study. PATIENTS: All patients undergoing percutaneous directional atherectomy shortly after failed coronary or peripheral balloon angioplasty at St Paul's Hospital, Vancouver, British Columbia, are reported. INTERVENTIONS: Salvage atherectomy was performed in six patients following failed balloon angioplasty prior to hospital discharge. In each case, a discrete mural flap resulted in a compromised lumen and ischemia. MAIN RESULTS: Percutaneous directional atherectomy successfully recovered atheromatous intimal fragments with restoration of arterial patency in all patients. Media was identified in one specimen and adventitia in none. Perforation did not occur and there were no complications. One patient had documented restenosis and a second had a significant lesion at a more proximal site with a follow-up of four to 15 months (mean nine). Both patients underwent uncomplicated repeat balloon angioplasty without angiographical dissection. CONCLUSIONS: Salvage atherectomy has a limited--but still useful--role in the management of discrete, obstructive arterial dissection flaps complicating balloon angioplasty.