Ultrasound guidance for transfemoral access in coronary procedures: an individual participant-level data metaanalysis from the femoral ultrasound trialist collaboration.

BACKGROUND: Randomised controlled trials of ultrasound (US)-guided transfemoral access (TFA) for coronary procedures have shown mixed results. AIMS: We aimed to compare US-guided versus non-US-guided TFA from randomised data in an individual participant-level data (IPD) meta-analysis. METHODS: We completed a systematic review and an IPD meta-analysis of all randomised controlled trials comparing US-guided versus non-US-guided TFA for coronary procedures. We performed a one-stage mixed-model meta-analysis using the intention-to-treat population from included trials. The primary outcome was a composite of major vascular complications or major bleeding within 30 days. RESULTS: A total of 2,441 participants (1,208 US-guided, 1,233 non-US-guided) from 4 randomised clinical trials were included. The mean age was 65.5 years, 27.0% were female, and 34.5% underwent a percutaneous coronary intervention. The incidence of major vascular complications or major bleeding (34/1,208 [2.8%] vs 55/1,233 [4.5%]; odds ratio [OR] 0.61, 95% confidence interval [CI]: 0.39-0.94; p=0.026) was lower in the US-guided TFA group. In the prespecified subgroup of participants who received a vascular closure device, those randomised to US-guided TFA experienced a reduction in the primary outcome (2.1% vs 5.6%; OR 0.36, 95% CI: 0.19-0.69), while no benefit for US guidance was observed in the subgroup without vascular closure devices (4.1% vs 3.3%; OR 1.21, 95% CI: 0.65-2.26; interaction p=0.009). CONCLUSIONS: In participants undergoing coronary procedures by TFA, US guidance decreased the composite outcome of major vascular complications or bleeding and may be especially helpful when using vascular closure devices.

Endovascular Stenting in 2 Patients with Benign Superior Vena Cava Syndrome.

Superior vena cava syndrome has typically been associated with malignant conditions; however, the number of benign cases has started to grow as the use of upper-extremity venous lines and implantable cardiac devices increases. Whereas endovascular techniques are standardly used to treat patients with malignancies, the optimal care of patients with benign causes is less clear because they typically have longer life expectancies. We describe 2 cases of benign superior vena cava syndrome successfully managed with endovascular stenting, and we review the relevant literature. Of 145 cases in 10 series (average follow-up time, 24 mo), 96% of patients experienced symptomatic relief after endovascular management, with a primary patency rate of 66% and a secondary rate of 93%. Although few data exist to compare open surgical and endovascular techniques directly, both approaches appear to produce similar rates of patency. Both approaches frequently necessitate secondary intervention to maintain patency, but endovascular management is associated with fewer complications. We conclude that endovascular management of benign superior vena cava syndrome is a safe, effective, and reasonable initial management approach.

Contemporary Arterial Access in the Cardiac Catheterization Laboratory.

Obtaining femoral and radial arterial access in the cardiac catheterization laboratory using state-of-the-art techniques is essential to optimize outcomes, patient satisfaction, and procedural efficiency. Although transradial access is increasingly used for coronary angiography and percutaneous coronary intervention, femoral access remains necessary for numerous procedures, many requiring large-bore access, including complex high-risk coronary interventions, structural procedures, and procedures involving mechanical circulatory support. For femoral access, contemporary access techniques should combine the use of fluoroscopy, ultrasound, micropuncture needle, femoral angiography, and vascular closure devices, when feasible. For radial access, ultrasound may reveal important anatomic features and expedite access. Despite randomized controlled trials supporting use of routine ultrasound guidance for femoral and/or radial arterial access, ultrasound remains underused in cardiac catheterization laboratories. This article reviews contemporary techniques to achieve optimal arterial access in the cardiac catheterization laboratory.

Endovascular versus surgical treatment for acute limb ischemia: a systematic review and meta-analysis of clinical trials.

