Cardiogenic Shock Complicating Acute Myocardial Infarction Treated With Percutaneous Coronary Intervention Supported by Impella: Implications of Advanced Age and Refractory Shock on Outcomes.

With percutaneous left ventricular mechanical circulatory support devices becoming increasingly available for patients with cardiogenic shock due to acute myocardial infarction and the lack of a clear mortality benefit to date, identifying optimal candidates for this technology is crucial. We studied the effectiveness of Impella Cardiac Pow (Abiomed, Danvers, MA) in various stages of cardiogenic shock and elderly cohorts. DESIGN: Retrospective review. SETTING: Data were collected for patients at a single community hospital between January 1, 2018, and December 31, 2019. SUBJECTS: Thirty-one consecutive adult patients with cardiogenic shock due to acute myocardial infarction who received Impella Cardiac Pow support. Shock stages were defined by the Society for Cardiovascular Angiography and Intervention (Stages A-E). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was in-hospital death across Society for Cardiovascular Angiography and Intervention cardiogenic shock stages and in patients greater than or equal to 80 and less than 80 years old. Secondary outcomes were Valve Academic Research Consortium-2 vascular and bleeding complications, stroke, and renal failure requiring dialysis. The median age of the study population was 64 years, with seven patients (23%) being greater than or equal to 80 years old. No patients were in Society for Cardiovascular Angiography and Intervention Stage A, whereas there were seven in B, eight in C, six in D, and 10 (32%) in E. Overall in-hospital mortality occurred in 61% of patients. All 10 patients in Stage E died before hospital discharge. Mortality occurred in 54% of patients (13/24) age less than 80 years compared with 86% of those 80 years or older (6/7). A total of 38.7% of patients (12/31) and 32.3% of patients (10/31) experienced Valve Academic Research Consortium-2 bleeding and vascular events, which were evenly distributed across Society for Cardiovascular Angiography and Intervention cardiogenic shock Stages. CONCLUSIONS: In conclusion, patients with shock in extremis and those 80 years old and older may have a prohibitively high mortality despite Impella use. These findings merit further prospective investigation in a larger number of patients to evaluate the effectiveness of Impella (and other left ventricular mechanical circulatory devices) and the inherent resource utilization in advanced cardiogenic shock and the elderly.

Differences in Baseline Characteristics and Outcomes in Young Caucasians and African Americans with Acute Myocardial Infarction.

BACKGROUND: The incidence of acute myocardial infarction (AMI) in young patients is increasing. While race-related differences in clinical characteristics and outcomes for older AMI patients have been well-studied, such differences in young patients are unknown. METHODS: We performed a retrospective review of charts of Caucasian and African American (AA) patients <50 years of age, presenting with AMI between 2010 and 2017 in an urban, community hospital in Detroit, Michigan. RESULTS: A total of 271 patients were identified with 156 being AAs (57.5%). Mean age was 43 years which was similar in both groups. AAs with AMI were 2.2 times more likely to be women and to have a history of diabetes and 1.2 times more likely to have BMI >30 kg/m2. History of coronary artery disease (1.8-fold) and hypertension (1.5-fold) were also more common in AAs. Overall presenting features were similar, other than that AAs presented more often with non-ST-elevation MI and tended to present less often with cardiac arrest. No differences were observed in the angiographic findings or in-hospital outcomes in the two groups, with the exception of lower need of mechanical support in AAs. CONCLUSIONS: In conclusion, our data provide important, not previously described information on race-related differences in history, presentation, clinical and angiographic features and outcomes in AAs compared with Caucasians younger than 50 with AMI. These findings may have implications for tailoring specific preventive strategies to decrease the incidence of AMI and its associated adverse events in both racial groups.

Association of Operator and Hospital Experience With Procedural Success Rates and Outcomes in Patients Undergoing Percutaneous Coronary Interventions for Chronic Total Occlusions: Insights From the Blue Cross Blue Shield of Michigan Cardiovascular Consortium.

