Current management of coronary artery disease prior to vascular surgery: A clinical dilemma.

Here we present a case of an elderly man who underwent cardiac stress testing as a preoperative evaluation prior to femoral-popliteal bypass surgery. He subsequently underwent a preoperative coronary angiogram after a high-risk stress test with the latter demonstrating obstructive three-vessel coronary artery disease. We discuss the clinical challenges that such a common clinical scenario presents particularly when it comes to preoperative coronary revascularisation prior to vascular surgery. We examine the case within the framework of the latest revascularisation guidelines and discuss the available evidence for preoperative revascularisation and its limitations.

Real world single center experience with saphenous vein grafts interventions: should filters be filtered out?

BACKGROUND: Percutaneous coronary intervention (PCI) of saphenous vein grafts (SVG) can be challenging due to no reflow phenomenon from distal embolization of debris and microvascular vasoconstriction, resulting in myocardial injury post-procedure. Guidelines promote the use of distal embolic protection devices (EPD) to protect the distal arterial bed during SVG PCI. However, this approach has shown less-than-optimal results in many studies. We report our data using the Borgess protocol [prophylactic intracoronary (IC) nicardipine injection and direct stenting], as an alternative to EPDs in a large series of SVG interventions. METHODS: This is a retrospective, cohort study of our single center experience with SVG interventions between 2017 and 2021. The primary outcome of the study was major adverse cardiovascular events (MACE) [a composite of death, emergent coronary artery bypass graft surgery (CABG), myocardial infarction (MI), and target vessel revascularization (TVR)] at 30 days post-procedure. RESULTS: There were 424 consecutive SVG interventions performed during the study period, and 76% of cases presented with acute coronary syndrome. Full adherence to the Borgess protocol was observed in 36% of cases; IC nicardipine was utilized in 72% of cases. MACE rate was 3.5% at 30 days driven primarily by MI (2.6%). CONCLUSION: The Borgess protocol approach to vein graft interventions proved good outcomes when compared to SVG PCI in randomized trials utilizing EPDs. Our study is limited by the retrospective nature and single center experience.

Management of Atrial Fibrillation Post Transcatheter Aortic Valve Implantation.

Atrial fibrillation (AF) is a common complication in patients who underwent transcatheter aortic valve implantation. Some of these patients have preexisting AF as well. The management of these patients is complex, especially after the procedure, when there is a sudden change in hemodynamics. There are no established guidelines about the management of the patients who underwent transcatheter aortic valve replacement with preexisting or new-onset AF. This review article discusses the management of these patients with rate and rhythm control strategies with medications. This article also highlights the role of newer oral anticoagulation medications and left atrial occlusion devices to prevent stroke after the procedure. We will also discuss new advances in the care of this patient population to prevent the occurrence of AF after transcatheter aortic valve implantation. In conclusion, this article is a synopsis of both pharmacologic and device interventions for the management of AF in patients who underwent transcatheter aortic valve replacement.

Rates of Intracoronary Imaging Optimization in Contemporary Percutaneous Coronary Intervention: A Report From the BMC2 Registry.

BACKGROUND: Intracoronary imaging (ICI) during percutaneous coronary intervention (PCI) improves outcomes, yet hospital- and physician-level variabilities in ICI and its impact on ICI use in contemporary PCI remain unknown. This study was performed to evaluate hospital- and physician-level use of ICI to optimize PCI. METHODS: Using data from a large statewide registry, patients undergoing PCI between July 2019 and March 2021 were studied. The primary measure of interest was ICI (intravascular ultrasound or optical coherence tomography) optimization during PCI. A fitted hierarchical Bayesian model identified variables independently associated with ICI optimization. The performing hospital and physician were included as random effects in the model. RESULTS: Among 48 872 PCIs, ICI optimization was performed in 8094 (16.6%). Median [interquartile range] hospital- and physician-level frequencies of ICI were 8.8% [3.1%, 16.0%] and 6.1% [1.1%, 25.0%], respectively. Bayesian modeling identified left main PCI (adjusted odds ratio [aOR], 4.41; 95% credible interval [3.82, 5.10]), proximal left anterior descending artery PCI (aOR, 2.28 [2.00, 2.59]), PCI for in-stent restenosis (aOR, 1.55 [1.40, 1.72]), and surgical consult prior to PCI (aOR, 1.21 [1.07, 1.37]) as independent predictors of ICI optimization. The hospital-level median odds ratio, an estimate of the contribution of inter-hospital variability in odds of ICI use, was 3.48 (2.64, 5.04). Physician-level median odds ratio was 3.81 (3.33, 4.45). CONCLUSIONS: Substantial hospital- and physician-level variation in ICI was observed. Except for performance of left main PCI, the hospital and physician performing the PCI were more strongly associated with ICI optimization than any patient or procedural factors.

