The absence of evidence is not the evidence of absence: A case report on the challenges in diagnosing ostial left main stenosis.

Because left main (LM) coronary artery stenosis is known to have higher mortality and morbidity compared to lesions in other territories, an early diagnosis and management are crucial to prevent worse outcomes. Due to limitations of coronary angiography (CA), the diagnosis of ostial LM stenosis solely based on CA may result in underdiagnosis of such lesions. Therefore, additional testing is often needed either by pressure wire or intravascular ultrasound (IVUS) to make appropriate diagnosis. We, hereby, present a case of left main ostial stenosis in a 56-year-old male that was missed on multiple coronary angiograms, and highlights many of the considerations in the diagnosis of LM disease.

Novel approach to coronary artery perforation repair.

Coronary artery perforation (CAP) during percutaneous coronary intervention is a rare but serious complication. Treatment options of CAP include prolonged balloon inflation, covered stent, and coil embolization. Although most cases of CAP can be treated with prolonged balloon inflation, some cases, especially Ellis grade III CAP require covered stents or coiling. Covered stents may require a large bore guide catheter and have a high rate of restenosis, which can be a limiting factor in patients with severe peripheral arterial disease. Coil embolization is generally used in distal CAP because coiling in the proximal vessels results in a large territory of infarction. We present a case of an Ellis grade III CAP during rotational atherectomy successfully treated with a novel coiling technique whereby the thrombogenic coil extends through the perforation outside of the vessel, and the intraarterial portion of the coil is excluded from the lumen by drug-eluting stent placement over the proximal portion of the coil.

Transulnar versus transradial access for coronary angiography or percutaneous coronary intervention: A meta-analysis of randomized controlled trials.

BACKGROUND: Although transfemoral access (TFA) remains the standard of care for patients undergoing coronary angiography (CA) or percutaneous coronary intervention (PCI) in the USA, TRA is being increasingly used over TFA due to lower bleeding and mortality rates on the basis of meta-analyses and recently published MATRIX trial. In patients with unsuccessful ipsilateral radial access, TUA has been used as an alternative approach. The randomized controlled trials (RCTs) comparing TUA and TRA have reached mixed conclusions regarding the use of transulnar approach for coronary procedures. OBJECTIVES: To systematically review and perform a meta-analysis of published RCTs comparing the safety and efficacy of transulnar access (TUA) vs. transradial access (TRA) in patients undergoing CA or PCI. METHODS: PubMed, EMBASE, and CENTRAL databases were searched for RCTs since inception through December, 2014. Meta-analysis was performed using random-effects model. RESULTS: Five RCTs involving 2,744 total patients were included in the meta-analysis. TUA compared with TRA had similar risks of MACE [risk ratio (RR): 0.87; 95% confidence interval (CI): 0.56-1.36; P = 0.54] and access-related complications [RR: 0.92 (0.67-1.27); P = 0.62]. Higher rates of access cross-over [RR: 2.31 (1.07-4.98); P = 0.003] and number of punctures [1.57 vs. 1.4; mean difference (MD): 0.17; 95% CI: 0.08-0.26; P = 0.0002] were noted with TUA. There was no difference in arterial access time [12.8 vs. 10.9 min; MD: 1.86 (-1.35-5.7); P = 0.26], fluoroscopy time [7.6 vs. 7.2 min; MD: 0.37 (-0.39 - 1.13); P = 0.34] and contrast volume [151 vs. 153.7 ml; MD: -2.74 (-17.21 - 11.73); P = 0.71]. CONCLUSION: For patients requiring CA or PCI, TUA compared with TRA has similar efficacy and safety except for higher puncture rates and access cross-over.

Innovation in Data Abstraction, Education, and Consistent Application of Best Practice Guidelines: Experience and Real-World Results from a University Hospital in a Cost-Centric Environment.