BACKGROUND: A number of small studies have suggested that outcomes following endovascular (ENDO) therapy are comparable to those following surgical (SURG) revascularization for patients presenting with acute limb ischemia (ALI). We sought to compare mortality, limb amputation and recurrent ischemia across both revascularization strategies. METHODS: A comprehensive database search of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) electronic databases from January 1990 through January 2016 was performed to identify studies of ENDO versus SURG for ALI. Two independent reviewers selected studies and extracted the data. Random-effects meta-analysis was used to pool results across studies. Heterogeneity of treatment effect among trials was assessed using the I2 statistics. The primary endpoints were mortality and limb amputation at 1 month, 6 and 12 months. Secondary endpoint was recurrent ischemia at one year. RESULTS: A total of 1,773 patients were included from six studies (five randomized prospective and one observational retrospective) comparing ENDO and SURG in the setting of ALI. The mean age was 67 years and 65% of patients were male. There were no differences in mortality between the two groups at 1 month [risk ratio (RR) for ENDO vs. SURG is 0.70; 95% confidence interval (CI), 0.33 to 1.50], 6 months (RR 1.12; CI, 0.78 to 1.61) or 12 months (RR 0.74; CI, 0.29 to 1.85). Similarly, there was no significant difference in amputation rates between ENDO and SURG at 1 month (RR 0.75; CI, 0.40 to 1.42), 6 months (RR 0.87; CI, 0.52 to 1.48) or 12 months (RR 0.81; CI, 0.55 to 1.18). When looking into secondary outcomes, recurrent ischemia was not different between the two groups (RR 1.12; CI, 0.75 to 1.67). CONCLUSIONS: In patients presenting with ALI (<2 weeks of duration), ENDO and SURG approaches have similar rates of short-term and 12 month mortality, limb amputation and recurrent ischemia.

Comparison of Inferior Vena Cava Filters Placed at the Bedside via Intravenous Ultrasound Guidance Versus Fluoroscopic Guidance.

BACKGROUND: IVCFs are usually placed under fluoroscopic guidance in dedicated angiography suites. Bedside placement of inferior vena cava filters (IVCF) is possible in patients not suitable for transportation, but data regarding their use are limited. The objective of this study is to compare utilization, procedural outcomes, complications, and long-term patient outcomes associated with bedside placement of IVCFs using intravascular ultrasound (IVUS) and fluoroscopic placement of IVCF. METHODS: All patients receiving IVCF between January 2009 and December 2011 at a tertiary care institution were retrospectively identified. Data regarding patient characteristics, IVCF indications, complications, and outcomes were collected, and comparisons were made between patients receiving fluoroscopic-guided and IVUS-guided bedside IVCF. RESULTS: There were 117 bedside and 571 fluoroscopic-guided IVCF placed during this period. Patients receiving bedside IVCF were younger (50.8 vs. 60.7 years, P < 0.001), less often had malignancy (22.2% vs. 42.6%, P < 0.001), and received prophylactic filters more commonly (59.9% vs. 29.9%, P < 0.001). Placement-related complications occurred in 4.3% and 0.6%, respectively (bedside IVCF: 4 malpositions, 1 severe tilt; fluoroscopic-guided IVCF: 1 malposition, 1 severe tilt, P = 0.01). Indwelling IVCF-related complications occurred equally during median follow-up of 463 and 488 days, respectively (deep vein thrombosis: 13.7% vs. 13.3%, P = 0.92; pulmonary embolism: 5.1% vs. 4.0%, P = 0.61; filter thrombosis: 3.4% vs. 3.9%, P = 0.82). Time to indwelling complication was similar between groups (74 vs. 127 days, P = 0.29). CONCLUSIONS: Bedside placement of IVUS-guided IVCF is safe, but with higher procedural complications when compared with fluoroscopic placement. Long-term indwelling complications are similar between IVCF placed via bedside IVUS guidance and fluoroscopic approach.

The Importance of Global Health Experiences in the Development of New Cardiologists.