BACKGROUND: An inverse relationship has been described between procedural success and outcomes of all major cardiovascular procedures. However, this relationship has not been studied for percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). METHODS: We analyzed the data on patients enrolled in Blue Cross Blue Shield of Michigan Cardiovascular Consortium registry in Michigan (January 1, 2010 to March 31, 2018) to evaluate the association of operator and hospital experience with procedural success and outcomes of patients undergoing CTO-PCI. CTO-PCI was defined as intervention of a 100% occluded coronary artery presumed to be ≥3 months old. RESULTS: Among 210 172 patients enrolled in the registry, 7389 (3.5%) CTO-PCIs were attempted with a success rate of 53%. CTO-PCI success increased with operator experience (45% and 65% in the lowest and highest experience tertiles) and was the highest for highly experienced operators at higher experience centers and the lowest for inexperienced operators at low experience hospitals. Multivariable logistic regression models (with spline transformed prior operator and institutional experience) demonstrated a positive relationship between prior operator and site experience and procedural success rates (likelihood ratio test=141.12, df=15, P<0.001) but no relationship between operator and site experience and major adverse cardiac event (likelihood ratio test=19.12, df=15, P=0.208). CONCLUSIONS: Operator and hospital CTO-PCI experiences were directly related to procedural success but were not related to major adverse cardiac event among patients undergoing CTO-PCIs. Inexperienced operators at high experience centers had significantly higher success but not major adverse cardiac event rates compared with inexperienced operators at low experience centers. These data suggested that CTO-PCI safety and success could potentially be improved by selective referral of these procedures to experienced operators working at highly experienced centers.

Giant Right Coronary Artery Aneurysm: An Association With Primary Varicose Veins?

Coronary artery aneurysms are rare conditions with potentially devastating consequences. We describe the case of an athletic 40-year-old woman who received a diagnosis of giant right coronary artery aneurysm while she was undergoing a work-up for lower extremity varicose veins. She underwent successful surgical treatment without any complications. (Level of Difficulty: Intermediate.).

Meta-analysis of fractional flow reserve guided complete revascularization versus infarct related artery only revascularization in patients with ST-elevation myocardial infarction and multivessel coronary artery disease.

BACKGROUND: Multivessel coronary artery disease is found in 30-50% of patients with ST-elevation myocardial infarction (MI) and is associated with adverse outcomes. It is not yet clear if outcomes are improved by utilizing fractional flow reserve (FFR) guided percutaneous coronary intervention (PCI) of noninfarct related artery (non-IRA) along with primary PCI. METHODS AND RESULTS: To evaluate this, we performed a metanalysis of published randomized controlled trials by performing systematic search of PubMed, Medline, Google Scholar and Cochrane Central. Three studies met the inclusion criteria, with total of 1633 patients; 689 underwent FFR-guided complete revascularization and 944 underwent IRA only revascularization. FFR-guided PCI of non-IRA along with primary PCI led to significant reduction of major adverse cardiovascular events (composite of death, MI and repeat revascularization) compared to PCI of IRA only [odds ratio (OR) = 0.55; 95% confidence interval (CI) = 0.42-0.72; P < 0.001]. This difference was primarily due to significant reduction in repeat revascularization (OR = 0.37; 95% CI = 0.26-0.53; P < 0.001). The rates of all-cause mortality (OR = 1.24; 95% CI = 0.65-2.35; P = 0.51) and MI (OR = 0.79; 95% CI = 0.46-1.36; P = 0.48) were similar in two groups. CONCLUSION: This meta-analysis demonstrated that FFR-guided PCI of non-IRA along with primary PCI was associated with lower rate of major adverse cardiovascular events compared with PCI of IRA-only in patients with ST-elevation MI and multivessel disease. The difference was driven by lower rate of repeat revascularization in FFR-guided PCI of non-IRA group.

Association of Race with Long-Term Outcomes in Patients Undergoing Popliteal and Infra-Popliteal Percutaneous Peripheral Arterial Interventions.