BACKGROUND: Adhering to core measures and consistent application of best practice guidelines in patients with acute coronary syndromes is challenging for hospitals. METHODS: A task force addressed gaps in care and adherence to guidelines, and included Emergency Medical Services (EMS) in the decision pathway. RESULTS: Previously, our institutional performance on most core metrics was in the lower tertile nationally. Task force recommendations and the recognition of EMS's role in care produced significant improvement. Seventy-four percent of our cardiac catheterization laboratory activations were prehospital activations, which resulted in expeditious revascularization. Our composite acute myocardial infarction (MI) performance in 2014 was 97.5% for Q1, 97.2% for Q2, 97.3% for Q3, and 97.3% for Q4. Compliance in most of the individual parameters was greater than 95%. CONCLUSION: Identification of systemic gaps, application of best practice guidelines, and partnering with EMS improved our core measures and patient outcomes without the need for additional resources.

Post-surgical External Coronary Artery Compression: A Rare Cause of ST Elevation Myocardial Infarction.

Iatrogenic ST elevation myocardial infarction (STEMI) after aortic valve surgery is a rare complication. Myocardial infarction (MI) due to mediastinal drain tube compression on the native coronary artery is also seen rarely. We present a case of ST elevation inferior myocardial infarction due to post-surgical drain tube placed after aortic valve replacement compressing on the right-sided posterior descending artery (rPDA). A 75-year-old female presented with exertional chest pain and was found to have severe aortic stenosis (AS). After a normal coronary angiogram and proper risk stratification, the patient underwent surgical aortic valve replacement (SAVR). One day after surgery in the post-operative area, the patient was complaining about central chest pain suggestive of anginal pain. Electrocardiogram (ECG) revealed that she has ST elevation myocardial infarction in the inferior wall. Immediately, she was taken to the cardiac catheterization laboratory, which revealed that she has occlusion of the posterior descending artery due to compression by a post-operative mediastinal chest tube. All features of myocardial infarction resolved after simple manipulation of the drain tube. The compression of the epicardial coronary artery after aortic valve surgery is very unusual. There are a few cases of other coronary artery compression due to mediastinal chest tube, but posterior descending artery compression causing ST elevation inferior myocardial compression is unique. Though rare, we need to be vigilant about mediastinal chest tube compression, which can cause ST elevation myocardial infarction after cardiac surgery.

Routine Invasive Strategy in Elderly Patients with Non-ST Elevation Acute Coronary Syndrome: An Updated Systematic Review and Meta-analysis of Randomized Trials.

Invasive treatment with coronary angiography is preferred approach for patients with non-ST elevation acute coronary syndrome (NSTE-ACS) compared to medical therapy alone. The results from the randomized clinical trials (RCT) that compared the invasive treatment strategy vs. conservative approach in the elderly (≥75 years) with NSTE-ACS has been inconsistent. To compare invasive and conservative strategies in the elderly (>75 years) with NSTE-ACS. We searched PubMed, Cochrane CENTRAL Register and ClinicalTrials.gov (inception through July 10, 2021) for RCTs comparing invasive and conservative strategies in the elderly with NSTE-ACS. We used random-effects model to calculate risk ratio (RR) with 95% confidence interval(CI). A total of 6 RCT including 2,323 patients were included in the meta-analysis. The median follow-up duration was 13.5 months. When invasive approach was compared to conservative strategy, it showed no difference in all-cause mortality in patients aged ≥75 years with NSTE-ACS (RR of 0.85; 95% CI 0.70-1.04; P = 0.12; I2 = 0%). There was significant reduction in MI (RR 0.59; 95% CI 0.49 0.71; P < 0.001; I2 = 0%) and unplanned revascularization (RR 0.30, 95% CI 0.17-0.53, P <0.001, I2 = 0%). Invasive strategy was associated with higher risk of major bleeding when compared to conservative treatment (RR 2.12, 95% CI 1.21-3.74, P = 0.009, I2 = 0%). Comparison of both strategies showed no significant difference in stroke (RR 0.75; 95% CI 0.38-1.46, P = 0.40; I2 = 0%). This updated meta-analysis suggests that in elderly patients (>75 years) with NSTE-ACS, a routine invasive strategy is associated with a reduction in MI and revascularization, while increasing the risk of major bleeding, but without difference in all-cause mortality and stroke.

