Cardiologist operated ultrasound guided thrombin injection as a safe and efficacious first line treatment for iatrogenic femoral artery pseudoaneurysms.

OBJECTIVES: To assess the efficacy and safety of ultrasound guided thrombin injection (UGTI) as a first line treatment for post arterial cannulation iatrogenic femoral artery pseudoaneurysms (IFAP). BACKGROUND: IFAPs complicate up to 1% of diagnostic and 8% of interventional cardiac catheterisation procedures. UGTI remains a second line or non-attempted treatment after ultrasound guided manual compression (UGMC) and surgical repair in many centres. METHODS: A retrospective review was undertaken of 121 consecutive patients who received UGTI as a first line treatment for IFAPs following cardiac diagnostic, interventional or catheter ablation procedures between 1999 and 2011 at our centre. The mean patient age was 70.7 years and 63% were male. At the time of injection, 89% were on at least one antiplatelet or anticoagulant. Pseudoaneurysms had a mean maximum dimension of 26.7mm (range 10-122mm) and 25% were multilobed. UGTI was performed by an interventional cardiologist with a mean bovine thrombin dose of 648 IU (range 50-5000 IU). RESULTS: Primary success, defined as immediate IFAP thrombosis with UGTI, was achieved in 111 (92%) patients. Recurrence occurred in seven patients, three of whom required surgical repair. Multilobed IFAPs had significantly lower primary success rates than unilobed IFAPs (80% vs. 96%, p=0.016). Antiplatelet and anticoagulant use and IFAP size did not significantly affect outcomes. UGTI was not associated with any serious complications (such as thromboembolism, aneurysm rupture, venous thrombosis or abscess formation). CONCLUSION: Interventional cardiologist operated UGTI should be considered as a first line therapy for uncomplicated IFAPs following interventional and diagnostic cardiac procedures. Despite high rates of concomitant antiplatelet and antithrombotic therapy, initial thrombosis rates exceeded 90% and we did not experience serious complications.

Initial experience of a single referral centre using excimer laser coronary atherectomy-assisted expansion in undilatable stents: Excimer laser in undilatable stents.

Aims: Undilatable stents with severe peri-stent calcification are an important cause of target lesion failure and therapeutic options are limited. We report our initial experience with the safety and efficacy of excimer laser coronary atherectomy (ELCA)-assisted expansion of undilatable stents. Methods and results: ELCA was performed with saline, blood and contrast-enhanced trains. All lesions were post-dilated at high pressures and treated with a drug-eluting balloon. Thirty-one lesions with undilatable stents were included at a single centre with experienced operators from March 2016 to February 2021. The mean number of prior procedures for in-stent restenosis was three and 14 lesions had multiple layers of stent. Procedural success (>50% increase in minimal stent diameter [MSD]) and adequate stent expansion (MSD >70% of reference vessel diameter) was achieved in all lesions. At six-month follow-up (N=26 lesions), there were six periprocedural myocardial infarctions due to slow flow, two cardiac deaths and one target lesion revascularisation. There were no perforations. Conclusions: Our niche experience at a centre with experienced operators demonstrated that ELCA led to larger final lumen and stent dimensions in highly selected patients with undilatable stents and recurrent restenosis at the cost of relatively frequent slow flow.

Valve-in-Ring Transcatheter Heart Valve for Severe Tricuspid Regurgitation.

We report the case of a man with recurrent decompensated right-sided heart failure secondary to severe tricuspid regurgitation after tricuspid annuloplasty. He was unfit for repeat surgical intervention and thus was considered for a valve-in-ring transcatheter heart valve. We detail the procedural complexities encountered and our approach to overcoming them. (Level of Difficulty: Advanced.).

Final myocardial blush grade predicts troponin I elevation in unstable angina patients undergoing percutaneous intervention.

BACKGROUND: Improved myocardial blush grade is associated with better MACE outcomes in acute myocardial infarction patients but there are no data on myocardial blush grade (MBG) assessment in unstable angina (UA) patients treated with coronary intervention. We sought to evaluate the use of angiographic MBG assessment in a cohort of UA patients treated with angioplasty. METHODS: Three hundred and seventy-two consecutive UA patients (mean age 68+/-1 years) treated with PCI were included. No patients had a pre-procedural troponin I (TnI) elevation. Final MBG was recorded for the territory subserving the PCI treated culprit lesion in each patient and graded 0 (no blush), 1 (minimal blush), 2 (moderate blush) and 3 (normal blush). TnI (normal range <0.1 microg/L) was measured 24h post-procedure. Patients who did not have a TnI elevation (i.e. <0.1 microg/L) were ascribed a value of 0.1 microg/L. Patients were followed up (mean 962+/-83 days) by postal questionnaire. RESULTS: Baseline risk factors were comparable between final MBG groups. There was no significant difference in mortality rate between groups. Post-procedural troponin I elevations were 0.34+/-0.12, 0.68+/-0.26, 0.14+/-0.01 and 0.11+/-0.01 for MBG groups 0, 1, 2 and 3 (p<0.001). Patients with minimal MBG underwent proportionately more target vessel revascularisation (p<0.05). CONCLUSIONS: Improved blush grade in UA patients undergoing PCI is associated with lower post-procedural TnI elevation. Identification of UA patients with poor final MBG may allow a window of opportunity for the administration of adjuvant therapies to improve microvascular perfusion in the future.

Disassembly of a rotablator: getting out of a trap.

The rotablator burr rarely becomes trapped within calcified lesions. Manual traction can be ineffective and dangerous. We report a case that illustrates a novel technique involving use of a percutaneous snare in conjunction with partial disassembly of the rotablator device to remove a trapped burr without need for open surgical intervention.

New bifurcation stenting technique: shunt stenting.

The optimal treatment of bifurcation lesions remains controversial. We describe a new technique we term shunt stenting. This technique incorporates both the new technology of drug-eluting stents and a novel procedure for optimizing the ostial side branch stent positioning. To date, early angiographic and clinical follow-up have been encouraging.