Case of paradoxical embolic transient ischemic attack from an unusual extra cardiac shunt detected on a contrast-enhanced echocardiogram.

Paradoxical embolism due to extracardiac right to left shunts (RLSs) manifesting as stroke remains anecdotal. We describe a case of 63-year-old female who presented with a transient ischemic attack and at agitated saline contrast echocardiogram was found to have an unusual type of an extracardiac RLS. Further evaluation leads to diagnosis of superior vena cava (SVC) thrombosis from a prior indwelling central venous catheter. The SVC thrombosis induced systemic-pulmonary venous collaterals were responsible for this unusual extracardiac RLS and paradoxical transient ischemic attack. We discuss the diagnosis and management of this rare clinical case.

RX Herculink Elite(®) renal stent system: a review of its use for the treatment of renal artery stenosis.

The management of renal artery stenosis (RAS) remains controversial. While some evidence suggests that treatment with stent placement is beneficial, randomized trials have failed to demonstrate a significant benefit. Ongoing clinical trials should help to better define the role for stenting of RAS while avoiding limitations seen with earlier trials. When it comes to stenting for RAS, several stents have been used; however, many stents which have been used previously and which are still being used are biliary stents that are used "off-label." These stents have typically come onto the market through the 510(k) pathway. To date, a total of five stents have been approved by the United States Food and Drug Administration for use in the renal arteries. Of the five stents that have received approval, the Bridge™ Extra Support (Medtronic Cardio- Vascular, Santa Rosa, CA) and the Palmaz(®) (Cordis Corporation, Bridgewater, NJ) stents are no longer available. Currently, the Express(®) SD (Boston Scientific, Natick, MA), Formula™ (Cook Medical, Bloomington, IN), and Herculink Elite(®) (Abbott Vascular, Santa Clara, CA) stents are Food and Drug Administration approved and available for use. The Herculink Elite is the most recently approved of the renal stents, having received approval in late 2011. The Herculink Elite stent is the only cobalt chromium stent approved for use in the renal arteries. Although trial data are limited and direct comparisons among renal stents is not possible, the Herculink Elite stent has demonstrated good performance. Additionally, the design of the Herculink Elite offers some advantages that may translate into improved outcomes.

Spontaneous coronary artery dissection: to treat or not to treat--2 atypical cases and a review of the literature.

Spontaneous coronary dissection is an unusual cause of acute coronary syndrome and sudden death, with a predilection for otherwise healthy young women. Presentation during the peri-partum period accounts for a quarter of the cases. We describe 2 cases of spontaneous coronary dissection with some atypical features. Both patients differed in their demographics, clinical presentations, and management strategies. Posited pathogenetic mechanisms for spontaneous coronary dissection are varied and remain poorly understood. Optimal management strategies depend on the vessels involved and the presence of ongoing symptoms. Patients who survive to presentation typically have a good prognosis.

Impact of an acute coronary syndrome pathway in achieving target heart rate and utilization of evidence-based doses of beta-blockers.

Beta-blockers remain a cornerstone of therapy in the management of acute coronary syndrome (ACS). The 2007 American College of Cardiology/American Heart Association unstable angina/non-ST elevation myocardial infarction guideline revisions recommend a target heart rate (HR) of 50-60 beats per minute (bpm). Despite improved trends toward utilization of beta-blockers therapy, beta-blockers continue to be underdosed. Guideline-based tools have been shown to improve adherence to evidence-based therapy in patients with ACS. Implementation of a standardized ACS pathway would lead to titration of beta-blockers to recommended dosages with improved HRs in eligible patients. The ACS clinical protocol was implemented at the University of Toledo Medical Center in May 2007. A retrospective study of 516 patients admitted during a comparable 6-month period, before and after the institution of the protocol, was conducted. The preprotocol and protocol group included 237 and 279 patients, respectively. Patient information extracted from the medical records included age, gender, HR on admission, blood pressure on admission, duration of hospital stay, preadmission use of beta-blocker, type of beta-blocker and dosage, discharge beta-blocker and dosage, peak troponin levels, and therapeutic intervention. A target HR of less than 60 bpm was achieved in 19% of the protocol group, as compared with 6% in the preprotocol group (P < 0.001). The protocol group had a significantly lower mean discharge HR than the preprotocol group (67 vs. 74 bpm; P < 0.001). The mean discharge dose of metoprolol in the protocol group was noted to be significantly higher (118 vs. 80 mg/d; P < 0.001). The institution of an ACS clinical pathway led to utilization of beta-blockers in significantly higher dosages, resulting in improved HR control and increased attainment of target HR.

