Usefulness of collagen plugging with VasoSeal after PTCA as compared to manual compression with identical sheath dwell times.

This study investigated the usefulness of collagen plugging with VasoSeal (Datascope Corporation, Montvale, New Jersey) in patients after PTCA compared to a control group having identical sheath dwell times and therefore comparable levels of anticoagulation. A total of 150 patients were enrolled in this prospective and randomized study. Sheaths were pulled at exactly 5 hours after arterial puncture. Time to hemostasis and local complications were determined. There were no statistical differences in baseline characteristics. The mean time to hemostasis in the collagen group was significantly shorter (3 +/- 3 minutes) than that of the control group (17.4 +/- 7 minutes). At 24 hours, 23% of the collagen group patients had a small, 1% a medium and 4% a large hematoma. In the control group, 32% had a small and 4% a medium-sized hematoma, but no patient a large hematoma. After collagen, one patient developed a pseudoaneurysm needing vascular surgery. In the control group, no major complications occurred. Compared to patients with manual compression at an identical sheath dwell time and an identical level of anticoagulation, there was a significant reduction in time to hemostasis but no statistical difference regarding local complications. Although the incidence of medium or large hematoma was low, the trend towards a decreased risk of smaller hematomas seemed to be counterbalanced by an increased risk of larger hematomas.

Usefulness of collagen plugging with VasoSeal after PTCA as compared to manual compression with identical sheath dwell times.

This study investigated the usefulness of collagen plugging with VasoSeal in patients after PTCA compared to a control group having identical sheath dwell times and therefore comparable levels of anticoagulation. A total of 150 patients were enrolled in this prospective and randomized study. Sheaths were pulled at exactly 5 h after arterial puncture. Time to hemostasis and local complications were determined. There were no statistical differences in baseline characteristics. The mean time to hemostasis in the collagen group was significantly shorter (3 +/- 3 min) than that of the control group (17.4 +/- 7 min). At 24 h, 23% of the collagen group patients had a small, 1% a medium and 4% a large hematoma. In the control group, 32% had a small, 4% a medium sized, but no patient a large hematoma. After collagen, one patient developed a pseudoaneurysm needing vascular surgery. In the control group, no major complication occurred. Compared to patients with manual compression at an identical sheath dwell time and an identical level of anticoagulation, there was a significant reduction in time to hemostasis but no statistical difference regarding local complications. Although the incidence of medium or large hematoma was low, the trend towards a decreased risk of smaller hematomas seemed to be counterbalanced by an increased risk of larger hematomas.

Sheath pulling immediately after PTCA: comparison of two different deployment techniques for the hemostatic puncture closure device: a prospective, randomized study.

Sheath pulling immediately after percutaneous transluminal coronary angioplasty (PTCA) increases patients' comfort, decreases burden for the medical staff, and may reduce hospital costs by shortening the length of stay. Immediate sheath pulling in anticoagulated patients with a low risk of bleeding complications is feasible using hemostatic devices. For the hemostatic puncture closing device (HPCD), published data regarding sheath pulling in patients immediately after PTCA is limited. Furthermore, no study addressed the question whether the recommended deployment time (DT) of 30 min can be reduced to a few minutes. We, therefore, performed a prospective study, randomizing 140 patients to a DT of 5 and 30 min, respectively. There were no statistical differences in gender, age, height, weight, or cardiovascular risk factors between the two groups. Blood pressures measured invasively immediately before sheath removal were comparable. Activated coagulation time just prior to sheath removal was 227 +/- 52 sec in the DT-5 group and 223 +/- 37 sec in the DT-30 group. After deployment, 74% of the DT-5 patients and 71% of the DT-30 patients showed immediate and complete hemostasis. The remaining patients showed only little oozing with complete hemostasis at the time of the final device removal. Hematoma size after 24 hr was 6.2 +/- 4.4 cm2 for DT-5 and 6.8 +/- 8.2 cm2 for DT-30 patients. There was no statistical difference between both groups. No severe bleeding or major complications were observed in either group. Thus, the use of a collagen system with an intra-arterial anchor (HPCD) is effective and safe when sheaths are pulled immediately after PTCA. The reduction of deployment time from 30 to 5 min is not related to an increased risk of bleeding or other vascular complications; patients can be transferred much faster to the ward, therefore reducing the burden on the personnel in the catheterization laboratory and increasing patients' comfort by allowing them to return to their rooms without a sheath.

Impact of various compression rates on interpretation of digital coronary angiograms.