BACKGROUND: Race-related differences in clinical features, presentation, treatment and outcomes of patients with various cardiovascular diseases have been reported in previous studies. However, the long-term outcomes in black versus white patients with popliteal and/or infra-popliteal peripheral arterial disease (PAD) undergoing percutaneous peripheral vascular interventions (PVI) are not well known. METHODS AND RESULTS: We retrospectively evaluated long-term outcomes in 696 patients (263 blacks and 433 whites) who underwent PVI for popliteal and/or infra-popliteal PAD at our institution between 2007 and 2012. When compared to white patients, black patients were younger (70 ±â€¯11 vs. 72 ±â€¯11; P = 0.002) and had more comorbidities: higher creatinine (2.04 ±â€¯2.08 vs. 1.33 ±â€¯1.16; P < 0.0001) with more ESRD (19% vs. 6%; P < 0.0001) and more diabetes (64% vs. 55%; P = 0.004). At mean follow-up of 36 ±â€¯20 months, there was no statistically significant difference between black and white patients either in all-cause mortality (29% vs. 32%; P = 0.38) or in major amputation (4.4% vs. 4.2%; P = 0.88), respectively. In a multi-variate Cox proportional hazard model, repeat ipsilateral percutaneous revascularization or bypass were lower in black patients (HR = 0.64 [95% CI 0.46-0.89]; P = 0.007) and major adverse vascular events (MAVE) were lower in black patients as well (HR = 0.7 [95% CI 0.56-0.89]; P = 0.003). CONCLUSION: Black patients undergoing popliteal or infra-popliteal PVI had similar mortality and major amputation, but lower repeat revascularization and MAVE compared to white patients. These data support the use of PVI in minorities despite higher baseline comorbidities and call for more research to understand the mechanisms underlying the high mortality irrespective of race.

Coronary Artery Embolism: Two Case Reports and a Review of the Literature.

Coronary embolism (CE) is an uncommon and unique cause of acute myocardial infarction. In this report, we review 216 cases of CE including 2 new cases from our institution. The mean patient age was 52.5 years and 62% of the patients were males. Chest pain was the most common presenting symptom followed by dyspnea, and the most commonly affected vessel was the left anterior descending artery. Leading etiologies of the embolus were atrial fibrillation, septic emboli, and iatrogenic causes. Treatment approaches varied with thrombus aspiration being used in 30% of cases. In-hospital mortality rate was 36% and 13% of the cases were complicated by cerebrovascular accident. CE is a unique pathology that leads to acute myocardial infarction. It portends a high mortality rate and requires a high level of suspicion as symptoms may be misleading. Further research is needed in order to improve recognition and management and to lower associated mortality.

Meta-analysis of drug eluting stents compared with bare metal stents in high bleeding risk patients undergoing percutaneous coronary interventions.

OBJECTIVES: To determine the efficacy and safety of drug-eluting stents (DESs) and bare metal stents (BMSs) when used with short or tailored dual antiplatelet therapy (DAPT) in high bleeding risk (HBR) patients. BACKGROUND: DES have been shown to reduce target lesion revascularization (TLR) as well as stent thrombosis (ST) compared to BMS in patients undergoing percutaneous coronary intervention (PCI). However, patients at HBR continue to receive BMS given the fear of bleeding or ST from premature discontinuation of DAPT in patients receiving DES. METHODS: We performed a meta-analysis of randomized controlled trials by performing systematic search for studies comparing DES with BMS in HBR patients using PUBMED, MEDLINE, and Cochrane Central, reported until March 1, 2018. RESULTS: Three randomized controlled studies met the inclusion criteria with total of 4,460 patients; 50% received DES. Major adverse cardiovascular event (MACE); composite of death, myocardial infarction (MI), and TLR, at 1 year was significantly lower (RR = 0.63, 95% CI 0.50-0.80) in DES group compared to BMS. This difference was primarily driven by lower TLR (RR = 0.46, 95% CI 0.35-0.61) in DES group. Definite or probable ST (RR = 0.59, 95% CI = 0.32-1.08) and major (RR = 0.94, 95% CI = 0.74-1.20) bleeding were similar. CONCLUSIONS: DES was associated with lower MACE without increased risk of bleeding or ST compared to BMS when used with short or tailored DAPT in patients with HBR.

Meta-Analysis of Transcatheter Valve-in-Valve Implantation Versus Redo Aortic Valve Surgery for Bioprosthetic Aortic Valve Dysfunction.