As the global burden of cardiovascular disease continues to increase worldwide, nurturing the development of early-career cardiologists interested in global health is essential to create a cadre of providers with the skill set to prevent and treat cardiovascular diseases in international settings. As such, interest in global health has increased among cardiology trainees and early-career cardiologists over the past decade. International clinical and research experiences abroad present an additional opportunity for growth and development beyond traditional cardiovascular training. We describe the American College of Cardiology International Cardiovascular Exchange Database, a new resource for cardiologists interested in pursuing short-term clinical exchange opportunities abroad, and report some of the benefits and challenges of global health cardiovascular training in both resource-limited and resource-abundant settings.

Stent and Non-Stent Based Outcomes of Infrainguinal Peripheral Artery Interventions From the Multicenter XLPAD Registry.

BACKGROUND: There are limited data regarding contemporary use of stent and non-stent based treatment strategies of infrainguinal peripheral artery disease (PAD). METHODS: We analyzed data from the ongoing multicenter XLPAD registry between July 2005 and October 2013 to report on the use of non-stent (atherectomy ± balloon angioplasty) and stent-based treatment of superficial femoral artery (SFA), popliteal, and below-the-knee (BTK) vessels in contemporary clinical practice. RESULTS: A total of 584 interventions (SFA, 82.5%; popliteal, 7.2%; BTK, 9.9%) were performed in 372 patients (mean age, 63.2 years; diabetes mellitus, 57.7%; Rutherford category 1-3, 73.5%; Rutherford category 4-6, 20.1%). Stents were deployed in 389 lesions (66.6%; SFA, 90.5%; popliteal, 5.1%; BTK, 4.1%) and non-stent strategy (atherectomy, 49%) in 195 lesions (33.4%; SFA, 66.7%; popliteal, 11.3%; BTK, 21.5%). In the stent and non-stent groups, mean lesion lengths were 133.9 mm and 86.0 mm (P<.001), chronic total occlusions (CTOs) constituted 63.0% and 49.7% (P<.01), and restenotic lesions were 12.6% and 32.3% (P<.001), respectively. At a mean follow-up of 260 ± 130 days, in the stent and non-stent treated patients, all-cause mortality was 4.3% and 3.5% (P=.65), clinically indicated repeat revascularization was 17.5% and 14.9% (P=.42), and amputation was 4.6% and 9.2% (P<.01), respectively. SFA lesion location, long lesion length, and CTO were associated with the use of stents. Advanced Rutherford class was associated with a non-stent treatment strategy. CONCLUSION: The majority of endovascular peripheral arterial interventions are performed in the SFA; most include a CTO and in patients with diabetes mellitus. Operators use stents to primarily treat complex SFA lesions with overall similar outcomes, except for fewer amputations compared to a non-stent strategy.

Real-time ultrasound guidance facilitates transradial access: RAUST (Radial Artery access with Ultrasound Trial).

OBJECTIVES: This study sought to assess the utility of ultrasound (US) guidance for transradial arterial access. BACKGROUND: US guidance has been demonstrated to facilitate vascular access, but has not been tested in a multicenter randomized fashion for transradial cardiac catheterization. METHODS: We conducted a prospective multicenter randomized controlled trial of 698 patients undergoing transradial cardiac catheterization. Patients were randomized to needle insertion with either palpation or real-time US guidance (351 palpation, 347 US). Primary endpoints were the number of forward attempts required for access, first-pass success rate, and time to access. RESULTS: The number of attempts was reduced with US guidance [mean: 1.65 ± 1.2 vs. 3.05 ± 3.4, p < 0.0001; median: 1 (interquartile range [IQR]: 1 to 2) vs. 2 (1 to 3), p < 0.0001] and the first-pass success rate improved (64.8% vs. 43.9%, p < 0.0001). The time to access was reduced (88 ± 78 s vs. 108 ± 112 s, p = 0.006; median: 64 [IQR: 45 to 94] s vs. 74 [IQR: 49 to 120] s, p = 0.01). Ten patients in the control group required crossover to US guidance after 5 min of failed palpation attempts with 8 of 10 (80%) having successful sheath insertion with US. The number of difficult access procedures was decreased with US guidance (2.4% vs. 18.6% for ≥5 attempts, p < 0.001; 3.7% vs. 6.8% for ≥5min, p = 0.07). No significant differences were observed in the rate of operator-reported spasm, patient pain scores following the procedure, or bleeding complications. CONCLUSIONS: Ultrasound guidance improves the success and efficiency of radial artery cannulation in patients presenting for transradial catheterization. (Radial Artery Access With Ultrasound Trial [RAUST]; NCT01605292).

