8 french transradial coronary interventions: clinical outcome and late effects on the radial artery and hand function.

BACKGROUND: Limited information is available on the effects of 8 French (Fr) transradial procedures on radial patency. In addition, the effects of radial procedures and radial occlusion on hand function are unknown. METHODS: Two groups were recruited: twenty-four patients who had undergone 26 transradial 8 Fr interventions and 16 patients who had undergone 16 transradial 6 Fr procedures. At 1 year, radial patency, hand strength and hand endurance were measured. RESULTS: No major adverse cardiac events or vascular complications were noted in either group. Late radial occlusion was noted in 2/18 (11%) 8 Fr patients and 3/16 (19%) 6 Fr patients (p = ns). There were no differences in the 8 Fr group between the catheterized and uncatheterized radial arteries for diameter (3.2 +/- 1.1 mm versus 3.3 +/- 0.7 mm, respectively; p = NS) or volumetric flow (55 +/- 51 ml/minute versus 57 +/- 45 ml/minute, respectively; p = NS). No differences in hand strength or hand endurance were seen between the catheterized and uncatheterized arms in the 8 Fr group, between the 8 Fr and 6 Fr groups, or between occluded and non-occluded patients. CONCLUSION: Transradial use of 8 Fr guiding catheters appears to be feasible and safe in highly selected patients, albeit associated with a low incidence of silent radial occlusion. Additionally, neither the use of 8 Fr sheaths nor the presence of radial artery occlusion appear to adversely affect hand strength or endurance.

Renal artery angioplasty and stent placement: predictors of a favorable outcome.

BACKGROUND: Renal artery stenosis is a common disorder and is an established cause of hypertension and renal insufficiency. Although treatment with renal artery stents has been shown to improve blood pressure and renal function for some patients, the patient population most likely to benefit is unknown. The current study was designed to determine which factors are predictive of improved blood pressure and renal function when patients with renal artery stenosis are treated with renal artery angioplasty and stent placement. METHODS: In a prospective evaluation 127 consecutively enrolled patients with renal artery stenosis in 171 vessels were treated with angioplasty and intravascular stents. Blood pressure and serum creatinine concentration were measured before stent placement and during the follow-up period. RESULTS: The mean length of the follow-up period was 15 +/- 14 months. Mean systolic blood pressure improved among patients with hypertension (from 177 +/- 26 mm Hg before stent placement to 151 +/- 24 mm Hg 6 months after stent placement (P <.001). The greatest improvement occurred among those with the highest baseline systolic blood pressure. This beneficial effect on blood pressure was sustained for 3 years. Sex, age, diastolic blood pressure, number of vessels into which stents were placed, serum creatinine concentration, presence of bilateral disease, race, and severity of stenosis were not predictive of improved blood pressure. Mean creatinine concentration was not significantly changed for the group as a whole. A significant decrease in serum creatinine concentration occurred among 43% of patients with baseline renal insufficiency. None of the examined variables was predictive of improvement. CONCLUSIONS: Renal artery angioplasty and stent placement produced a significantly greater reduction in systolic blood pressure among patients with the highest baseline systolic blood pressure. Other examined variables were not predictive of a significant improvement in blood pressure. No examined variable was predictive of improved renal function. We concluded that management of renal artery stenosis with renal artery angioplasty and stent placement is most likely to result in significant improvement in systolic blood pressure among patients with the highest baseline systolic blood pressure.

Effect of transradial access on quality of life and cost of cardiac catheterization: A randomized comparison.

BACKGROUND: Transradial access is a recently developed alternative for diagnostic cardiac catheterization. Its effects on quality of life after the procedure, patient preference, and cost are unknown. METHODS AND RESULTS: We performed a randomized single-center trial in which 99 patients underwent transfemoral and 101 underwent transradial diagnostic cardiac catheterization. Quality of life was measured with the SF-36 and visual analog scales at baseline, 1 day, and 1 week. Patients were examined at 1 day and at 1 week after for complications. Costs were measured prospectively. One patient in the femoral group and 2 in the radial group crossed over to the alternative access site. There were no major access site complications. One patient in the transfemoral group had a minor stroke. Transradial catheterization significantly reduced median length of stay (3.6 vs 10.4 hours, P <.0001). Over the first day after the procedure, measures of bodily pain, back pain, and walking ability favored the transradial group (P <.05 for all comparisons). Over the week after the procedure, changes in role limitations caused by physical health, bodily pain, and back pain favored the transradial group (P <.05 for all comparisons). There was a strong patient preference for transradial catheterization as well (P <. 0001). Transradial catheterization led to significant reductions in bed, pharmacy, and total hospital costs ($2010 vs $2299, P <.0001). CONCLUSIONS: Among patients undergoing diagnostic cardiac catheterization, transradial access leads to improved quality of life after the procedure, is strongly preferred by patients, and reduces hospital costs.