Transcatheter valve-in-valve implantation (ViV-TAVI) has evolved as an alternative to redo surgical valve replacement (redo-SAVR) for high-risk patients with aortic bioprosthetic valve (BPV) dysfunction. The differences in procedural success and outcomes in a large number of patients who underwent ViV-TAVI compared with redo-SAVR for aortic BPV dysfunction are not known. We conducted a meta-analysis of the previously reported studies to determine outcomes after ViV-TAVI and redo-SAVR. PubMed, MEDLINE, and Google Scholar databases were searched for studies that reported comparative outcomes of patients who underwent either ViV-TAVI or redo-SAVR. Four observational studies met the inclusion criteria, with a total of 489 patients, 227 of whom underwent ViV-TAVI and 262 underwent redo-SAVR. Thirty-day mortality was similar in 2 groups (5% vs 4%; odds ratio [OR] = 1.08, 95% confidence interval [CI] = 0.44 to 2.62) despite the higher operative risk in the ViV-TAVI cohort as evidenced by significantly higher EuroSCORE I or II. There were similar rates of stroke (2% vs 2%; OR = 1.00, 95% CI = 0.28 to 3.59), myocardial infarction (2% vs 1%; OR = 1.08, 95% CI = 0.27 to 4.33), and acute kidney injury requiring dialysis (7% vs 10%; OR = 0.80, 95% CI = 0.36 to 0.1.77) between 2 groups but a lower rate of permanent pacemaker implantation in the ViV-TAVI group (9% vs 15%; OR = 0.44, 95% CI = 0.24 to 0.81). This meta-analysis of nonrandomized studies with modest number of patients suggested that ViV-TAVI had similar 30-day survival compared with redo-SAVR for aortic BPV dysfunction.

Long-term outcomes of patients with diabetes mellitus undergoing percutaneous intervention for popliteal and infrapopliteal peripheral arterial disease.

OBJECTIVES: To evaluate the association of diabetes mellitus (DM) with clinical and angiographic characteristics and outcomes of patients with popliteal and infrapopliteal peripheral arterial disease (PAD) undergoing peripheral vascular intervention (PVI). BACKGROUND: Clinical features and outcomes in patients with DM and popliteal or infrapopliteal PAD undergoing PVI are not well described. METHODS: Using the data from the laser in popliteal and infrapopliteal stenosis study, we retrospectively examined the association of diabetes with clinical and angiographic characteristics and risk adjusted short- and intermediate term outcomes (all cause death, major adverse events (MAE) [composite of death, ipsilateral major amputation, or repeat revascularization]) in patients with popliteal and infrapopliteal PAD undergoing PVI for critical limb ischemia treated either with laser-assisted balloon angioplasty or balloon angioplasty alone. RESULTS: Of 714 patients, 418 had DM (58.5%). Patients with DM were younger with higher prevalence of history of coronary artery disease, heart failure, end-stage renal disease, and prior contralateral limb amputation compared to those without DM. At 5 years, mean event free survival for all cause mortality (39.9 vs. 45.5 months; P = 0.001), MAE (29.3 vs. 36.8 months; P < 0.001), ipsilateral major amputation (55.3 vs. 57.4 months; P = 0.001), and repeat revascularization (42.0 vs. 45.8 months; P = 0.03) were significantly lower in DM patients. On multivariate analysis, DM was associated with significantly higher all cause mortality (HR = 1.83, 95% CI 1.33-2.52), MAE (HR = 1.73, 95% CI 1.35-2.23), and ipsilateral major amputation (HR = 5.52, 95% CI 1.82-16.71). CONCLUSIONS: Among patients with popliteal and infrapopliteal PAD undergoing PVI, DM was associated with higher mortality, major amputations and MAE that was independent of baseline comorbidities. Our data suggested the need for future studies evaluating existing and/or novel therapies to improve the poor long-term outcomes in diabetic patients with popliteal and infrapopliteal PAD.

Association of Anemia With Outcomes in Patients Undergoing Percutaneous Peripheral Vascular Intervention: Insights From the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2 VIC).

OBJECTIVES: To evaluate the clinical features and outcomes of patients with anemia undergoing percutaneous peripheral vascular intervention (PVI) in a contemporary registry. METHODS: We evaluated the differences in the clinical features and outcomes of patients with and without anemia undergoing PVI in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2 VIC) registry. Anemia was defined using World Health Organization criteria. RESULTS: Baseline anemia was present in 42.3% of 15,683 patients undergoing PVI. Compared to patients without anemia, those with anemia were older (mean age, 67 years vs 71 years), were more often black (16% vs 29%), and had higher comorbidities. Anemic patients were twice as likely to present with acute limb ischemia (5% vs 11%) and undergo urgent PVI (6% vs 15%) or below-the-knee PVI (18% vs 35%). Many in-hospital adverse events were higher in anemic patients. In a propensity-matched cohort, any adverse outcome (3.4% vs 8.4%; odds ratio [OR], 2.58; 95% confidence interval [CI], 1.94-3.42) or major cardiovascular event, defined as death, myocardial infarction, stroke, or amputation (1.1% vs 3.2%; OR, 2.96; 95% CI, 1.83-4.79) was more likely in anemic patients. Of all adverse events, the highest odds were observed for post-PVI transfusions and amputations in anemic patients. Multivariable logistic regression showed that baseline hemoglobin (1 g/dL below the normal value) was associated with greater risk of any adverse event (OR, 1.57; 95% CI, 1.47-1.68). CONCLUSION: The prevalence of anemia was high among PVI patients and was associated with significantly greater likelihood of amputation, any adverse event, and major cardiovascular events. Whether preprocedure correction of anemia has the potential to decrease post-PVI adverse events remains to be studied.