Crossing of infrainguinal peripheral arterial chronic total occlusion with a blunt microdissection catheter.

PURPOSE: Crossing of lower-extremity arterial chronic total occlusion (CTO) can be challenging. Use of the Viance peripheral CTO crossing device (Covidien) in the superficial femoral (SFA), popliteal, and below-the knee (BTK) arterial locations has received limited study. METHODS: Fifty-eight patients from the Excellence in Peripheral Artery Disease (XLPAD) registry (NCT01904851) were treated between April 2010 and November 2013 with the Viance device. The procedural and 30-day clinical outcomes were collected. RESULTS: Mean age was 65.5 ± 8.7 years and 55.1% had diabetes mellitus. Most lesions (n = 58) were TASC classification type C (n = 16; 27.6%) and D (n = 16; 27.6%), with mean lesion length 140.0 ± 71.0 mm; 93.1% of lesions were de novo and 81.0% were severely calcified. Technical success (crossing without the use of a reentry device) was achieved in 87.9% of cases and procedural success was obtained in 86.2%; 51.7% of lesions received stents, with the remaining treated with balloon angioplasty and/or atherectomy. Average fluoroscopy time was 39.1 ± 21.2 min, with 187.8 ± 72.0 mL of contrast and 210.0 ± 212.0 Gy cm² radiation dose-area product. There was 1 periprocedural complication (access-site hematoma treated conservatively without blood transfusion). At 30 days post procedure, there was significant improvement in ankle-brachial index (0.72 ± 0.30 to 0.84 ± 0.16; P=.01) and Rutherford class (3.33 ± 0.81 to 1.54 ± 1.47; P<.001). Clinically-indicated target vessel revascularization, surgical intervention or amputation at 30 days was 5.2%. CONCLUSION: Use of Viance to cross infrainguinal arterial CTO was associated with high success, low complication rates, and significant symptom improvement.

Risk assessment for carotid artery stenting.

Carotid artery stenting (CAS) is an effective and increasingly utilized therapy for carotid stenosis. Despite its safety, CAS does have procedural risks, which necessitates meticulous technique and careful patient selection for this procedure. A number of patient and anatomical characteristics have been shown to increase CAS risk, and recently, prediction models have been constructed to gauge individual patient risk objectively and comprehensively. This review discusses CAS risk assessment and offers a practical approach to the management of patients with carotid stenosis for which CAS is a viable treatment option.

Hemorrhagic and ischemic outcomes after bivalirudin versus unfractionated heparin during carotid artery stenting: a propensity score analysis from the NCDR.

BACKGROUND: The direct thrombin inhibitor, bivalirudin, is associated with similar efficacy and superior safety in patients undergoing percutaneous coronary intervention. However, the role of direct thrombin inhibitors in carotid artery stenting is not well defined. The objective of this study was to compare the safety and effectiveness of bivalirudin and unfractionated heparin (UFH) for carotid artery stenting. We hypothesized that bivalirudin would be associated with less in-hospital postprocedure bleeding than UFH but similar rates of in-hospital and 30-day ischemic outcomes. METHODS AND RESULTS: We compared the incidence of in-hospital hemorrhagic and in-hospital/30-day ischemic outcomes among patients in the CARE Registry who underwent carotid artery stenting between May 2005 and March 2012 using bivalirudin or UFH. Propensity score matching was used to obtain a balanced cohort of 3555 patients in each treatment group. Patients treated with bivalirudin had a significantly lower incidence of bleeding or hematoma requiring red blood cell transfusions (0.9% versus 1.5%; odds ratio, 0.57 [0.36-0.89]; P=0.01) when compared with UFH-treated patients. The incidence of in-hospital and 30-day ischemic outcomes, including death, myocardial infarction, stroke, transient ischemic attack, and the composite outcome, death/myocardial infarction/stroke, did not differ significantly between groups. CONCLUSIONS: Bivalirudin was associated with lower rates of hemorrhagic outcomes compared with UFH during the index hospitalization for carotid artery stenting. In-hospital and 30-day ischemic events were similar between the 2 groups. Randomized comparisons of these agents are needed to confirm these findings.