Survival of geriatric idiopathic pulmonary arterial hypertension patients.

BACKGROUND: Idiopathic pulmonary arterial hypertension (IPAH) is increasingly being diagnosed in patients of advanced years. We sought to investigate observed vs expected mortality among geriatric IPAH patients treated with specific pulmonary arterial hypertension (PAH) therapy. METHODS: From the University of Connecticut's Pulmonary Vascular Disease Program database, 20 IPAH patients over 65 years of age were identified. Patient demographics, cardiopulmonary hemodynamics, PAH therapy, and mortality were retrospectively analyzed. Based on observed follow-up time, the probability of death was calculated for each subject using a prediction formula for PAH patients developed by the National Institutes of Health (NIH). Byar's method for Poisson counts was used to compare observed and expected tallies of deaths within the study sample. A P value < or = 0.05 was considered statistically significant. RESULTS: The mean age of the 20 geriatric IPAH patients was 77 years (+/- 6.6) of which 70% were female. The mean cardiopulmonary hemodynamic values for the cohort were: right atrial pressure: 10 mmHg (+/- 4); mean pulmonary artery pressure: 45 mmHg (+/- 9); pulmonary artery occlusion pressure: 11 mmHg (+/- 3); cardiac output: 4.1 L/min (+/- 1.2); cardiac index: 2.3 L/min (+/- 0.5); and pulmonary vascular resistance: 712 dynes / sec / cm-5 (+/- 319). Fourteen subjects received PAH monotherapy with bosentan, sildenafil, or epoprostenol. Six subjects received PAH combination therapy with bosentan, sildenafil, iloprost, or treprostinil. Total follow-up across the 20 subjects was 58.7 years, with average follow-up of 2.9 yrs (+/- 1.7) per subject. Based upon the NIH formula, the expected number of deaths for this cohort was 9.4. During follow-up, three deaths actually occurred. Thus, observed mortality was only 31.9% of expected (P = 0.03, 95% C.I. = [6.4%, 93.2%]). CONCLUSION: Geriatric patients are increasingly being diagnosed with IPAH. Efficacy of PAH therapy in geriatric patients is unknown. In this cohort of subjects, the outcomes of older adults treated with specific PAH therapy demonstrates improved survival relative to that predicted by the NIH formula.

A Case of Isolated External Iliac Vein Compression Syndrome and the Role of Advanced Imaging.

Isolated external iliac vein compression syndrome is an uncommon cause of nonthrombotic venous stenosis that causes chronic venous hypertension leading to painful swelling, skin discoloration, and ulcer formation. We present a case of an 86-year old man with refractory lower extremity edema for several years who had been treated with diuretics and antibiotics without relief of symptoms. With the help of invasive and noninvasive imaging modalities, we were able to diagnose and manage isolated nonthrombotic left external iliac vein stenosis as a result of ipsilateral external iliac artery compression.

A Successful CardioMEMS™ Implantation via Brachial Vein Access: A Case Report.

The CardioMEMS™ HF system (Abbott, Chicago, IL), a wireless pulmonary artery (PA) pressure sensor, was approved by the FDA after demonstration of reduction of heart failure hospitalization in New York Heart Association class III patients. These devices are implanted into the desired PA branch via either common femoral or jugular vein access. However, in some patients who cannot undergo the procedure via these routine access sites for various reasons, alternative access is needed. We describe, to our knowledge, the first case of successful CardioMEMS™ implantation via brachial vein access.

Renal Denervation in the Management of Hypertension: A Meta-Analysis of Sham-Controlled Trials.