Intraaortic balloon pump insertion after percutaneous revascularization in patients with severe peripheral vascular disease.

Severe aortoiliac peripheral vascular disease (PVD) is considered a contraindication for the placement of an intraaortic balloon pump (IABP) because of a high risk of limb ischemia. Recent advances in percutaneous transluminal angioplasty (PTA) and stenting have altered the treatment of iliac stenoses such that the results of PTA with stenting compare favorably with surgery. We reviewed our experience with placement of IABP between July 1994 and February 1996. Of 64 patients receiving IABP, 17 had known or suspected peripheral vascular disease. Severe iliac or distal aortic stenoses were present in 9. These 9 patients underwent PTA with or without stenting prior to 10 IABP insertions. Limb ischemia occurred in 10% of PVD patients treated with percutaneous revascularization, compared to 11% in patients without PVD. No patient had a serious vascular complication or required vascular surgery. We conclude that percutaneous revascularization in patients with severe aortoiliac PVD, for whom this IABP insertion had previously been considered contraindicated, results in a low rate of limb ischemia.

U.S. experience of transradial coronary stenting utilizing Palmaz-Schatz stents.

Transradial coronary stenting has been associated with a low frequency of vascular complications and shortened hospital length of stay, but few reports of safety and feasibility are available. To determine the safety and efficacy of transradial coronary stenting, our initial experience in 38 patients was reviewed. Palmaz-Schatz stents hand-mounted on Predator (Cordis Corp., Miami Lakes, FL) balloons were delivered through 6 Fr guide catheters. In 1 of 38 patients (3%) radial access could not be achieved. Fifty-five stents were implanted in 44 lesions (3 total occlusion, 18 type A, 19 type B, 9 type C, National Heart Lung Blood Institute Classification). Access time was 7.7 +/- 4.6 min. Procedural success was achieved in 36 patients (97%). In one patient, a stent could not be delivered to a distal circumflex lesion due to marked proximal tortuosity and calcification. Poststenting residual stenosis was 0 +/0 10%. No access-related complications occurred. One patient had stent thrombosis and required repeat angioplasty and stenting. We conclude that transradial coronary stenting is both feasible and safe with a low risk of access complications and with excellent procedural results.

Current status of percutaneous vascular procedures.

The current nonsurgical therapeutic options for patients with peripheral vascular disease are rapidly expanding. No longer is conservative management the only alternative for patients with significantly symptomatic but noncritical limb ischemia. Certainly for vascular disease above the inguinal ligament interventional procedures especially with adjunctive stent placement have excellent success and long term patency. Femoropopliteal vascular disease of relatively limited nature also is well-treated with interventional procedures. Infrapopliteal vascular disease treated with a surgical venous bypass appears to have superior results than intervention. However, for poor surgical risk patients or in patients without the necessary venous conduit, limb salvage is still good with a percutaneous approach. Renal artery stenosis appears now to be well treated with interventional techniques. Early data with up to one year follow-up shows that even ostial stenoses respond well when vascular stents are utilized. Extending the life of failing hemodialysis grafts is another area where interventional techniques are of benefit. In the future, more extensive vascular disease and other vascular disease entities such as cerebrovascular disease and abdominal aortic aneurysm may be successfully treated by a percutaneous approach.

Two-vessel coronary artery dissection in the peripartum period. Case report and literature review.

The authors report a case of early peripartum myocardial infarction resulting from spontaneous dissection of the left anterior descending coronary artery and right coronary artery in a twenty-four-year-old woman. This is the first report of double-vessel coronary dissection involving both the left and right coronary arteries diagnosed antemortem and successfully treated.

Ancrod infusion for anticoagulation during and after PTCA in a patient with heparin-induced thrombocytopenia.