A Next-Generation Guide Extension System for Percutaneous Coronary Intervention.

BACKGROUND: Guide catheter extension is an integral part of percutaneous coronary intervention (PCI). First generation guide catheter extension devices are monorail, blunt ended tubular structures with limitations. The CrossLiner™ is a next generation guide extension "system" intended to allow safe, deep, coronary intubation. METHODS: The CrossLiner was tested in a head-to-head study with the GuideLiner™ and GuideZilla™ in a porcine coronary model, with stenting. Data were collected from 8 coronary vessels from four animals, to evaluate the ability to deeply intubate the vessel with the guide extension. RESULTS: The CrossLiner crossed distally and through a distal stented segment in 8/8 vessels, while the first-generation devices were stuck proximal to the stent (n=2/8) or at the stent edge (n=4/8), or passed partially into the deployed stent with difficulty (2/8) vessels (p < 0.0002 for deliverability). The average depth of guide extension delivery/ "intubation" was 12.9±3.6 cm for the CrossLiner and 5.6±1.1 cm for the first-generation guide extension (p < 0.001). CONCLUSIONS: The CrossLiner is a next generation guide extension system that may offer advantages over first generation devices. Further clinical evaluation will be required to assess the role of this new device in PCI.

Usefulness of multislice computed tomographic coronary angiography to identify patients with abnormal myocardial perfusion stress in whom diagnostic catheterization may be safely avoided.

Computed tomographic angiography (CTA) has been validated for noninvasive assessment of coronary anatomy. The aim was to establish whether CTA could guide the use of invasive coronary angiography (ICA) in symptomatic patients with intermediate risk after myocardial perfusion stress imaging (MPSI). From April 2005 to February 2006, patients referred for CTA to a cardiology practice were entered into a database. Inclusion required symptoms suggestive of coronary artery disease and intermediate-risk MPSI. Subjects with intermediate risk after MPSI underwent CTA, and if severe stenosis or moderate stenosis matching a perfusion defect was found, ICA was performed. If appropriate, patients were then sent for revascularization. Clinical follow-up was completed until December 2006. Main outcome measures were number of patients sent for ICA, immediate revascularization after ICA, and adverse outcomes (death, myocardial infarction, and late revascularization). Four hundred twenty-one patients were included. Adequate diagnostic-quality images were obtained in 99%. After MPSI-CTA assessment, 78 patients (18.5%) were sent for ICA and 343 (81.5%) were medically managed. Follow-up was 15+/-3 months. In the group referred for ICA, there were 50 cases of immediate revascularization, 1 non-ST-segment elevation myocardial infarction, 1 death, and 5 patients requiring repeat ICA, 3 of whom underwent late revascularization. In the medically managed group, 6 patients required late ICA, 1 of whom underwent revascularization. In conclusion, in symptomatic patients with suspected coronary artery disease and intermediate-risk MPSI results, CTA can identify up to 80% of patients at low risk of events in whom ICA may be safely avoided. Additional studies assessing new technologies combining MPSI-CTA are needed to refine imaging strategies in these patients.

Demographic parameters related to 30-day readmission of patients with pulmonary embolism: Analysis of 650,819 hospitalizations.

BACKGROUND: Pulmonary embolism (PE) is a serious medical condition associated with major morbidity, mortality and economic burden. Preventable hospital readmissions are a major economic challenge for the healthcare organizations and identifying patient subsets at risk of readmission will help report the issue. This retrospective study was performed to determine demographic parameters and major diagnosis linked with 30day readmission after a PE. METHODS: Nationwide Inpatient Sample (NIS) data was used to extract data of patients discharged after PE during index admission for years 2009-2013. Patients were identified by Diagnosis Related Group (DRG) number 175 and 176 which represents PE with major complications and comorbidities (MCC) and PE without MCC. Demographic parameters associated with high readmission rate were identified along with causes related to readmissions. RESULTS: We identified a total of 650,819 hospitalizations with PE as the index stay DRG of which 13.44% were readmitted within 30 days after hospitalizations. Patients with age >65years (14.05%), female (13.87%), Medicaid insurances (20.49%), low median income for zip code (15.1%) and metropolitan areas (13.71%) were associated with higher 30day readmission rates. The most common identified cause of readmission in PE with MCC from 2009 to 2010 was heart failure (4.25%) and from 2011 to 2013 was severe sepsis (4.8%) while for PE without MCC from 2009 to 2013 was PE without MCC itself (10.24%). CONCLUSIONS: Interventions need to be directed against these set of patients and the identified causes of readmissions to reduce the rehospitalisations from PE.

