Evaluation of the incidence of radial artery occlusion using different introducer sheaths and hemostasis techniques.

BACKGROUND: Radial artery occlusion (RAO) remains one of the most important complications of transradial access (TRA). Despite the identification of multiple predictors, the interaction between these predictors on the occurrence of RAO has not been evaluated. METHODS: Consecutive patients undergoing TRA coronary angiography (CA) or percutaneous coronary intervention (PCI), were retrospectively analyzed to compare the effect of standard patent hemostasis using a one-bladder band versus two-bladder band with simultaneous ipsilateral ulnar artery compression and two introducer sizes on the primary endpoint of RAO. Access was obtained using 6-Fr slender introducer sheath or 7-Fr slender introducer sheath and hemostasis with either a one-bladder band or a two-bladder band. The radial artery was evaluated using ultrasound. RESULTS: Total of 2019 patients undergoing CA or PCI were included in the analysis. In the one-bladder band group, the incidence of RAO with a 6-Fr slender introducer sheath was 4.2%. In those receiving hemostasis with a two-bladder band, RAO occurred in 1% of patients receiving a 6-Fr slender introducer sheath versus 0.9% in those receiving a 7-Fr slender introducer sheath (p = 0.68). Larger radial artery diameter, larger body weight, and a two-bladder hemostasis band with ipsilateral ulnar compression were independently associated with a lower incidence of RAO. CONCLUSION: A two-bladder band with simultaneous ipsilateral ulnar artery compression when used for radial artery hemostasis, is associated with a lower incidence of RAO, and can mitigate the penalty for a larger catheter with reassuring implications for use of a 7-Fr capable system for complex transradial PCI.

Factors Affecting Image Resolution in a Modern Angiographic Suite: A Phantom-Based Study.

BACKGROUND: Improvements in angiographic imaging systems technology provide options to decrease radiation exposure. The effect of these variations on image resolution is unknown. METHODS: Using an American National Standards Institution phantom, a high-contrast (line-pair) and low contrast (Gammex 151) phantoms, 5 second images were acquired using a Phillips Allure angiographic suite, using fluoroscopic capture (FC) as well as cineangiography (CA) in posterior anterior (PA) and left anterior oblique (LAO) projections as well as high and low table positions. Image resolutions were measured as ranked by three independent trained observers blinded to the purpose of the assessments. Comparative analyses were performed. Interobserver agreement was evaluated. RESULTS: High contrast image resolution was significantly lower with FC compared to CA (median [interquartile range], 1.69 [1.52-1.69] mm, vs 2.09 [1.88-2.09] mm, P < 0.001). No significant differences were observed in between PA and LAO projections as well as low and high table positions. Low contrast resolution was also lower with FC compared to CA (5 [6.5-5] vs 3 [5-3] mm, P < 0.001). No significant differences in high-contrast or low-contrast resolution were noted between PA and LAO projections, or high and low table positions. Both low and high-contrast image resolution improved with higher radiation exposure. Good interobserver agreement was noted (Fleiss-Kappa ranging from 0.69-0.74). CONCLUSION: Image resolution was perceived to be better with CA compared to FC, although not significantly affected by beam angulation or table height. Aligning resolution needs with imaging modality and maximizing table height may improve procedural efficacy and safety.

Successful WATCHMAN Device Placement Despite Left Atrial Appendage Perforation in Two Cases.

The WATCHMAN (Boston Scientific, Marlborough, USA) is a device used to occlude the left atrial appendage (LAA) in patients of non-valvular atrial fibrillation (NVAF) with a high CHA2DS2-VASc score who are poor candidates for oral anticoagulation. LAA perforation is a well-known complication of the WATCHMAN device placement. Here we present two cases of NVAF where oral anticoagulation was not advisable due to recurrent bleeding episodes. They underwent the WATCHMAN procedure for stroke prevention. During the placement of the WATCHMAN device into the left atrial appendage (LAA) in both cases, pericardial staining was noted that worsened over the next few minutes. It was decided to deploy the 27 mm WATCHMAN device into the LAA. In one case, satisfactory hemostasis was achieved with the device deployment eliminating the need for cardiothoracic surgery. However, the second case led to pericardial tamponade and was managed by the placement of a pericardial window. To our knowledge, this is the first case series describing the use of a WATCHMAN device upon detection of LAA perforation.