INTRODUCTION: Sympathetic renal denervation (RD) can potentially reduce blood pressure (BP) in people with resistant hypertension (RH) and uncontrolled hypertension (UH). While a large sham-controlled trial (SCT) showed similar outcomes of RD vs. sham control, in the recent trials, RD was effective in reducing BP in hypertensive people. We performed a meta-analysis of SCTs of RD vs. sham in hypertensive patients. METHODS: Multiple electronic databases were searched since inception through September 2018 for SCTs that compared RD vs. sham. Change in 24-hour, daytime and nighttime ambulatory and office BP were efficacy outcomes. Various adverse events were safety outcomes. RESULTS: A total of 7 SCTs were included in the analysis. RD vs. sham significantly reduced 24-hour ambulatory SBP by 3.45 mmHg [95% CI (-5.01, -1.88); P < 0.0001] and DBP by 1.87 mmHg [(-3.59, -0.15); P = 0.01], office DBP by 2.97 mmHg [(-4.76, -1.18); P = 0.001] and daytime ambulatory SBP by 4.03 mmHg [(-6.37, -1.68); P = 0.0008] and DBP by 1.53 mmHg [(-2.69, -0.37); P = 0.01]. RD vs. sham caused non-significant reduction in office SBP by 3.99 mmHg [(-8.10, 0.11); P = 0.06] and nighttime ambulatory SBP by 3.05 mmHg [(-6.86, 0.75), P = 0.12] and DBP by 1.03 mmHg [(-3.01, 0.96); P = 0.31]. There was no difference in the risk of hypertensive crisis/emergency [0.62; 0.24-1.60; P = 0.33] between the two strategies. CONCLUSIONS: Current meta-analysis shows that RD reduces ambulatory BP and office DBP in patients with hypertension. Future trials with longer follow-up should confirm these findings.

NOAC-Based Sual Therapy Versus Warfarin-Based Triple Therapy After Percutaneous Coronary Intervention or Acute Coronary Syndrome in Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis.

BACKGROUND: Several randomized clinical trials (RCTs) have compared the use of dual therapy (DT), or one of the non-vitamin K antagonist oral anticoagulants (NOAC) with a P2Y12 agent, versus triple therapy (TT), consisting of a vitamin-K antagonist (VKA) along with dual antiplatelet therapy, in patients with concomitant atrial fibrillation after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS). We performed a meta-analysis and systematic review of RCTs to evaluate the safety and efficacy of NOAC-based DT in such patients. METHODS: The major efficacy outcome was major adverse cardiovascular and cerebrovascular events (MACCE), defined as a composite of mortality, myocardial infarction, stroke, stent thrombosis (ST), and urgent revascularization. The International Society on Thrombosis and Hemostasis (ISTH) major or clinically relevant non-major bleeding (CRNM) was the major primary safety outcome. RESULTS: A total of 4 RCTs were included in the meta-analysis with 7942 total patients for analysis (DT: 4377 & TT: 3565). Compared to TT, DT resulted in similar risk of MACCE (OR: 1.12; 95% CI: 0.94-1.34; P = 0.20) and other efficacy endpoints with a trend in increased risk of ST in the DT group (1.55; 0.99-2.44; P = 0.06). DT resulted in lower risk of ISTH major or CRNM bleeding (0.56; 0.41-0.76; P < 0.01), and all other bleeding outcomes except for a trend of reduced risk of TIMI minor bleeding. CONCLUSION: In conclusion, patients with atrial fibrillation who undergo PCI or develop ACS, NOAC-based dual therapy reduces bleeding outcomes without significantly increasing ischemic outcomes. Future trials should explore the possible differences in stent thrombosis.

Multimodality Imaging of a Right Atrial Cardiac Mass.

Work up of a right atrial mass usually requires multimodality imaging and sometimes a biopsy to affirm histological diagnosis. We present a case of a 74-year-old woman with primary cutaneous melanoma (wildtype BRAF) of the right toe who was found to have a large heterogeneous mass in the right atrium on routine surveillance CT scan. She did not have any cardiac symptoms. Vital signs and physical examination were unremarkable. Cardiac magnetic resonance (CMR) imaging demonstrated a bilobed mass with an intramural component and a mobile blood pool component, with interposed thrombus. Three-dimensional transesophageal echocardiogram (3D-TEE) revealed the mass and its site of attachment on the lateral wall of the right atrium. Given the large size of the tumor and its potential for obstruction of tricuspid inflow, the right atrial mass was surgically resected. Pathology confirmed metastatic melanoma. The patient tolerated cardiac surgery well and was discharged shortly thereafter. In the present case, a large cardiac metastasis was discovered in the absence of clinically detectable disease elsewhere. CMR allowed a comprehensive evaluation of the location, extension, and tissue characterization of the cardiac mass. Transthoracic echocardiogram (TTE) and 3D-TEE allowed assessment of the hemodynamic consequences of this mass and aided in operative planning.