Renal artery stenosis: optimizing diagnosis and treatment.

Renal artery stenosis (RAS) is the most commonly caused by atherosclerosis, with fibromuscular dysplasia being the most frequent among other less common etiologies. A high index of suspicion based on clinical features is essential for diagnosis. Revascularization strategies are currently a topic of discussion and debate. When revascularization is deemed appropriate, atherosclerotic RAS is most often treated with stent placement, whereas patients with fibromuscular dysplasia are usually treated with balloon angioplasty. Ongoing randomized trials should help to better define the optimal management of RAS.

Management of renal artery stenosis: 2010.

OPINION STATEMENT: Renal artery stenosis (RAS) is a relatively common manifestation of atherosclerosis, although in a small percentage of cases it is due to fibromuscular dysplasia and less frequently may have other etiologies. RAS may be treated by revascularization, using either percutaneous or open surgical techniques. Currently, technical success with percutaneous revascularization utilizing angioplasty and stenting is achieved in 95% or more of cases in which it is attempted. Despite this, at least one third of patients undergoing renal artery stenting do not receive any measurable benefit. Furthermore, randomized trials of stenting for RAS have failed to demonstrate a benefit over medical management alone. Thus, the clinician is faced with a challenge when determining how to manage an individual patient with RAS. In the current era, all patients with RAS should receive "optimal medical therapy." This approach should use medicines to control blood pressure, and specifically utilize agents proven to reduce cardiovascular morbidity and mortality. Other components of "optimal medical therapy" include the use of anti-platelet drugs such as aspirin and statins to minimize progression of atherosclerosis. In addition to these strategies, consideration should be given to revascularization therapy. When deciding to revascularize RAS, the patient should have an appropriate clinical indication, in addition to a significant anatomic stenosis. Importantly, stents should not be placed due to the "oculostenotic reflex." Specifically, patients who continue to have uncontrolled blood pressure or worsening renal function despite an aggressive approach with medical therapy may be particularly good candidates for renal artery stenting. Despite the lack of benefit in randomized trials to date, there is likely still a role for renal artery stenting in RAS; however, careful patient selection is essential to maximize the potential benefit.

Stroke in a patient with a surgically ligated left atrial appendage: should warfarin be continued after left atrial appendage ligation?

We report on a 74-year-old woman who presented with embolic stroke of the brainstem and right cerebellum. She had undergone coronary bypass surgery and prophylactic ligation of the left atrial appendage in the past. On further investigations, a source of emboli was found to be an incompletely ligated left atrial appendage. Anticoagulation with warfarin if started after surgery would have reduced the risk of embolism in this patient.

Acute mitral regurgitation after acute myocardial infarction in a patient with a patent foramen ovale: review of the diagnosis and management of acute ischemic mitral regurgitation.

We discuss the diagnosis and the management of a 78 year old woman who devoloped acute ischemic mitral regurgitation as a result of ruptured anterior chordal structures of the mitral valve. The patient in addition had a patent formen ovale.

Predictors of embolization during protected renal artery angioplasty and stenting: Role of antiplatelet therapy.

