Common femoral artery anatomy is influenced by demographics and comorbidity: implications for cardiac and peripheral invasive studies.

We assessed the angiographic size of the common femoral artery (CFA) and the influence of demographics and comorbidites. In addition, the location of the CFA bifurcation and the site of femoral puncture were also assessed. Consecutive CFA angiograms (n = 200) were prospectively analyzed. CFA diameter was 6.9 +/- 1.4 mm and length 43.3 +/- 16.2 mm. By multivariate analysis, only diabetes (P < 0.001), female gender (P < 0.0005), and small body surface area (P < 0.01) predicted small vessel size. Vessel length correlated with patient height (P < 0.0005). CFA bifurcation occurred at or below the femoral head center in 98.5%. The femoral puncture was into a vessel other than the CFA in 13%, and 54% of punctures were in a less than ideal anatomical location. In conclusion, the CFA is a relatively small diameter vessel, particularly in diabetics and women. Puncture above the femoral head center and below the superior margin of the acetabulum accurately predicts an ideal puncture site. Thus, routine fluoroscopic guidance should be considered. Cathet Cardiovasc Intervent 2001;53:289-295.

Decreased rate of coronary restenosis after lowering of plasma homocysteine levels.

BACKGROUND: We have previously demonstrated an association between elevated total plasma homocysteine levels and restenosis after percutaneous coronary angioplasty. We designed this study to evaluate the effect of lowering plasma homocysteine levels on restenosis after coronary angioplasty. METHODS: A combination of folic acid (1 mg), vitamin B12 (400 microg), and pyridoxine (10 mg)--referred to as folate treatment--or placebo was administered to 205 patients (mean [+/-SD] age, 61+/-11 years) for six months after successful coronary angioplasty in a prospective, double-blind, randomized trial. The primary end point was restenosis within six months as assessed by quantitative coronary angiography. The secondary end point was a composite of major adverse cardiac events. RESULTS: Base-tine characteristics and initial angiographic results after coronary angioplasty were similar in the two study groups. Folate treatment significantly lowered plasma homocysteine levels from 11.1+/-4.3 to 7.2+/-2.4 micromol per liter (P<0.001). At follow-up, the minimal luminal diameter was significantly larger in the group assigned to folate treatment (1.72+/-0.76 vs. 1.45+/-0.88 mm, P=0.02), and the degree of stenosis was less severe (39.9+/-20.3 vs. 48.2+/-28.3 percent, P=0.01). The rate of restenosis was significantly lower in patients assigned to folate treatment (19.6 vs. 37.6 percent, P=0.01), as was the need for revascularization of the target lesion (10.8 vs. 22.3 percent, P=0.047). CONCLUSIONS: Treatment with a combination of folic acid, vitamin B12, and pyridoxine significantly reduces homocysteine levels and decreases the rate of restenosis and the need for revascularization of the target lesion after coronary angioplasty. This inexpensive treatment, which has minimal side effects, should be considered as adjunctive therapy for patients undergoing coronary angioplasty.

Balloon coarctation angioplasty: follow-up of 103 patients.

OBJECTIVE: To evaluate the role of balloon coarctation angioplasty (BCA) in the management of patients with native coarctation of the aorta. BACKGROUND: BCA has emerged as an alternative to surgery for patients with native coarctation of the aorta. However, its role remains controversial. METHODS: Over a 7-year period, 103 patients undergoing BCA were enrolled in the study. Hemodynamic evaluation was obtained at baseline and immediately following BCA; 75% of patients returned for follow-up evaluation at 26 +/- 20 months. RESULTS: The systolic gradient across the coarcted segment decreased from 59 +/- 18 mmHg to 10 +/- 11 mmHg following BCA (p < 0.001). The procedure was successful in 82% of patients, and partial improvement was obtained in 17%. Repeat intervention was performed in 13% of the follow-up group. Surgical intervention was needed in 8 patients. CONCLUSION: Balloon angioplasty is an effective first-line intervention in patients with native coarctation of the aorta.