Late-Onset Nonthrombotic Left Common Iliac Vein Compression Secondary to Degenerative Lumbar Disc: A Case Report of May-Thurner Variant.

May-Thurner syndrome (MTS) refers to venous outflow obstruction caused by extrinsic compression of the left common iliac vein (LCIV) by the overlying pulsatile right common iliac artery against lumbar vertebrae. The classic clinical presentation is acute unilateral left leg painful swelling due to deep venous thrombosis in a young woman in the second or third decade of life. We present a case of a 66-year-old woman who presented with late-onset left leg swelling caused by nonthrombotic venous hypertension due to degenerative lumbar disc bulge leading to LCIV compression against the left common iliac artery which was confirmed by computed tomography and intravascular ultrasound. Our case highlights the importance of high index of suspicion for MTS in elderly patients with unilateral leg swelling and the importance of multimodality imaging for understanding the mechanism and appropriate treatment of MTS.

Stenosis Caused by Suture-Mediated Vascular Closure Device in an Angiographic Normal Common Femoral Artery: Its Mechanism and Management.

Vascular closing devices (VCDs) are widely used to replace manual compression at the femoral puncture site and to reduce the discomfort of patients undergoing percutaneous coronary procedure by shortening bed rest. Among the vascular complications related to these devices, the femoral artery stenosis or occlusion is rarely reported, and its standard management is not well established. We report a case of symptomatic femoral artery stenosis caused by suture-mediated VCD and managed using rotational atherectomy device and balloon angioplasty. In addition, we propose the possible mechanisms for this complication.

Ischemic and bleeding outcomes of triple therapy in patients on chronic anticoagulation undergoing percutaneous coronary intervention: A meta-analysis of randomized trials.

BACKGROUND: Triple therapy (TT) that includes oral anticoagulation and dual antiplatelet therapy is recommended in patients who are on chronic anticoagulation and undergo percutaneous coronary intervention (PCI). The randomized clinical trials (RCTs) comparing the effectiveness and safety of TT compared to double therapy (DT), which consists of an oral anticoagulation and one of the P2Y12 inhibitors, have shown increased risk of bleeding; however, none of the individual studies were powered to show a difference in ischemic outcomes. To compare the clinical outcomes of TT and DT, we performed this meta-analysis of RCTs. METHODS: Electronic search of PubMed, EMBASE and Cochrane CENTRAL databases was performed for RCTs comparing TT and DT in patients who were on oral anticoagulation (Vitamin K antagonist or non-vitamin K antagonist oral anticoagulant) who underwent PCI. All-cause and cardiovascular mortality, myocardial infarction (MI), stroke, stent thrombosis (ST) and TIMI major and minor bleeding were the major outcomes. RESULTS: An analysis of 5 trials including 10,592 total patients showed that TT, compared to DT, resulted in non-significant difference in risk of all-cause [odds ratio (OR); 1.14;95% confidence interval (CI):(0.80-1.63); P = 0.46) and cardiovascular mortality [1.43(0.58-3.36); P = 0.44], MI [0.88 (0.64-1.21); P = 0.42], stroke [1.10(0.75-1.62); P = 0.63] and ST [0.82(0.46-1.45); P = 0.49]. TT, compared to DT resulted in higher risk of TIMI major bleeding [1.61(1.09-2.37); P = 0.02], TIMI minor bleeding [1.85(1.23-2.79); P = 0.003] and TIMI major and minor bleeding [1.81 (1.38-2.38); P < 0.0001; I2 = 52%]. CONCLUSION: Compared to DT, the patients receiving TT are at a higher risk of major and minor bleeding with no survival benefit or impact on thrombotic outcomes.