OBJECTIVE: The objective of this study was to identify the predictors of distal embolization (DE) during protected renal artery angioplasty and stenting. BACKGROUND: DE may contribute to worsening renal function after renal artery stenting. The factors associated with DE, rates of platelet-rich emboli, and treatments that may prevent DE during renal stenting have not been evaluated. METHODS: The current study evaluated patients randomized to receive an embolic protection device (EPD) in the RESIST trial. Forty-two patients were identified for inclusion in this study. These patients were further randomized to abciximab (N = 22) or placebo (N = 20). Modification in Diet in Renal Disease glomerular filtration rate (GFR) was used as the primary measure of renal function. Creatinine was measured by a modified Jaffe reaction using the IDMS-traceable assay. The primary endpoint was capture of platelet rich emboli in the angioguard basket. RESULTS: DE occurred in 15/42 (35%) of the patients and platelet rich DE in 10 (24%) of the patients who received an EPD. Of the angiographic characteristics only lesion length was significantly higher in patients with DE (16 +/- 7 mm vs. 10 +/- 5 mm, P = 0.04). Preprocedural abciximab reduced DE from 42 to 8% (P = 0.02). The rate of platelet rich emboli was 50% with neither abciximab nor a thienopyridine, 36% with thienopyridine only, 15% abciximab only, and 0% in patients who received both a thienopyridine and abciximab. Only Abciximab use was associated with improved renal function at 1-month, thienopyridine was not. Angiographic characteristics including percent stenosis, minimal luminal diameter (MLD), reference diameter, change in MLD, contrast volume, and procedure time were not predictors of DE during renal stenting. CONCLUSION: Capture of DE and specifically platelet DE are common during protected renal stenting using a filter-type EPD. Abciximab use, and potentially combined thienopyridine and abciximab use, decreased the rate of platelet rich DE; however, only abciximab improved renal function at 1-month.

Cardiovascular morbidity and mortality and renal artery stenosis.

Renal artery stenosis (RAS) is a common manifestation of atherosclerosis and is associated with many other atherosclerotic conditions. Cardiovascular morbidity and mortality is increased among patients with RAS. This increase is likely due in part to the associated disease states; however, RAS itself may also contribute. Current strategies to limit cardiovascular morbidity and mortality in RAS include various pharmacologic interventions targeting both RAS atherosclerosis in general. Additionally, revascularization has been advocated; however, clear data are lacking. Ongoing clinical trials such as the Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial will ultimately help to determine the best strategies to limit the morbidity and mortality associated with RAS.

A retrospective analysis and case series of glycoprotein IIb/IIIa inhibitor associated diffuse alveolar hemorrhage: two case reports.

INTRODUCTION: Glycoprotein IIb/IIIa inhibitors have a key role in the treatment of patients with acute coronary syndromes undergoing percutaneous interventions. Although, an increased risk of bleeding complications is well recognized, its association with diffuse alveolar hemorrhage is much less recognized. Previous authors have suggested that the incidence of glycoprotein IIb/IIIa inhibitor associated diffuse alveolar hemorrhage has been significantly underestimated due to under reporting. CASE PRESENTATIONS: In order to help better determine the incidence of GP IIb/IIIa inhibitor associated DAH, a retrospective review of medical records was conducted over a 1 year period at a single high volume medical hospital. The medical records of all patients diagnosed with diffuse alveolar hemorrhage were evaluated for treatment with a GP IIb/IIIa inhibitor within 48 hours of its diagnosis. Each patient meeting the inclusion and exclusion criteria were included in the case series. This number was compared with the total number of patients receiving a GP IIb/IIIa inhibitor during the same time period and an incidence of the complication was calculated. 292 patients received either abciximab or eptifibatide during the one year review period and two patients were diagnosed with diffuse alveolar hemorrhage confirmed by serial bronchiolar lavage for an incidence of 0.68%. Of the total 292 patients receiving GP IIb/IIIa inhibitors, 172 patients received abciximab with one occurrence of diffuse alveolar hemorrhage for an incidence of 0.58% while 120 patients received eptifibatide with one occurrence for an incidence of 0.83%. Both patients developed significant morbidity as a result of the complication and 1 of the 2 patients died as a complication of the disease. CONCLUSIONS: Our findings support the claim that the incidence of GP IIb/IIIa induced diffuse alveolar hemorrhage is substantially higher than initially suggested by drug manufacturer studies. Although these drugs have proven mortality benefits, its association with diffuse alveolar hemorrhage is likely under-recognized leading to significant under-reporting. The best way to more accurately determine the true incidence of this complication and decrease its morbidity and mortality is to increase awareness as well as include diffuse alveolar hemorrhage as a serious complication in product labeling.

Common femoral artery access techniques: a review.

The increasing burden of coronary artery disease has resulted in more percutaneous coronary artery interventions. The common femoral artery remains the most widely accepted site for percutaneous coronary artery access. Local access site, vascular complications remain a considerable source of morbidity during common femoral arterial puncture. This has prompted angiographers, over the years, to define various reliable landmarks and techniques to access the common femoral artery, in an attempt to minimize and avoid complications. In this discourse, we discuss the various techniques of obtaining common femoral arterial access, with their relative benefits and disadvantages. The literature supporting the various palpatory or radiographic landmark-guided methods is reviewed. There are limited data on the superiority of any individual method.

