Spontaneous duodenal hematoma: a rare complication of triple antithrombotic therapy case report.

Triple therapy is defined as concurrent use of an anticoagulant and dual antiplatelet therapy. We aimed to review the clinical course of a patient who developed a spontaneous duodenal hematoma on triple therapy and appraise current guidelines regarding triple antithrombotic therapy use. A 59-year-old man presented with acute heart failure and an apical mural thrombus. After medical stabilization, the patient underwent elective coronary stent placement. He was placed on triple antithrombotic therapy and subsequently developed a spontaneous duodenal hematoma. This case describes a rare but potentially fatal complication of triple therapy and underscores the importance of underutilizing this therapy. In conclusion, we report the clinical presentation and management of a rare bleeding complication in a patient on triple therapy.

The use of multiple types of blood-thinning medications is common in patients with blood clots, atrial fibrillation and heart disease, which can increase their risk of bleeding. We present the case of a rare type of gastrointestinal bleeding (a spontaneous duodenal hematoma) that occurred shortly after a patient with new heart failure and a blood clot in the left ventricle was placed on three different types of blood-thinning medications following a cardiac stent procedure. This case highlights the importance of careful management of comorbid cardiac conditions as well as the avoidance of using three blood-thinning medications simultaneously.

A safe and simple method for axIABP placement using a left axillary-radial technique.

In patients with severe heart failure, a percutaneous axillary intraaortic balloon pump (axIABP) may permit ambulation while awaiting destination therapy. Traditionally, an "axillary-femoral" approach has been used with femoral access for axillary angiography during insertion. We describe an "axillary-radial" technique for axIABP insertion and removal using the left radial artery.

Orbital Atherectomy for Treatment of Severely Calcified Coronary Artery Bifurcation Lesions: A Multicenter Analysis.

OBJECTIVE: This study evaluated the safety and efficacy of orbital atherectomy (OA) for the treatment of severely calcified coronary artery bifurcation lesions. BACKGROUND: Percutaneous coronary intervention (PCI) of severely calcified coronary artery lesions is associated with lower procedural success and higher rates of target lesion failure compared to non-calcified lesions. OA is an effective treatment for calcified coronary artery lesions prior to stent implantation. However, there is little data regarding the safety and efficacy of OA in patients with coronary artery bifurcation lesions. METHODS: Data were obtained from analysis of patients with severe coronary artery calcification who underwent OA and coronary stent implantation at ten high-volume institutions. Data were pooled and analyzed to assess peri-procedural outcomes and 30-day major adverse cardiac events (MACE). RESULTS: A total of 1156 patients were treated with OA and PCI. 363 lesions were at a coronary artery bifurcation. There were no statistically significant differences in baseline characteristics between the bifurcation and non-bifurcation groups. In the bifurcation group, treatment involved the left anterior descending artery and its branches more frequently and right coronary artery less frequently. After propensity score matching, the 30-day freedom from MACE was not statistically significant between the two groups. CONCLUSION: In this multicenter cohort analysis, patients with severely calcified coronary bifurcation lesions had low rates of MACE and target vessel revascularization at 30 days at rates comparable to non-bifurcation lesions. This analysis demonstrates that OA is safe and effective for complex coronary lesions at both bifurcation and non-bifurcation locations.

Procedural and Long-Term Ischemic Outcomes of Tight Subtotal Occlusions Treated with Orbital Atherectomy: An ORBIT II Subanalysis.

BACKGROUND/PURPOSE: Orbital atherectomy is an effective treatment strategy to modify severely calcified coronary lesions prior to stent placement. Traversing a severely calcified subtotal occlusion with the crown may be more challenging compared with a less severely stenotic lesion. The purpose of this ORBIT II subanalysis was to evaluate outcomes post-orbital atherectomy (OA) treatment of lesions with ≥95% stenosis. METHODS/MATERIALS: ORBIT II, a single-arm, prospective, multicenter trial, enrolled 443 subjects with severely calcified coronary lesions. Patients with chronic total occlusions were excluded from the trial. Subjects with the OA device activated were stratified based on pre-procedure percent stenosis: ≥95% stenosis (N = 91) and <95% stenosis (N = 341). Procedural success and 3-year major adverse cardiac event (MACE) rates were compared. RESULTS: The severe angiographic complications rates were 6.6% and 6.7% in the ≥95% and <95% stenosis groups, respectively. There was no significant difference in procedural success (94.5% vs. 88.3%, p = 0.120). 3-year MACE rates were similar (27.1% vs. 22.5%, p = 0.548), as were the rates of cardiac death (5.7% vs. 7.1%, p = 0.665) and MI (7.9% vs. 12.1%, p = 0.244). The TVR rate was higher in the ≥95% stenosis group (19.1% vs. 7.5%, p = 0.004). CONCLUSIONS: In ORBIT II, OA treatment of lesions with ≥95% stenosis resulted in a high rate of procedural success. Although the 3-year revascularization rate was higher in the ≥95% stenosis group, it is not unexpected given the challenge of treating such complex lesions. The results of this analysis suggest that OA may be a reasonable treatment strategy for tight, severely calcified subtotal occlusions. SUMMARY: The purpose of this ORBIT II subanalysis was to evaluate outcomes post-orbital atherectomy (OA) treatment of lesions with ≥95% stenosis. In ORBIT II, OA treatment of lesions with ≥95% stenosis resulted in a high rate of procedural success. Although the 3-year revascularization rate was higher in the ≥95% stenosis group, it is not unexpected given the challenge of treating such complex lesions. The results of this analysis suggest that OA may be a reasonable treatment strategy for tight, severely calcified subtotal occlusions.