Who benefits from percutaneous closure of patent foramen ovale vs medical therapy for stroke prevention? In-depth and updated meta-analysis of randomized trials.

BACKGROUND: A few randomized clinical trials (RCT) and their meta-analyses have found patent foramen ovale closure (PFOC) to be beneficial in prevention of stroke compared to medical therapy. Whether the benefit is extended across all groups of patients remains unclear. AIM: To evaluate the efficacy and safety of PFOC vs medical therapy in different groups of patients presenting with stroke, we performed this meta-analysis of RCTs. METHODS: Electronic search of PubMed, EMBASE, Cochrane Central, CINAHL and ProQuest Central and manual search were performed from inception through September 2018 for RCTs. Ischemic stroke (IS), transient ischemic attack (TIA), a composite of IS, TIA and systemic embolism (SE), mortality, major bleeding, atrial fibrillation (AF) and procedural complications were the major outcomes. Random-effects model was used to perform analyses. RESULTS: Meta-analysis of 6 RCTs including 3560 patients showed that the PFOC, compared to medical therapy reduced the risk of IS [odds ratio: 0.34; 95% confidence interval: 0.15-0.78; P = 0.01] and the composite of IS, TIA and SE [0.55 (0.32-0.93); P = 0.02] and increased the AF risk [4.79 (2.35-9.77); P < 0.0001]. No statistical difference was observed in the risk of TIA [0.86 (0.54-1.38); P = 0.54], mortality [0.74 (0.28-1.93); P = 0.53] and major bleeding [0.81 (0.42-1.56); P = 0.53] between two strategies. Subgroup analyses showed that compared to medical therapy, PFOC reduced the risk of stroke in persons who were males, ≤ 45 years of age and had large shunt or atrial septal aneurysm. CONCLUSION: In certain groups of patients presenting with stroke, PFOC is beneficial in preventing future stroke compared to medical therapy.

Use of rotational atherectomy for reducing significant dissection in treating de novo femoropopliteal steno-occlusive disease after balloon angioplasty.

BACKGROUND: Development of arterial dissection is thought to be an important key factor for bailout stenting in femoropopliteal disease. We aimed to evaluate the difference in dissection rate and outcomes between the treatment group with rotational atherectomy and without it. METHODS: From January 2011 to October 2016, we compared the angiography after balloon angioplasty (BA) of de-novo, femoropopliteal, steno-occlusive lesions whether they were treated by rotational atherectomy prior to the BA or not. Fifty-nine lesions (8 occlusions; 3 involving popliteal segment; lesion length: 86.3 ± 66.8 mm) in 44 patients (29 males; mean age 66.9 ± 9.7 years) were enrolled for this review. RESULTS: Forty-two lesions were treated using rotational atherectomy, prior to BA while 17 were recanalized firstly by BA. Clinical and lesion characteristics were not different between the groups. However, the rate of significant arterial dissection (type C to F) was lower in the atherectomy group (88.2% vs. 42.9%; P = 0.001). In multivariate analysis, use of the atherectomy device was the only risk factor for prevention of development of significant dissection (P = 0.013; OR = 0.12; 95% CI: 0.025-0.642). Patients were treated either by the angioplasty alone, drug coated balloon or stent insertion. There was lower trend in target vessel revascularization and primary patency toward the atherectomy group (low rank P = 0.108 and 0.166), however secondary patency was significantly better (low rank P = 0.001). CONCLUSIONS: Rotational atherectomy before BA reduced the rate of significant dissection and therefore, might be a valuable option for minimizing need of bailout stenting.

A comparison of standard versus low dose heparin on access-related complications after coronary angiography through radial access: A meta-analysis of randomized controlled trials.