Complete versus partial distal embolic protection during renal artery stenting.

OBJECTIVE: The aim of this study was to evaluate whether complete embolic protection is superior to partial embolic protection for preservation of kidney function during renal artery angioplasty and stenting. BACKGROUND: Renal artery angioplasty and stenting (RAAS) is a common treatment for atherosclerotic renal artery stenosis. However, RAAS may be complicated by peri-procedural loss of kidney function. METHODS: In total, 44 patients were randomized to embolic protection devices (EPD) use; 25 complete and 19 partial embolic protection. These patients were further randomized to receive abciximab (n = 23) or placebo (n = 21). [corrected] MDRD glomerular filtration rate (GFR), was used as the primary measure of renal function. Creatinine was measured by a modified Jaffe reaction using the IDMS-traceable assay. The primary endpoint was the percent change in estimated glomerular filtration rate (eGFR) 1 month following stent placement. RESULTS: There was no difference in percent change eGFR at 1 month between complete or partial protection (-4 +/- 25 vs. +3 +/- 30, P = 0.45). Abciximab was associated with a net improvement in eGFR when compared with placebo (+0.5 +/- 27 vs. -11 +/- 20, P = 0.04). On subgroup analysis, the use of abciximab was associated with significantly improved eGFR in the partial distal embolic protection group (+14 +/- 33 vs. -17 +/- 13 %, P = 0.018) but not in the complete distal embolic protection group (+2.5 +/- 26 vs. -11 +/- 24, P = 0.42), however, there was no interaction between completeness of protection and abciximab on eGFR (P = ns). Capture of embolic material was more likely with complete protection when compared with those receiving partial protection (51% vs. 21%, P < 0.05). CONCLUSION: Complete protection was superior to partial protection for the capture of athermanous debris during renal artery stenting. However, this was not associated with improved renal function. Importantly, Abciximab conferred a benefit for renal function that was independent of the degree of embolic protection.

Pneumopericardial tamponade resulting from a spontaneous gastropericardial fistula.

Pneumopericardium is a rare but serious cause of morbidity and mortality. Untreated, it can lead to cardiac tamponade and thus must be promptly identified to treat the underlying etiology. Here, we report a case of spontaneous pneumopericardium secondary to gastric ulcer perforation in association with a hiatal hernia. The diagnosis of pneumopericardium was first made under fluoroscopy during cardiac catheterization and a follow-up CT of the chest revealed a gastropericardial fistula as the initiating event. The patient underwent emergent thoracotomy and partial esophagogastrectomy which eventually resulted in a full recovery and discharge on postoperative day 19. Our unique experience with this rare and often fatal disease suggests that early diagnosis combined with an early and aggressive surgical strategy is critical for minimizing morbidity and mortality.

Renal insufficiency as a predictor of adverse events and mortality after renal artery stent placement.

BACKGROUND: Renal artery stenosis (RAS) is associated with substantial morbidity and mortality. This relationship is strongest in the presence of renal insufficiency (RI). The goal of this study is to assess the relationship between RI, mortality, and adverse events in the setting of renovascular disease. METHODS: Two hundred sixty-one patients with significant RAS treated with endovascular stenting were followed up prospectively for 21 +/- 18 months (range, 0 to 85 months). Blood pressure (BP), renal function, medication use, and comorbidities were assessed. Death was verified through the Social Security Death Master Index File, and cause of death was derived from death certificates. Medical records of 230 subjects subsequently were reviewed to identify adverse cardiovascular and renal events. RESULTS: Overall, 37% of patients experienced at least 1 adverse event postprocedure. Myocardial infarction (MI) and congestive heart failure (CHF) events increased with degree of baseline RI. Seventy-three deaths (28%) occurred postprocedure (range, 13 to 2,457 days). Baseline characteristics associated with mortality included advanced age, decreased use of beta-blockers, increased use of diuretics, increased serum creatinine (Cr) level, decreased Cr clearance (CrCl), bilateral stenoses or stenosis of a solitary kidney, history of CHF, and history of MI. Follow-up characteristics associated with mortality included lower systolic and diastolic BP, increased serum Cr level, and decreased CrCl. RI at baseline and follow-up remained associated with mortality after adjusting for other clinically and statistically significant variables. Patients in whom renal function improved after stenting appeared to show improved survival over those without improved renal function (45% versus 0% cumulative survival, P < 0.05). CONCLUSION: In patients with RAS undergoing stent therapy, baseline RI is associated with an increased incidence of adverse events, as well as decreased survival, independent of other baseline clinical factors. Importantly, improvement in renal function appears to be associated with increased survival.