Myocardial Infarction Secondary to Blunt Chest Trauma.

Myocardial infarction (MI) following blunt chest trauma is rare, but potentially fatal. We treated a young patient for acute MI after falling chest-first on ice while playing hockey. Coronary artery bypass grafting (CABG) was performed after percutaneous stenting attempts were unsuccessful. By reviewing the related literature, we found 179 cases, the majority of which affected young males following road accidents. Left anterior descending artery was most frequently affected followed by right coronary artery particularly in their proximal thirds. Prior to the advent of emergent angioplasty for MI, conservative management was frequently pursued, whereas subsequently both stenting and CABG were performed as initial therapy. Several cases required CABG after the failure of stenting attempts. Trauma-associated MI is uncommon but should be suspected to be properly diagnosed and managed; the potential need for CABG requires that a cardiac surgeon be informed at the time of angiography to avoid possible delay in revascularization.

Multiple embolic strokes as a result of Libman-Sacks endocarditis associated with lupus and secondary antiphospholipid antibody syndrome: a case report.

BACKGROUND: Libman-Sacks endocarditis (LSE) is an infrequently recognized pathogenesis of embolic cerebrovascular disease. Patients often have asymptomatic valvular dysfunction which if not recognized promptly, can lead to serious complications such as heart failure, arrhythmias, cerebroembolic phenomena with increased neurocognitive disability, and even death. It can be associated with systemic lupus erythematosus and/or antiphospholipid antibody syndrome (APLS). CASE SUMMARY: Previously very healthy and active, 49-year-old Caucasian female with past medical history of mild lupus, for which she stopped treatment 10 year ago, saw a primary care physician complaining of intermittent double vision of 2 months duration. Urgent brain magnetic resonance imaging revealed multiple embolic infarcts of the brain stem. Further comprehensive work-up led to diagnosis of mitral LSE and APLS. After 2 months of systemic anticoagulation with warfarin and immunosuppressive therapy with hydroxychloroquine sulfate, repeat imaging demonstrated resolution of the mitral valve vegetation with no clinical recurrence of thromboembolic events at 6 months. DISCUSSION: Mild, often silent, autoimmune disease as described in our case can lead to significant cerebrovascular disease. Patients who present with cryptogenic strokes with high suspicion of underlying autoimmune disease should be worked up thoroughly for possible valvular heart disease associated with lupus, APLS, or both. Acquisition of transoesophageal images proved superior to transthoracic approach and it should be implemented in these subsets of patients. With this case report, we highlight the importance of early recognition of cardiac manifestations, amelioration of risk factors, as well as close follow-up of lupus or APLS patients, as crucial steps in reducing their morbidity and mortality along with preventing recurrence or progression of cerebrovascular disease.

Rupture of sinus of Valsalva aneurysm: Two case reports and a concise review of the literature.

BACKGROUND: The rupture of sinus of Valsalva aneurysm (RSoVA) is a rare disorder that affects the integrity of the cardiovascular system, disrupting its dynamics and resulting in a variety of manifestations. In this report, we discuss two cases of RSoVA that we encountered and review similar cases reported in the literature. METHODS: literature review of reported cases of RSoVA in PubMed and Google Scholar. RESULTS: A total of 223 cases were found and the final analysis included 225 cases, of which 69% occurred in males and the mean age was 38.9 years. Dyspnea was the most common presenting symptom and 76% of the cases described continuous murmur on examination. The right sinus was affected in 61% of the cases and the fistula connected to the right chambers of the heart 73% of the time. CONCLUSION: RSoVA is a rare condition that is difficult to diagnose, it should be considered in the right context, particularly in young patients with symptoms of heart failure and the presence of continuous murmur on cardiac examination.

The association of race with quality of health in peripheral artery disease following peripheral vascular intervention: The Q-PAD Study.