According to the ACC/ACR/NEMA/ESC-guidelines, digital techniques should be replaced by cinefilm for coronary angiography. The ad hoc group of experts recently chose CD-R (CD recordable) as transport media and the JPEG standard for image compression. To avoid a possible loss of image quality, the guidelines allow a maximal data compression of only 2:1. This, however, leads to a considerable limitation: coronary angiograms cannot be viewed in real-time directly from CD. Since the possible influence of higher compression rates on image quality of coronary angiograms had not been investigated in a controlled study, we evaluated 8 various compression rates (ranging from 5:1 to 43:1) according to a prospective, randomized and blinded protocol. Four independent observers assessed 1440 angiograms using a semiquantitative score. We found that angiograms with a compression rate of 5:1 and 6:1 did not lead to a clinically relevant deterioration of image quality, whereas 11:1 was still acceptable, but 43:1 becomes unacceptable. Since no clinically relevant loss of information at a compression rate of 6:1 was experienced in our study, a modification of the ACC/ACJ/NEMA/ESC-guidelines allowing higher compression rates should be considered.

[Waiting times and death on the waiting list for coronary artery bypass operation. Experiences in Munich with over 1,000 patients]. / Wartezeiten und Tod auf der Warteliste für eine koronare Bypass-Operation. Erfahrungen in München an über 1000 Patienten.

Short-term and long-term results are the classical parameters for quality assurance in coronary artery bypass graft surgery (CABGS). In contrast, waiting times and the inherent risks of waiting lists are usually neglected. Although the problem of "death on the waiting list" is generally known, related publications are scarce. Therefore, in January 1994, we started a prospective study to document the waiting times and the occurrence of severe complications in our patients waiting for CABGS. Between January 1, 1994 and July 31, 1996, we catheterized 1125 patients with indication for CABGS. 968 patients had social health insurance (SOCL); 157 patients were privately insured (PRIV). The urgency of CABGS was classified as "emergent", "ery urgent" and "less urgent" according to the clinical experience of the responsible cardiologists. All emergency cases could be operated the same day. 69% of the very urgent SOCL patients had to travel beyond the Munich area to be operated, while 84% of the respective PRIV patients were operated in Munich. SOCL patients were therefore separated from their families 4.3 times more frequently then PRIV. Not so urgent SOCL cases were separated from their families 1.8 times more often than PRIV. The mean waiting time for SOCL was 39.5 +/- 39.1 days in 1994, 34.9 +/- 31.5 days in 1995 and 22.7 +/- 16 days in 1996. The corresponding values of PRIV are 19.1 +/- 16.2, 19.8 +/- 14.1 and 17.2 +/- 12.6 days. The risk of dying while waiting for CABGS was 1.3% per month (15/1125). The reduction of waiting times by the factor of two between 1994 and 1996 did not, however, influence the death on the waiting list, because all deaths occurred within 4 weeks after diagnostic catheterization. Our results show that triage practices for patients requiring CABGS are not reliable. To minimize the risk of the "death on the waiting list", CABGS must be offered within a week after diagnostic coronary angiography, even for "elective" cases.

[Clinical significance of aberrant coronary artery--origin from the aorta (author's transl)]. / Klinische Wertigkeit von Koronargefässanomalien Myokardischämie und plötzlicher Tod in jugendlichem Alter.

It is demonstrated the unusual case of a 14-year-old boy, dying suddenly after physical stress with myocardial infarction. Autoptically it was found a coronary artery anomaly of the "malign type" and in addition a significant narrowing of the left main coronary artery. There are presented until now in the literature 17 cases of sudden death in young patients (up to 22 years) in connection with the "malign coronary artery anomaly origin" of both coronary arteries from the right coronary sinus and course of the left coronary artery between the truncus of pulmonary artery and aorta. All 17 cases of sudden death were male. No explanation of the predominance of the male sex is known. Always physical stress preceded the fatal event. Obviously all other abnormalities of coronary artery origin of the aorta and course--except the Bland-White-Garland Syndrome--are of minor clinical importance. In the course of life all coronary vessel anomalies can be accompanied by atherosclerotic processes, followed by clinical symptoms of coronary artery disease. The additional speciality of the demonstrated case is the significant stenosis (75%) in the abnormal course of the main coronary artery. Practical consequence of the presented case is: Even in young patients and children one must be aware of the possibility of a myocardial infarction with coronary artery abnormality if clinical symptoms are present. There may be diagnostic (coronary arteriography) and therapeutic (coronary artery surgery) consequences, if the patient survives the life-threatening event.

[Histotopography of chronic gastritis in localized processes of the gastric wall and in resected stomach (author's transl)]. / Histotopographie der chronischen Gastritis bei umschriebenen Magenwandprozessen und im Stumpfmagen.

The topography of gastritis was investigated by selective endoscopic biopsies from the antrum and body of the stomach in 231 patients with duodenal or gastric ulcers, 165 patients with gastric carcinoma, 83 patients with polyps of the gastric epithelium and 122 patients after gastric resection (Billroth II). The results of this study show that gastritis, even with localized gastric processes or lesions is not a general inflammation involving the whole of the gastric mucosa. Gastric epithelial polyps and gastric carcinoma are associated with a chronic atrophic gastritis in the affected gastric mucosal areas in less than or in about 50% of cases. A diffuse uniform gastritis was found in little more than 65% of gastric resections.