Ancrod is a rapid-acting defibrinogenating agent derived from the venom of the Malayan pit viper which has been used successfully as an alternative to heparin sulfate for anticoagulation during peripheral vascular procedures and coronary artery bypass surgery. We describe the first use of ancrod for anticoagulation before and during percutaneous transluminal coronary angioplasty (PTCA) in a patient with heparin-associated thrombocytopenia.

"Serpentine heart". Direct observation of the human heart during profound hyperkalemia.

We observed cardiac contractility in a patient who had inadvertently received a massive overdose of potassium chloride during open heart surgery. Slowly advancing waves of contraction were present while the surface electrocardiogram showed the sine wave configuration typical of severe hyperkalemia. This is the first report of such an observation and may serve to promote proper diagnosis and treatment of similar cases.

Pacemaker-induced friction rub and apical thrill.

A patient with acute myocardial infarction developed a loud systolic sound and apical thrill. Doppler ultrasound excluded interventricular septal rupture and significant mitral or tricuspid regurgitation. Auscultatory abnormalities disappeared after removal of a temporary pacing electrode, suggesting that the friction it created with intracardiac structures was responsible for these findings.

Successful balloon aortic valvuloplasty in a patient with mitral valve endocarditis.

A critically-ill 73-year-old man was admitted with simultaneous mitral valve endocarditis and aortic stenosis. Balloon aortic valvuloplasty was performed successfully and without complications and was followed by prompt clinical improvement. Balloon aortic valvuloplasty should be considered in patients with aortic stenosis and nonaortic valve endocarditis.

Comparison of thrombolytic therapy for acute myocardial infarction in rural and urban settings.

In this study, a tertiary care hospital served as a registry and information source to rural hospitals in northwestern Ohio where thrombolytic therapy had not previously been used. The study was designed to compare the safety and efficacy of intravenous thrombolytic therapy for acute myocardial infarction in the two settings. Fifty-five patients in eight rural hospitals and 36 patients in the urban tertiary care center received intravenous streptokinase. Of the 87 patients whose symptoms first occurred out of the hospital, 63 percent were treated within three hours. There were no significant differences in rates of clinically determined coronary artery recanalization (63 percent versus 69 percent for rural and tertiary hospitals, respectively), in-hospital mortality (5.4 percent versus 11 percent), bleeding complications (3.6 percent versus 5.5 percent), or time from the onset of pain to infusion of streptokinase (3.4 hours versus 2.9 hours). There were also no differences in the completeness of collection of serial coagulation data and cardiac enzyme values, or in the documentation of chest pain onset and cessation. Major differences between rural centers and the tertiary care center involved the use of serial electrocardiography (58 percent versus 89 percent, respectively), subsequent cardiac catheterization (49 percent versus 86 percent), and the timing of catheterization, when performed (30.4 days versus 4.6 days) (p less than 0.005 for all values). Thrombolytic therapy for acute myocardial infarction can be administered quickly, safely, and effectively in rural hospital settings even by physicians previously unfamiliar with this form of treatment.

Relation of effectiveness of intracoronary thrombolysis in acute myocardial infarction to systemic thrombolytic state.

Twenty-nine patients received intracoronary thrombolytic therapy for acute myocardial infarction 3.5 +/- 1.4 hours (mean +/- standard deviation) after the onset of pain. Ten patients received urokinase (UK) and 19 patients received streptokinase (SK). Laboratory variables of the coagulation system were measured before and immediately after therapy. When comparing patients in whom coronary artery recanalization occurred vs those in whom the artery remained occluded, those in whom recanalization was achieved had greater alterations in fibrinogen, prothrombin time, activated partial thromboplastin time, fibrin/fibrinogen degradation products and plasminogen by thrombolytic therapy than did those in whom recanalization was not achieved (p less than 0.05 for all variables). Euglobulin lysis time showed a similar but nonsignificant trend (p = 0.114). Patients who received SK showed markedly greater alterations in coagulation parameters than did patients treated with UK (p less than 0.05 for 5 of 6 variables measured) and had a much higher incidence of successful thrombolysis (74% for SK, 20% for UK). These data indicate that the development of a systemic fibrinolytic state contributes to success when using intracoronary thrombolytic agents in acute myocardial infarction. Rather than being considered an adverse effect of therapy, a systemic lytic state may serve as a reasonable clinical goal in attempting to produce thrombolysis.