BACKGROUND: Transradial access (TRA) is preferred for coronary angiography (CA) or percutaneous coronary intervention due to reduced access-related complications, and mortality especially for patients with ST elevation myocardial infarction. Radial artery occlusion (RAO) is a known complication of TRA, and precludes its use as a future access site, conduit for coronary artery bypass grafting or for hemodialysis fistula placement. Although a standard dose (SD) heparin of 5000 Units is used during TRA, the risks of RAO and hematoma compared to lower dose (LD) remain unclear. To compare the risks of RAO and hematoma using SD vs. LD heparin after CA through TRA, we performed a meta-analysis of randomized controlled trials (RCT). METHODS: We searched PubMed, EMBASE, CINAHL and CENTRAL for RCTs since inception through 06/30/2017 and used random effects model for analysis. The outcomes analyzed were RAO, hematoma formation and radial artery compression time (RACT). RESULTS: We identified a total of 6 RCTs with a total of 2239 patients. SD heparin resulted in a trend toward a lower risk of RAO [4.2% vs. 10.7%; risk ratio (RR): 0.40, 95% confidence interval (CI): 0.16-1.0; P=0.05], a trend toward increased risk of hematoma [2.2% vs. 1.1%; 1.83 (0.91-3.66); P=0.09], and a longer duration of RACT [mean difference: 9.64min (4.01-15.28); P=0.0008] compared to LD. CONCLUSIONS: The current meta-analysis showed a trend towards reduction in the risk of RAO with the use of standard dose heparin. Larger randomized trials should explore the appropriate dosing of heparin to prevent radial artery occlusion.

Comparison of manual compression and vascular hemostasis devices after coronary angiography or percutaneous coronary intervention through femoral artery access: A meta-analysis of randomized controlled trials.

OBJECTIVES: To compare the efficacy and safety of manual compression (MC) with vascular hemostasis devices (VHD) in patients undergoing coronary angiography (CA) or percutaneous coronary intervention (PCI) through femoral artery access. INTRODUCTION: The use of femoral artery access for coronary procedures may result in access-related complications, prolonged immobility and discomfort for the patients. MC results in longer time-to-hemostasis (TTH) and time-to-ambulation (TTA) compared to VHDs but its role in access-related complications remains unclear in patients undergoing coronary procedures. METHODS: We searched MEDLINE, EMBASE, Cochrane CENTRAL and relevant references for English language randomized controlled trials (RCT) from inception through September 30, 2016. We performed the meta-analysis using random effects model. The outcomes were time-to-hemostasis, time-to-ambulation, major bleeding, large hematoma >5cm, pseudoaneurysm and other adverse events. RESULTS: The electronic database search resulted in a total of 44 RCTs with a total of 18,802 patients for analysis. MC, compared to VHD resulted in longer TTH [mean difference (MD): 11.21min; 95% confidence interval (CI) 8.13-14.29; P<0.00001] and TTA [standardized mean difference: 1.2 (0.79-1.62); P<0.00001] along with excess risk of hematoma >5cm formation [risk ratio (RR): 1.38 (1.15-1.67); P=0.0008]. MC resulted in similar risk of major bleeding [1.01 (0.64-1.60); P=0.95] pseudoaneurysm [0.99 (0.75-1.29); P=0.92], infections [0.52 (0.25-1.10); P=0.09], need of surgery [0.60 (0.29-1.22); P=0.16), AV fistula [0.93 (0.68-1.27); P=0.63] and ipsilateral leg ischemia [0.95 (0.57-1.60); P=0.86] compared to VHD. CONCLUSION: Manual compression increase time-to-hemostasis, time-to-ambulation and risk of hematoma formation compared vascular hemostasis devices.

Retrograde Use of Frontrunner Catheter in Superficial Femoral Artery for Flushing Long Segment Occlusions Involving Distal Common Femoral Artery.

We present the case of an 81-year-old female with flush occlusion of the superficial femoral artery (SFA) and percutaneous transluminal angioplasty. Initially, the antegrade approach failed due to flush occlusion without stump. Hard, round surfaced, calcific, and eccentric plaque of the ostium of SFA was also present, which involved distal common femoral artery (CFA). Thus, we successfully used a Frontrunner catheter for retrograde reentry at the lower position of the CFA. Various treatment strategies involving Frontrunner and atherectomy devices could make percutaneous procedures possible in femoropopliteal occlusive disease, involving the CFA.