Compliance with antihypertensive therapy after renal artery stenting.

Hypertension is an important clinical endpoint after renal artery revascularization for renal artery stenosis (RAS). Medication compliance is a critical determinant of blood pressure control. Although factors influencing compliance are known in essential hypertension, they have not been evaluated in studies investigating renal artery revascularization. The aim of this study was to assess the determinants of compliance to antihypertensive therapy in patients with RAS following renal artery stent placement (RASP). A cross-sectional study evaluating blood pressure, antihypertensive medications, quality of life, compliance, and determinants of compliance to antihypertensive therapy was undertaken in 112 patients undergoing RASP. Additionally, cardiovascular risk factors, antihypertensive medications, and cardiovascular history were reported. Self-reported compliance was 79% +/- 24% (scale of 0% [none] to 100% [complete] compliance) in patients after RASP. Determinants of compliance by multivariate analysis included physical symptoms, which correlated negatively to compliance and included loss of appetite (r2 = 0.26, P < 0.0001), dizziness (r2 = 0.06, P < 0.01), and cough (r2 = 0.03, P < 0.05). Systolic blood pressure correlated positively with compliance (r2 = 0.03, P < 0.05). The number or class of antihypertensive medications did not influence compliance. Patients' physical symptoms and level of systolic blood pressure, rather than the number or class of medications, influence compliance in patients with continued hypertension after RASP. Attention to physical symptoms may help to improve blood pressure control in this population.

Utility of a 0.014" pressure-sensing guidewire to assess renal artery translesional systolic pressure gradients.

Renal ischemia due to renal artery stenosis (RAS) is an important cause of secondary hypertension and renal insufficiency. Several methods are available to diagnose RAS; however, the identification of clinically significant lesions remains problematic. We measured the translesional systolic pressure gradient (TSPG) with a 4 Fr catheter and a 0.014" pressure-sensing guidewire and compared these data to angiographic findings. The TSPG obtained by pressure-sensing guidewire correlated more strongly with angiographic minimal lumen diameter (r(2) = 0.801) than those obtained by 4 Fr catheter (r(2) = 0.360). The relationship of TSPG with percent stenosis was not strong, regardless of the method used (r(2) = 0.228 with pressure-sensing guidewire, 0.358 with 4 Fr catheter). Using a 0.014" pressure-sensing guidewire is effective for assessing TSPG and provides a more reliable indication of stenosis significance than use of a 4 Fr catheter.

Intra-aortic balloon pump placement following aorto-iliac angioplasty and stent placement.

Approximately 20% of patients are unable to receive an intra-aortic balloon pump (IABP) due to aorto-iliac atherosclerotic disease. Aorto-iliac stenoses can be managed with angioplasty or stent placement; however, there are limited data about this strategy to facilitate IABP placement. Thirty-seven IABPs were placed in 35 patients. A total of 45 revascularization procedures were performed. With revascularization, the minimal lumen diameter increased from 2.78 +/- 1.46 to 6.75 +/- 2.36 mm (P < 0.0001). Limb ischemia occurred following 2/37 (5%) IABP insertions. Limb ischemia was managed with IABP removal and angioplasty. The mortality rate was 32%. Mortality was more common with chronic renal insufficiency (8/11, 73%; P = 0.0014), dialysis-dependent renal failure (3/3, 100%; P = 0.028), and presentation with acute myocardial infarction (8/15 patients, 53%; P = 0.036). Although no patients required vascular surgery for limb ischemia, one patient required surgery for bleeding. Angioplasty or stenting to facilitate IABP placement in patients with peripheral vascular disease is safe and effective.