Demographic parameters related to 30-day readmission of patients with acute myocardial infarction: Analysis of 2,371,867 hospitalizations.

BACKGROUND: Acute myocardial infarction (AMI) is the most common cause of mortality in the USA as per the data released by the CDC. Short term hospital readmissions account for a significant portion of health care budget and much of the focus recently has been on reducing 30day readmission rate aimed to identify the demographics associated with readmissions from AMI and major causes of readmissions. METHODS: We queried the Nationwide Inpatient Sample which represents 20% of all the United States hospital data for our study. AMI was identified through ICD9 Clinical Classification Software Code 100 for readmissions secondary to AMI for years 2009-2013. Chi-square was used for statistical analysis. RESULTS: A total of 2,371,867 admissions were identified with AMI and 15.87% of these readmitted within 30days after index hospitalizations due to any cause. Patients with age greater than 65years, female gender, Medicare and Medicaid insurances, low median income for zip code and metropolitan areas were associated with high 30day readmission rate. The most common identified cause of readmission from 2009-2011 was coronary atherosclerosis (15%) and from 2012-2013 the cause identified was congestive heart failure (13.5%) (p<0.001). CONCLUSION: Aggressive medical management needs to be targeted at this demography of patients and prevent the most causes of readmissions to reduce the cost and morbidity of patients admitted with AMI.

Giant Saphenous Venous Graft Aneurysm with Compression of the Pulmonary Artery: A Rare Cause of Heart Failure.

We report a case of a 74-year-old man who presented with dyspnea on exertion and pedal edema. He had five-vessel coronary artery bypass graft (CABG) surgery twenty-six years ago and redo three-vessel CABG done thirteen years later. Computed tomographic angiography (CTA) of the heart and coronary vessels demonstrated a giant aneurysm arising from the saphenous venous graft (SVG) to the first obtuse marginal of the left circumflex artery compressing the pulmonary artery (PA). He underwent coronary angiography, confirming the CTA findings. Surgical and percutaneous interventions were offered, but the patient opted for conservative management due to the high risk of morbidity and mortality.

Initial clinical experience using an ostial stent positioning system (Ostial Pro) for the accurate placement of stents in the treatment of coronary aorto-ostial lesions.

OBJECTIVE: To evaluate the safety and efficacy of a new nitinol stent positioning system to assist in the placement of aorto-ostial coronary stents. BACKGROUND: The stenting of aorto-ostial lesions is technically challenging. METHODS: We report the first clinical series using the Ostial Pro to assist in the precise placement of stents in coronary aorto-ostial lesions. These results were compared to matched cases performed without the ostial positioning system. RESULTS: The Ostial Pro is a simple nitinol device with self-expanding legs that are advanced just distal to the tip of the guiding catheter. The nitinol legs prevent the entry of the guiding catheter into the target vessel and align the tip of the guiding catheter. Using the Ostial Pro positioning device, angiographic and clinical success was achieved in 30/30 (100%) cases. Excellent stent positioning was confirmed by angiography (n = 30) and intravascular ultrasound (n = 28). The final true ostial dimension was larger than the stented segment minimum luminal diameter in 30/30 cases. In a matched consecutive cohort of 30 consecutive coronary aorto-ostial stent cases placed without the Ostial Pro, we observed an ostial stent malpositioning in 18/30 (60%) of cases (p < 0.0001 vs. cases performed with Ostial Pro). CONCLUSIONS: 1) The Ostial Pro is a new FDA-cleared nitinol device that is simple to use and effective in allowing the precise placement of stent(s) at the aorto-ostial location; 2) this approach appears to provide an efficient means to assure accurate stent placement and minimal residual stenosis in these difficult-to-treat lesions.