Vascular Complications During Catheter Ablation of Cardiac Arrhythmias: A Comparison Between Vascular Ultrasound Guided Access and Conventional Vascular Access.

INTRODUCTION: Vascular access related complications are the most common complications from catheter based EP procedures and have been reported to occur in 1-13% of cases. We prospectively assessed vascular complications in a large series of consecutive patients undergoing catheter based electrophysiologic (EP) procedures with ultrasound (US) guided vascular access versus conventional access. METHODS AND RESULTS: Consecutive patients undergoing catheter ablation procedures at VCU medical center were included. US guided access was obtained in all cases starting June 2015 (US group) while modified Seldinger technique without US guidance (non-US group) was used in cases prior to this date. All vascular complications were recorded for a 30-day period after the procedure. A total of 689 patients underwent 720 procedures. Ablations for ventricular tachyarrhythmias (ventricular tachycardia: VT, premature ventricular contractions: PVCs) accounted for 89 (12%) cases; atrial fibrillation (AF) ablations accounted for 328 procedures (46%) and other catheter based procedures accounted for 42% of cases. A significantly higher incidence of complications was noted in the non-US group compared with the US group (19 [5.3%] vs. 4 [1.1%], respectively, P = 0.002). Major complications were also higher among the non-US group (9 [2.5%] vs. 2 [0.6%], P = 0.03). Increasing age (P = 0.04) and non-US guided vascular access (P = 0.002) were associated with a higher risk of vascular access complications. CONCLUSION: In a large series of patients undergoing catheter based EP procedures for cardiac arrhythmias, US guided vascular access was associated with a significantly decreased 30-day risk of vascular complications.

Civilian casualties of terror-related explosions: The impact of vascular trauma on treatment and prognosis.

OBJECTIVES: A high prevalence (10%) of vascular trauma (VT) was previously described in terror-related trauma as compared with non-terror-related trauma (1%), in a civilian setting. No data regarding outcome of VT casualties of improvised explosive device (IED) explosions, in civilian settings, are available. The aim of the current study is to present the prognosis of civilian casualties of IED explosions with and without VT. METHODS: A retrospective analysis of the Israeli National Trauma Registry was performed. All patients in the registry from September 2000 to December 2005 who were victims of explosions were included. These patients were subdivided into patients with VT (n = 109) and non-VT (NVT) (n = 1,152). Both groups were analyzed according to mechanism of trauma, type and severity of injury, and treatment. RESULTS: Of 1,261 explosion casualties, there were 109 VT victims (8.6%). Patients with VT tended to be more complex, with a higher injury severity score (ISS): 17.4% with ISS 16 to 24 as compared with only 10.5%. In the group of critically injured patients (ISS, 25-75), 51.4% had VT compared with only 15.5% of the NVT patients. As such, a heavy share of hospitals' resources were used-trauma bay admission (62.4%), operating rooms (91.7%), and intensive care unit beds (55.1%). The percentage of VT patients who were admitted for more than 15 days was 2.3 times higher than that observed among the NVT patients. Lower-extremity VT injuries were the most prevalent. Although many resources are being invested in treating this group of patients, their mortality rate is approximately five times more than NVT (22.9% vs. 4.9%). CONCLUSIONS: Vascular trauma casualties of IED explosions are more complex and have poorer prognosis. Their higher ISS markedly increases the hospital's resource utilization, and as such, it should be taken into consideration either upon the primary evacuation from the scene or when secondary modulation is needed in order to reduce the burden of the hospitals receiving the casualties. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level V.

Platelet activation and microvascular injury in patients with ST-segment elevation myocardial infarction.

BACKGROUND: Dual antiplatelet therapy reduces the risk of thrombotic complications after primary percutaneous coronary intervention (PCI). AIM: To assess whether inhibition of platelet function attenuates microvascular damage in patients with ST-segment elevation myocardial infarction (STEMI). METHODS: We studied 83 STEMI patients treated with primary PCI. Platelet aggregation was measured on admission (ADM) and 4 days later (D4) by light transmission aggregometry after stimulation with 0.5 mM of arachidonic acid and after stimulation with 5 and 20 µM of adenosine diphosphate (ADP) on treatment with dual antiplatelet therapy with aspirin and clopidogrel. Platelet-neutrophil aggregate (PNA) and platelet-monocyte aggregate (PMA) were analysed by flow cytometry. Contrast-enhanced magnetic resonance imaging was performed 2-4 days after STEMI to detect the area of perfusion defect at rest and to determine the size of microvascular obstruction. Microvascular obstruction was expressed as a percentage of infarct area. RESULTS: Perfusion defect at rest was found in 56 (67.5%) patients whereas microvascular obstruction in 63 (75.9%) patients. Patients with perfusion defect at rest had on admission a significantly higher level of both PMA (7.0 vs. 4.5%, p = 0.004) and PNA (4.1 vs. 2.2%, p = 0.016), however there were no significant differences at D4. Platelet aggregation after stimulation with 5 µM of ADP on ADM was correlated (r = 0.37, p = 0.004) with microvascular obstruction area. Moreover, the higher the concentration of PMA(ADM) (r = 0.31, p = 0.016), PNA(ADM) (r = 0.34, p = 0.006) and PM(AD4) (r = 0.35, p = 0.005) the larger the size of microvascular obstruction. Infarct size (ß = 0.43, 95% CI 0.19 to 0.67, p 〈 0.0001), TIMI < 3 after PCI (ß = -0.27, 95% CI -1.90 to -0.11, p = 0.015) and PMA(D4) (ß = 0.21, 95% CI 0.13 to 1.86, p = 0.032) independently influenced the size of microvascular obstruction (R2 = 0.60, p 〈 0.0001). CONCLUSIONS: Excessive platelet activation during reperfusion in STEMI patients despite dual antiplatelet therapy is associated with greater microvascular impairment.

Vascular injury in the United kingdom.

Surgeons working within the United Kingdom's National Health Service have an established history of clinical innovation, research, and development in the field of vascular surgery but lack a unified trauma system to deliver optimal care for patients with vascular injury. The low incidence of vascular trauma, combined with lack of regional trauma systems, works against optimal delivery of care to the polytrauma patient. Providing care, robust data capture, and opportunities for training and education in vascular injury lag behind other elective domains of vascular practice. The challenge is to define ideal care pathways, referral networks, and standards of practice and to integrate the care of such patients. In 2010, a trauma system for London was introduced; it has provided vascular surgeons with a unique opportunity to study and advance the care of patients with vascular injury. This article discusses developing trauma network issues, particularly the organization and evolution of vascular trauma services in the United Kingdom.