Counterintuitively Crossing a Critically Stenosed Aortic Valve is a Diastolic Phenomenon.

Crossing of a critically stenosed aortic valve is a pivotal step during diagnostic cardiac catheterization to measure the transvalvular gradient, especially in patients with discordant clinical and echocardiographic findings and also during transcatheter aortic valve replacement procedures. However, there are no data in the literature indicating whether aortic valve crossing typically occurs during systole or diastole. We hypothesize that aortic valve crossing is a diastolic phenomenon and describe our technique for crossing critically stenosed aortic valves.

Jetstream atherectomy and balloon angioplasty with distal embolic protection for Angio-Seal related vascular access complications.

Arteriotomy closure devices (ACDs) are routinely used for vascular closure during invasive cardiovascular procedures. They decrease time to hemostasis as well as length of stay. Major complications such as arterial ischemia and occlusion can be encountered in a minority of patients. We are describing a series of 3 patients with access site closure using Angio-Seal after coronary angiography who developed intermittent claudication within 2-3 weeks of follow-up. Access site thrombosis/stenosis in the CFA was found in all the three cases. They were successfully revascularized using Jetstream atherectomy with embolic protection filter followed by balloon angioplasty. This technique can treat extensive thrombus burden as well as extract the collagen and foot plate of Angio-Seal through atherectomy with cutting blades and thrombectomy via rheolytic macerating aspiration port. All cases had excellent angiographic and clinical results.

Revascularization in Severe Left Ventricular Dysfunction: Does Myocardial Viability Even Matter?

Left ventricular dysfunction is a powerful prognostic predictor in patients with coronary artery disease and increasing number of patients with CAD and ischemic left ventricular (LV) dysfunction is a major clinical problem. Congestive heart failure is a frequent complication which is associated with significant health care costs and two-third of cases have ischemic cardiomyopathy. In such patients, coronary revascularization can lead to symptomatic and prognostic improvement and reversal of LV remodeling which led to the concept of viable myocardium to select patients in whom recovery of LV function and improvement of prognosis will outweigh the risk of surgical revascularization. The aim of this review article is to understand the different modalities for assessing myocardial viability and clinical impact of revascularization in relation to the evidence of viability in patients with LV dysfunction.

Immune alterations and emerging immunotherapeutic approaches in lung cancer.

INTRODUCTION: Subjects with lung cancer were shown to present a variety of immune abnormalities including cellular immune dysfunction, cytokine alterations, and antigen presentation defects. As discouraging results are commonly seen with the existing therapies in lung cancer, more innovative treatment strategies are needed. AREAS COVERED: The authors review comprehensively the immune abnormalities in individuals with lung cancer, describe the lung cancer immunotherapy candidates that are most advanced in their clinical development, and summarize recent data from clinical trials of these agents. EXPERT OPINION: Enhancing the immune system represents an appealing avenue for lung cancer therapy. Several immunomodulating agents have activity in this regard including ipilimumab, a monoclonal antibody against the CTLA-4, and talactoferrin, a dendritic cell activator. In addition, a significant activity was shown with belagenpumatucel-L, a whole-cell-based vaccine that blocks the action of TGF-ß2. Other promising vaccines are protein-specific vaccines against tumor antigens such as MAGE-A3, EGF, and MUC1. Although some of these immunotherapies may have lackluster performance as single agents in advanced disease, more impressive results are seen in combination with chemotherapy agents. Given their proven activity in lung cancer, these immunotherapies may soon become a powerful addition to the oncologist's toolbox.