Black patients have a higher prevalence of peripheral artery disease (PAD) than white patients, and also tend to have a greater extent and severity of disease, and poorer outcomes. The association of race with quality of health (QOH) after peripheral vascular intervention (PVI), however, is less well-known. In our study, we hypothesized that after PVI, black patients experience worse QOH than white patients. We retrospectively assessed racial differences in health status using responses to the Peripheral Arterial Questionnaire (PAQ) at baseline (pre-PVI) and up to 6 months following PVI among 387 patients. We used the PAQ summary score (which includes physical limitation, symptoms, social function and quality of life) as a measure of QOH. We compared QOH scores at baseline and at follow-up after PVI between black ( n=132, 34.1%) and white ( n=255, 65.9%) patients. We then computed the change in score from baseline to follow-up for each patient (the delta) and compared the median delta between the two groups. Multivariable regression was used to model the delta QOH after controlling for factors associated with race or with the delta QOH. There was no significant difference in mean QOH by race either at baseline ( p=0.09) or at follow-up ( p=0.45). There was no significant difference in the unadjusted median delta by race (white 25.3 vs black 21.5, p=0.28) and QOH scores improved significantly at follow-up in both groups, albeit the improvement was marginally lower in black compared with white patients after adjustment for baseline confounders ( b = -6.6, p=0.05, 95% CI -13.2, -0.11).

Distal Cuff Occlusion: A Novel, Simple Approach for Distal Embolic Protection in Peripheral Vascular Intervention.

AIM: To evaluate the feasibility, effectiveness, and safety of the cuff-occlusion method for distal embolic protection in peripheral artery disease. METHODS AND RESULTS: We evaluated 61 patients who underwent peripheral vascular intervention (PVI) for infrainguinal lesion at a single center where a blood pressure cuff occlusion method for distal embolic protection was utilized during the procedure. Primary endpoint included incidence of distal embolization, acute limb ischemia, or emergency limb amputation. Safety endpoints were freedom from bleeding, vessel perforation, or dissection. Lesion location was in the superficial femoral artery in 39% of cases and popliteal and infrapopliteal in 61% of patients. Procedural success was achieved in 98.4% of patients and 1 patient had distal embolization. There was no bleeding or perforation or major flow-limiting vessel dissection. CONCLUSION: Our study demonstrated that the cuff-occlusion strategy was feasible and safe for protection form distal embolization in PVI. Further study is required to evaluate the efficacy and safety of this novel method compared with existing devices for distal protection.

Relation of Baseline Renal Dysfunction With Outcomes in Patients Undergoing Popliteal and Infrapopliteal Percutaneous Peripheral Arterial Interventions.

Renal dysfunction is a major risk factor for peripheral arterial disease (PAD). Infrapopliteal PAD is associated with more co-morbid conditions and worse prognosis than suprapopliteal PAD. Long-term outcomes of patients with renal dysfunction and popliteal or infrapopliteal PAD undergoing peripheral vascular intervention (PVI) are not well described. We retrospectively evaluated long-term outcomes in 726 patients undergoing infrapopliteal PVI categorized into 3 glomerular filtration rate (GFR)-based groups: GFR (≥60 ml/min/1.73 m(2)), GFR (<60 ml/min/1.73 m(2)), and those on dialysis. At mean follow-up of 36 ± 20 months, amputation rates were 3%, 5%, and 11% with mortality rates of 23%, 36%, and 56% in normal renal function, chronic kidney disease (adjusted odds ratio [OR] for amputation 1.75, 95% CI 0.73 to 4.21; adjusted OR for mortality 1.53, 95% CI 1.05 to 2.23, p = 0.028), and dialysis (adjusted OR for amputation 2.43, 95% CI 0.84 to 7.02, p = 0.100; adjusted OR for mortality 4.51, 95% CI 2.46 to 8.26, p <0.0001) groups, respectively. Repeat revascularization was similar in all 3 groups at roughly 25%. In conclusion, chronic kidney disease and dialysis were associated with increased major amputations and mortality in patients who received PVI for popliteal and infrapopliteal PAD.

Association Of Bleeding Avoidance Strategies with age-related bleeding and In-hospital mortality in patients undergoing percutaneous coronary Interventions.

