Minimizing femoral access complications in patients undergoing percutaneous coronary interventions: a proposed strategy of bony landmark guided femoral access, routine access site angiography and appropriate use of closure devices.

INTRODUCTION: In this study we report local complication rates in patients undergoing percutaneous coronary intervention (PCI) utilizing a strategy of fluoroscopically guided puncture and preferential use of a closure device based on access site angiography. METHODS: We included 201 consecutive PCIs where the initial puncture was fluoroscopically guided using the inferior border of the femoral head as the guiding bony landmark. At the end of each PCI, access site angiography determined whether the deployment of a closure device, specifically the Angioseal device, was anatomically feasible. The access site was evaluated 3 and 24 hours post PCI. All patients were contacted by phone 30 days following the index procedure and questioned about any further incidents following hospital discharge. RESULTS: Deployment of the Angioseal device was feasible in 76% (153/201) of cases with a success rate over 99% (152/153). In the remaining 48 patients the access site was managed with manual compression, elastic bandage placement and prolonged bed rest. Patients who received the Angioseal device could be mobilized after 6 hours, while the group that was managed with manual compression required overnight bed rest. Local complication rates where very low for the study group as a whole (1.5%) without significant differences associated with the use of the Angioseal device. We did not observe any significant influence of the established risk factors for local complications, such as age, female sex, sheath size, elevated systolic blood pressure or use of glycoprotein IIb/IIIa platelet inhibitors, within our study population. CONCLUSION: The appropriate use of the Angioseal is feasible in three quarters of patients undergoing PCI and allows for more rapid mobilization while ensuring very low local complication rates.

Coronary artery disease following mediastinal irradiation.

Mediastinal irradiation is a known cause of late onset cardiac complications including coronary artery disease. We describe a 58-year-old female patient, without any of the traditional coronary risk factors, who presented with inferior infarction 23 years after radiotherapy for Hodgkin's lymphoma of the mediastinum. Coronary angiography demonstrated severe ostial stenoses of both coronary arteries. The patient underwent coronary artery bypass grafting and is doing well 10 months later. The therapeutic value of mediastinal irradiation is unquestionable. However, it may be associated with late complications from the irradiated tissues, including the heart. Long-term follow up of cancer survivors who have received mediastinal irradiation should therefore include annual cardiac ultrasound examinations, as well as functional testing for the detection of myocardial ischaemia.