Treatment of radial artery occlusions using balloon angioplasty and localized intra-arterial abciximab.

OBJECTIVES: To study an alternative strategy for the treatment of radial artery occlusion (RAO) using balloon angioplasty and intrathrombus administration of abciximab. BACKGROUND: RAO is a well-described complication of transradial procedures. The optimal method to restore the patency of the radial artery following its occlusion remains unclear. Spontaneous recanalization can occur in some patients and systemic anticoagulation can be recommended but is often unsuccessful. METHODS: A retrospective review of all patients in our database from 2009 to 2013 with RAO who underwent treatment with balloon angioplasty and intra-arterial abciximab administered directly at the site of occlusion. RESULTS: Four patients with symptomatic RAO following transradial catheterization were treated with balloon angioplasty and a 90-second intrathrombus infusion of abciximab. All procedures were successful and patency was documented the following day with duplex sonography and again at follow-up (mean 189 days). The patients also remained free of symptoms at follow-up. The fifth patient was treated with balloon angioplasty alone. This patient suffered symptomatic reocclusion of the radial artery. CONCLUSIONS: Balloon angioplasty and intrathrombus administration of abciximab via a catheter appears to be a safe, effective, and durable technique for reestablishing the patency of an occluded radial artery following transradial catheterization. Larger studies are needed to confirm our findings and establish the role for this technique in an algorithm for treatment of RAO.

Intracoronary glycoprotein IIb/IIIa inhibitor infusion via a perfusion coronary catheter to decrease thrombus burden: results from the ClearWay™ Multicenter Registry.

OBJECTIVES: This multicenter registry aimed to assess the ClearWay™ (CW) perfusion catheter in reduction of thrombus burden and improvement of the coronary flow during percutaneous coronary intervention (PCI). BACKGROUND: The presence or development of thrombus during PCI is associated with poor prognosis. METHODS: The utility of the CW perfusion catheter was assessed in patients who presented with intracoronary thrombus and were subjected to PCI. Data were collected by online survey from 15 US sites. Angiographic assessment of the coronary thrombus burden and the coronary flow after intracoronary infusion of glycoprotein (GP) IIb/IIIa inhibitors via the CW catheter was evaluated at baseline, immediately after infusion, and at the end of the procedure. The cohort included 102 patients; 71.6% presented with ST-elevation myocardial infarction (MI), 21.6% with non-ST-elevation MI, 5.9% with stable angina pectoris, and 2.9% with silent ischemia. The mean cohort age was 59.9±14.5years and comprised mostly of men (72.5%). RESULTS: GP IIb/IIIa inhibitors were infused via the CW catheter on average 1.1±0.3 times, with a mean pressure of 4.2±2.7atm and a mean infusion time of 55±55s. Following the infusion, Thrombolysis In Myocardial Infarction (TIMI) flow improved by 1° in 71 patients (69.6%) and by 2° in 51 patients (50%), while visible thrombus was reduced by 52% (p<0.001). In the final angiogram, TIMI flow was restored in 90.2% and clearance of a visible thrombus was obtained in 91.8% of the lesions. CONCLUSION: Intracoronary infusion of GP IIb/IIIa inhibitors via the perfusion CW catheter is associated with significant reduction in thrombus burden and with improvement of the coronary flow in patients presenting or developing thrombus burden during PCI.

Usage patterns and 2-year outcomes with the TAXUS express stent: results of the US ARRIVE 1 registry.

BACKGROUND: It is unclear how well the long-term safety and effectiveness of drug-eluting stents observed in tightly defined randomized controlled trials (RCT) translates to expanded use in routine practice. METHODS: The FDA-mandated TAXUS Express(2) ARRIVE 1 postmarket registry was designed to consecutively enroll patients receiving > or = 1 TAXUS stent in low-, medium-, and high-volume US sites (n = 50). All cardiac events plus an additional 20% sample of records were monitored and all endpoints were independently adjudicated. RESULTS: Detailed follow-up data through 2 years were compiled for 2,487 patients (95%). Simple-use (on-label) ARRIVE 1 patients (35%) had outcomes similar to 4 pooled TAXUS RCTs for death (3.5% vs. 3.4%, respectively, P = 0.78), Q-wave myocardial infarction (QWMI, 0.7% vs. 0.9%, P = 0.72), and stent thrombosis (ST, 2.2% vs. 1.2%, P = 0.12), but lower target vessel revascularization (7.8% vs. 13.4%, P < 0.0001). Compared with simple-use, cases representing expanded use to treat broader patient/lesion characteristics showed higher 2-year rates for death (7.4% vs. 3.5%, respectively, P = 0.0003), target lesion revascularization (9.4% vs. 5.8%, P = 0.0031), and ST (3.4% vs. 2.2%, P = 0.061, concentrated early in the first year). CONCLUSIONS: By including methods usually found in RCT, ARRIVE 1 captured a broad spectrum of disease treated in standard practice with high levels of ascertainment of clinical outcomes. In the more complicated cases, expectedly higher adverse event rates were seen compared to that found in the simple-use cases or pivotal RCT. These results have now been included in the Directions for Use, to aid in physician and patient decision-making.