BACKGROUND: The association of bleeding avoidance strategy (BAS) (consisting of a combination of radial access, bivalirudin [rather than heparin +/- glycoprotein GPIIb/IIIa antagonists], and/or vascular closure devices after femoral access) with bleeding and in-hospital outcomes has not been evaluated among elderly patients undergoing percutaneous coronary interventions (PCI). METHODS: We studied BAS use, bleeding and in-hospital mortality among 121,635 patients categorized by age (<50, 50-59, 60-69, 70-79, and ≥80years) undergoing PCI from the BMC2 registry (1/2010-12/2013). RESULTS: The use of BAS decreased marginally with age and despite improved utilization over time, remained lower among the elderly. BAS was used in a much lower risk cohort among all age groups. Nonetheless, compared with no BAS, the use of this strategy was associated with lower bleeding (adjusted OR 0.984, 95% CI 0.980-0.985) and in-hospital mortality (adjusted OR 0.996, 95% CI 0.994-0.997) among all age-groups. Similar relative reduction in the risk of bleeding was observed among all age groups with BAS use with lowest risk (thus greatest absolute risk reduction given their highest risk for bleeding) for the oldest cohort. CONCLUSIONS: BAS use decreased with age among patients undergoing PCI despite its association with lower in-hospital mortality. Although overall utilization improved over time, it still remained lower in the elderly cohort, a group likely to benefit most from it. These data identified an opportunity to design strategies to improve BAS use particularly among high-risk elderly patients undergoing PCI so as to decrease bleeding and reduce related adverse events and costs.

Novel CenterCross and MultiCross devices for the treatment of infrainguinal chronic total occlusions: initial single-centre experience.

AIMS: Our aim was to evaluate the effectiveness and safety of CenterCross/MultiCross devices to facilitate the crossing of chronic total occlusions in peripheral arteries. METHODS AND RESULTS: This was a single-centre study in which 53 consecutive patients who were not amenable to initial attempts at crossing using standard guidewires underwent an attempt to recanalise chronically occluded infrainguinal peripheral arteries with MultiCross/CenterCross devices. The primary endpoint of interest was the ability to advance the guidewire beyond the chronic total occlusion (CTO) lesions with the use of these devices. Safety endpoints were freedom from bleeding, distal embolisation and vessel perforation, dissection or need for emergent surgical intervention. Popliteal artery and below lesions were the most commonly treated, comprising 89% of the total. The CTO lesions were crossed successfully in 92.4% of the cases within a relatively short time (5.5±3.5 minutes). There was no bleeding, dissection or need for emergent surgery and 98.1% and 96.2% of the patients were free from distal embolisation and perforations, respectively. CONCLUSIONS: Our study demonstrated that MultiCross and CenterCross were effective and safe for recanalisation of peripheral CTO lesions which were not amenable to conventional guidewires. Further study is required to define the role of these novel devices in the treatment of complex lesions, particularly CTOs in patients with peripheral arterial disease.

Differences in sex-related bleeding and outcomes after percutaneous coronary intervention: insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) registry.

BACKGROUND: Bleeding after percutaneous coronary intervention (PCI) is more common in women than in men. However, the relationship of sex and bleeding with outcomes is less well studied. METHODS: We examined the sex-related differences in the incidence of bleeding and its association with in-hospital outcomes among 96,637 patients undergoing PCI enrolled in the BMC2 registry (2010-2012). RESULTS: Women had higher bleeding rate than did men (3.9% vs 1.8%) and thus received more blood transfusions (59% vs 41%). Both men (odds ratio [OR] 2.25, 95% CI 1.70-2.97) and women (OR 3.13, 95% CI 2.42-4.07) who bled had higher risk-adjusted death compared with their counterparts without bleeding. Although there was no difference in adjusted mortality between women and men without bleeding (OR 1.14, 95% CI 0.99-1.32), among patients who bled, adjusted death was higher in women (OR 1.28, 95% CI 1.11-1.47). Among patients with bleeding, transfusion was associated with similar increased risk of death in both men (OR 2.00, 95% CI 1.23-3.25) and women (OR 2.18, 95% CI 1.31-3.63) compared with their counterparts without transfusion(s). CONCLUSIONS: Post-PCI bleeding was more common and associated with higher-than-expected in-hospital death in women compared with men with bleeding. This trend for higher death in women with bleeding was independent of transfusion. Quality efforts geared toward reducing bleeding in general, with a special focus on women, need to be explored to help reduce post PCI-bleeding and mortality and decrease sex-related disparity in adverse events.