Is risk factor control and guideline-based medical therapy optimal in patients with nonobstructive coronary artery disease? A Veterans Affairs study.

BACKGROUND: Aggressive risk factor modification using evidence-based secondary prevention strategies is recommended in coronary artery disease (CAD). Utilization of such strategies was compared in patients with nonobstructive CAD (NOCAD) and obstructive CAD (OCAD). METHODS: Patients undergoing coronary angiography (excluding normal coronary angiograms), between January 2006 and June 2006, at the Veterans Affairs Medical Center were included. Demographic, clinical and treatment data were compared between the groups at baseline and 1 year. RESULTS: Of the 354 patients who underwent coronary angiography, 222 (63%) had follow-up data available at 12 ± 2 months. The mean age in the NOCAD (n = 119) and OCAD (n = 103) groups was similar. There was a lower prevalence of hypertension and heart failure (P < 0.05) in the NOCAD group. Compared with the OCAD group, aspirin use was similar but statin use was lower in the NOCAD group (P = 0.008). At 1 year, statin use (P = 0001) and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use (P = 0.001) were significantly lower, whereas the use of aspirin was numerically lower (P = 0.06) in the NOCAD group. Mean low-density lipoprotein cholesterol levels were at goal (<100 mg/dL) in the NOCAD group at baseline and 1 year, whereas the same slightly worsened in the OCAD group at 1 year. CONCLUSIONS: The use of evidence-based medical therapy is lower in patients with NOCAD compared with those with OCAD. Improved awareness among health care providers and a unified effort to implement secondary prevention strategies may help correct such deficiencies.

Pilot trial of cryoplasty or conventional balloon post-dilation of nitinol stents for revascularization of peripheral arterial segments: the COBRA trial.

OBJECTIVES: The purpose of this study is to compare post-dilation strategies of nitinol self-expanding stents implanted in the superficial femoral artery of diabetic patients with peripheral arterial disease. BACKGROUND: Endovascular treatment of superficial femoral artery disease with nitinol self-expanding stents is associated with high rates of in-stent restenosis in patients with diabetes mellitus. METHODS: We conducted a prospective, multicenter, randomized, controlled clinical trial of diabetic patients to investigate whether post-dilation of superficial femoral artery nitinol self-expanding stents using a cryoplasty balloon reduces restenosis compared to a conventional balloon. Inclusion criteria included diabetes mellitus, symptomatic peripheral arterial disease, and superficial femoral artery lesions requiring implantation of stents>5 mm in diameter and >60 mm in length. Primary endpoint was binary restenosis at 12 months, defined as ≥2.5-fold increase in peak systolic velocity by duplex ultrasonography. RESULTS: Seventy-four patients, with 90 stented superficial femoral artery lesions, were randomly assigned to post-dilation using cryoplasty (n=45 lesions) or conventional balloons (n=45 lesions). Mean lesion length was 148±98 mm, mean stented length was 190±116 mm, mean stent diameter was 6.1±0.4 mm, and 50% of the lesions were total occlusions. Post-dilation balloon diameters were 5.23±0.51 mm versus 5.51±0.72 mm in the cryoplasty and conventional balloon angioplasty groups, respectively (p=0.02). At 12 months, binary restenosis was significantly lower in the cryoplasty group (29.3% vs. 55.8%, p=0.01; odds ratio: 0.36, 95% confidence interval: 0.15 to 0.89). CONCLUSIONS: Among diabetic patients undergoing implantation of nitinol self-expanding stents in the superficial femoral artery, post-dilation with cryoplasty balloon reduced binary restenosis compared to conventional balloon angioplasty. (Study Comparing Two Methods of Expanding Stents Placed in Legs of Diabetics With Peripheral Vascular Disease [COBRA]; NCT00827853).

