Outpatient coronary stenting: femoral approach with vascular sealing.

Miniaturized devices and pressures for increased patient convenience and lowered cost have shortened length of stay for coronary interventions. A cohort of 60 patients was recruited to assess the feasibility of outpatient stenting with vascular sealing. Patients with stable and unstable angina or myocardial infarction > 24 hours were considered for this strategy. Mean time to hemostasis, ambulation and discharge were 6.1, 256 and 296 minutes, respectively, for the 6F group, and 11.0, 351 and 489 minutes for the 7 to 8F group. No acute procedural complications occurred, and there were no ischemic complications at 24 hours or 1 month. There was 1 pseudoaneurysm requiring surgical correction, but no other access site requiring treatment. The cost saved using the 6F approach is estimated at $478 and using the 8F approach, $437. Outpatient stenting using vascular sealing is feasible and safe, and may lead to significant nationwide cost reductions in the range of $40,000,000 yearly.

Outpatient coronary stenting using the femoral approach with vascular sealing.

PURPOSE: We report here the use of vascular sealing devices in conjunction with the use of small transfemoral guiding catheters to decrease time to ambulation, decrease cost associated with hospitalization and achieve early discharge. METHODS: Fifty patients were enrolled in this pilot project from two busy interventional practices between May 1997 and February 1999. Patients with stable or unstable angina or positive ETT and with recent myocardial infarction greater than 24 hours from the time of the procedure were included. Excluded patients included those who had received glycoprotein IIb/IIIa platelet inhibitors and those with intra-procedure access site complications. RESULTS: Of the 50 patients originally recruited, 49 underwent vascular sealing for hemostasis and 45 were discharged on the same day, as planned. Early home telephone follow-up was available on 41 of the 45 same-day discharge patients, of whom 30 noted no complaints. One patient, who had been re-accessed in the right femoral artery after a previous intervention, developed a pseudoaneurysm requiring surgical repair. One-month follow-up was available on all patients. No patient suffered a late ischemic event or access site complication requiring treatment. There were no instances of stent loss, acute closure or subacute thrombosis. CONCLUSION: Though limited by small numbers, this pilot study shows that selected patients undergoing coronary stenting via the femoral approach can be safely treated on an outpatient basis using vascular sealing devices. Cost savings may be significant using this strategy.

Prolonged intracoronary infusion of streptokinase: an alternative pharmacologic approach to extensive thrombus in native coronary artery.

Several reports suggest that pretreatment of intracoronary thrombus with fibrinolytic agents may reduce the risk for complications during subsequent balloon angioplasty. We report a case, for the first time, of successful lysis of an extensive thrombus in a native coronary artery by administering a prolonged intracoronary infusion of streptokinase to facilitate subsequent angioplasty and discuss the management strategy when intracoronary thrombus is encountered.

Diagnosis of stenosis in a pulmonary valve-conduit using an angioplasty guide and probing catheter.

A 42-year-old man who had undergone previous Blalock-Taussig anastomoses and placement of a homograft aortic valve-root conduit for tetralogy of Fallot presented with dyspnea at rest. Previous catheterization had shown homograft stenosis at the level of the pulmonic valve. Repeat catheterization necessitated the use of angioplasty guide and probing catheters to cross the stenosis, and pullback documented stenoses both across the homografted valve and within the homograft aortic root-native pulmonary artery conduit.

Exercise-related atrioventricular block. Influence of myocardial ischemia.

A 62-year-old woman was noted to have complete heart block immediately following an exercise stress test. Coronary arteriography subsequently revealed a significant lesion in the right coronary artery, which was successfully dilated. Thallium-exercise testing following angioplasty showed no evidence of inducible ischemia and no arrhythmia was seen, supporting the idea that exercise-related heart block may occur secondary to myocardial ischemia.

Effect of pretreatment with aspirin versus aspirin plus dipyridamole on frequency and type of acute complications of percutaneous transluminal coronary angioplasty.

It is unknown whether the addition of dipyridamole to aspirin as pretreatment for patients undergoing percutaneous transluminal coronary angioplasty (PTCA) decreases acute complications. In this study 232 patients were prospectively randomized to receive either aspirin 325 mg orally 3 times daily (group 1, n = 115) or aspirin 325 mg orally 3 times daily plus dipyridamole 75 mg orally 3 times daily (group 2, n = 117) before elective PTCA. All clinical, angiographic and PTCA-related variables were similar between groups. Angiographic success rate was 93% in both groups. Clinical success was achieved in 107 patients (92%) in group 1 and in 101 patients (88%) in group 2 (difference not significant). Q-wave myocardial infarction occurred in 2 patients (1.7%) in group 1 and 5 patients (4.3%) in group 2 (difference not significant). Emergency coronary artery bypass grafting was required in 3 patients (2.6%) in group 1 and 7 patients (6.1%) in group 2 (difference not significant). There was 1 in-hospital death (in group 2). In this study, the addition of dipyridamole to aspirin as pretreatment of patients undergoing PTCA did not significantly reduce acute complications compared to aspirin alone.

Platelet accumulation in experimental angioplasty: time course and relation to vascular injury.

Since platelet accumulation may be an important determinant of restenosis after angioplasty, the time course of 51Cr-labeled platelet accumulation after experimental angioplasty was evaluated in a deendothelialized, hypercholesterolemic rabbit preparation of atherosclerosis. Marked platelet accumulation (39.5 +/- 8.7 X 10(6) platelets/1 cm vessel length) was observed at 30 min and remained active until 4 hr after angioplasty. Total accumulation over 24 hr was 56.4 +/- 4.7 X 10(6) platelets/1 cm length. Histologic dissection was directly related to the degree of platelet accumulation, with 64 +/- 15 X 10(6) platelets/1 cm in the group with marked dissection and 8.7 +/- 3.7 X 10(6) platelets/1 cm in the group with minimal dissection (p less than .05). Increasing angiographic dissection also resulted in a trend toward increased platelet accumulation, and angiographic change in luminal diameter showed a significant correlation with platelet accumulation. It is concluded that marked platelet accumulation occurs early after transluminal angioplasty and is related to the extent of dissection. Restenosis may result from a complex interaction of platelet accumulation, vascular damage, and blood flow.