Current guidelines for the treatment of patients with rheumatic fever.

Rheumatic fever is a multisystem inflammatory disease that occurs as a delayed sequelae to group A streptococcal pharyngitis. The important clinical manifestations are migratory polyarthritis, carditis, chorea, subcutaneous nodules and erythema marginatum occurring in varying combinations. The pathogenesis of this disorder remains elusive: an antigenic mimicry hypothesis best explains the affliction of various organ systems after a lag period following pharyngeal infection. In its classic milder form, the disorder is largely self-limited and resolves without sequelae, but carditis may be fatal in severe forms of the disease. Chronic and progressive damage to the heart valves leads to the most important public health manifestations of the disease. Anti-inflammatory agents provide dramatic clinical improvement, but do not prevent the subsequent development of rheumatic heart disease. The role of corticosteroids in treatment of carditis is uncertain and controlled studies have failed to demonstrate improved long term prognosis. Chorea, once considered a benign self-limited disease, is now felt to require more aggressive treatment, in particular with sedatives. Prevention of first and subsequent attacks of rheumatic fever is the mainstay in the limited arsenal available to alter the natural history of this disease.

Successful redeployment of an unexpanded coronary stent.

We report on treatment of a patient in whom failure to deploy the distal portion of a Palmaz-Schatz stent occurred but was not recognized. After an unstable course, the patient underwent repeat coronary angiography, at which time the stent was rewired and redilated. Full deployment of the stent with restoration of TIMI grade 3 flow was achieved. The putative cause of the problem, incomplete deployment of the stent because of inadvertent advancement of the stent delivery sheath, should be avoided, and needs to be recognized if it occurs. Crossing and redilating the stent is possible, although technically difficult.

Percutaneous balloon mitral valvuloplasty.

Percutaneous balloon mitral valvuloplasty, first performed by Inoue in 1982, was a rational progression from 4 decades of experience with the blunt surgical dilatation technique of closed mitral commissurotomy. As with surgical commissurotomy, balloon valvuloplasty relieves mitral stenosis by the splitting of fused commissures. A series of studies have shown that balloon valvuloplasty achieves excellent acute hemodynamic results in close to 90% of patients, with a typical 100% increase in mitral valve area. Over the past 15 years since Inoue's first patient, a number of other techniques have been introduced and largely discarded in favor of the original approach. Advances have occurred along the lines of improved noninvasive assessment of mitral valve disease, which have allowed better case selection and prediction of outcome. Follow-up series have shown sustained improvement, with modest rates of complications and restenosis. Comparative studies have shown that balloon valvuloplasty is as effective and safe as surgical commissurotomy, and is a cost-effective procedure of first choice in ideal patients.

Retrospective comparative study of primary intracoronary stenting versus balloon angioplasty for acute myocardial infarction.

Balloon angioplasty has been shown to be an effective therapy for the treatment of acute myocardial infarction but is associated with a high restenosis rate, substantial early recoil, persistent thrombus and need for intracoronary thrombolysis, and a high rate of reclosure. Because many of the limitations of balloon angioplasty in the noninfarction setting are addressed by intracoronary stenting, we examined the results of primary stenting of 18 consecutive patients treated for acute myocardial infarction, and compared the results to those achieved with primary balloon angioplasty in 18 prior cases. Despite the presence of thrombus prior to angioplasty in 13 of the stented patients, no intracoronary thrombolytic therapy was required. Mean percent stenosis using quantitative coronary angiography was 17.7 +/- 10.2% after primary stenting compared with 43.7 +/- 20.3% after primary balloon angioplasty (P < .001). One stent patient who had all anticoagulant and antiplatelet therapy withdrawn early suffered subacute thrombosis. Patients were followed up to 3 yr. Complications were similar in two groups. We conclude that primary stenting for acute myocardial infarction results in superior angiographic appearance as well as resolution of thrombus without the need for routine thrombolysis, and is associated with a low complication rate and excellent short-term clinical patency.