Culprit-vessel percutaneous coronary intervention followed by contralateral angiography versus complete angiography in patients with ST-elevation myocardial infarction.

In patients with ST-elevation myocardial infarction, delay in door-to-balloon time strongly increases mortality rates. To our knowledge, no randomized studies to date have focused on reducing delays within the catheterization laboratory.We performed a retrospective analysis of all patients who presented with ST-elevation myocardial infarction at our institution from July 2006 through June 2010, looking primarily at time differences between percutaneous coronary intervention in the culprit vessel on the basis of ECG criteria, followed by contralateral angiography (Group 1), versus complete coronary angiography followed by culprit-vessel percutaneous intervention (Group 2).There were 49 patients in Group 1 and 57 patients in Group 2. No major differences in baseline characteristics were observed between the groups, except a higher prevalence of diabetes mellitus in Group 2. There was a statistically significant difference between Groups 1 and 2 in door-to-balloon time (median and interquartile range, 75 min [61-89] vs 87 min [70-115], P=0.03, respectively) and access-to-balloon time (12 min [9-18] vs 21 min [11-33], P=0.0006, respectively). Five Group 1 patients (10%) with inferior myocardial infarction had a contralateral culprit vessel. There were no differences in mortality rate or ejection fraction at the median 1-year follow-up. Four patients in Group 1 and 3 patients in Group 2 were referred for coronary artery bypass grafting after percutaneous intervention.This study suggests that performing culprit-vessel percutaneous intervention on the basis of electrocardiographic criteria, followed by angiography in patients with anterior ST-elevation myocardial infarction, might be the preferred approach, given the door-to-balloon time that is saved.

A new era of antithrombotic therapy in patients with atrial fibrillation.

Atrial fibrillation/flutter is the most common cardiac arrhythmia that can potentially result in stroke and death. For many years, aspirin and warfarin have been the cornerstone of stroke prevention among such patients. Although warfarin therapy has been advocated for patients with high likelihood of stroke, it requires close surveillance and monitoring, has a narrow therapeutic window and is quite often affected by medication interactions and diet. Thus, the need for a better and more consistent anticoagulant therapy was necessary and has been under development with various successes for many years. This article will review 3 new antithrombotic medications that may potentially become the mainstay for treatment of patients with atrial fibrillation in the near future.

Embolic protection device use and outcomes in patients receiving saphenous vein graft interventions--a single-center experience.

BACKGROUND: Percutaneous treatment of saphenous vein graft disease is hampered by high rates of periprocedural myocardial infarction (MI). The use of embolic protection devices (EPD) during these interventions is a class IB recommendation when technically feasible, yet they are used routinely in less than half of all cases. Our aim was to explore whether or not the under-utilization of EPDs led to any untoward cardiovascular events. METHODS: Consecutive vein graft interventions from 2003-2008 were identified and stratified by EPD use. Information pertaining to demographics, comorbidities, medication use, and procedural details was collected. Primary endpoint was to compare the incidence of periprocedural MI, defined as any creatinine kinase-MB fraction elevation greater than 3 times the upper limit of normal between patients who underwent percutaneous coronary intervention (PCI) for saphenous vein grafts (SVG) with EPD versus patients who underwent PCI for SVG without EPD. Secondary endpoints included comparison of the incidence of recurrent ischemia, MI, revascularization (PCI or coronary artery bypass graft [CABG]), and mortality in the above 2 groups by the end of 1 year. RESULTS: A total of 164 consecutive vein graft interventions were identified. EPDs were used in 71 cases (43.4%). The EPD group was further out since their CABG and had a higher prevalence of hypertension and diabetes. Periprocedural MI occurred in 22 cases; 12 in the non-EPD group and 10 in the EPD group (14.1 vs. 12.9%; P=.82). The composite endpoint of death, MI, or target vessel revascularization at 12 months was significantly lower when EPDs were used (11.3 vs. 25.8%; P=.03). On multivariate analysis, chronic kidney disease increased the risk of periprocedural MI (odds ratio [OR], 5.36; 95% confidence interval [CI], 1.90-15.13; P=.002), whereas the use of beta-blockers was protective (OR, 0.22; 95% CI, 0.07-0.70; P=.011). CONCLUSIONS: EPD use during vein graft interventions did not improve periprocedural MI rates. However, the composite endpoint of adverse cardiovascular outcomes at 1 year was significantly reduced. EPDs are used in a minority of vein graft interventions. Efforts aimed at improving adherence to EPD use may improve long-term outcomes, though this hypothesis should be tested using prospective, randomized studies.

Use of a novel adjunctive kissing-balloon technique with the Trellis device to successfully prevent embolization across juxtaposed kissing aortoiliac stents.

The Trellis thrombectomy system (Covidien) has been used successfully to perform isolated pharmacomechanical thrombectomy of both venous and arterial thrombi. The device is designed to provide localized treatment while preventing both systemic spread of the thrombolytic agent and also distal embolization. However, when this device is utilized to remove thrombi at bifurcation lesions, embolization into the contralateral vessel can potentially occur. We describe a novel and simple technique of adjunctive kissing balloon inflation while using the Trellis device for the management of an aortoiliac occlusion that occurred in one of two juxtaposed stents previously placed in the distal aorta into the bilateral iliac arteries. This technique prevented distal embolization into the contralateral iliac artery.

Retrograde access via the popliteal artery to facilitate the re-entry technique for recalcitrant superficial femoral artery chronic total occlusions.

Subintimal recanalization is beneficial in selected patients with peripheral chronic total occlusions (CTO). However, in complex cases, re-entry into the true arterial lumen may prove to be unsuccessful with a conventional guidewire or a re-entry catheter when using standard femoral artery access. Our case series describes these technical dilemmas along with strategies that can be utilized to overcome these challenges.

Effect of statin therapy on contrast-induced nephropathy after coronary angiography: a meta-analysis.

BACKGROUND: Although the pleiotropic effects of statins are postulated to be renoprotective, clinical studies have demonstrated conflicting results. We undertook a meta-analysis of published trials to evaluate the impact of statin therapy on the incidence of contrast-induced nephropathy (CIN) in patients undergoing coronary angiography. METHODS: We searched MEDLINE and EMBASE databases through December 2010 for articles evaluating the effect of statins on the incidence of CIN in patients undergoing coronary angiography. Odds ratios (OR) with 95% confidence intervals (CI) were calculated using random effects modeling. RESULTS: Three randomized controlled trials involving 770 patients (330 in the statin group and 340 in the control group) and 7 non-randomized studies involving 31,959 patients (11,936 statin-pretreated and 20,023 statin-naïve). The definition of CIN varied somewhat among the studies. Based on the pooled estimate across the 3 randomized controlled trials, statin therapy did not significantly reduce the incidence of CIN compared to control (OR=0.76, 95% CI: 0.41-1.41, p=0.39). No significant heterogeneity was found in the randomized studies (I(2)=0%, p=0.48). The pooled analysis of the non-randomized studies showed a marginally significant benefit associated with statin therapy (OR=0.60, 95% CI: 0.36-1.00, p=0.05). There was significant heterogeneity among the non-randomized studies (I(2)=88%, p<0.00001). CONCLUSIONS: Our meta-analysis suggests that statin therapy might be associated with a significant reduction in the incidence of CIN in patients undergoing coronary angiography. Further studies are warranted to clarify this issue.