Reduction of vascular complication rates from femoral artery access in contemporary women undergoing cardiac catheterization.

BACKGROUND: Femoral arterial access (FAA) during diagnostic coronary angiography (CAG) and percutaneous coronary interventions (PCI) are associated with several vascular complications (VC). VC rate in our experience a decade ago was 3.02% and higher in women (4.7% in women, and 1.67% in men, p < 0.0006), with an OR of 2.81 (95% CI: 1.51-5.22). METHODS: Patients who underwent CAG and PCI utilizing FAA (n = 2617) were separated into Period 1 (2005 to 2008; 1970 patients; Male 1045; Female 925) and Period 2 (2016-2017; 647 patients; Male 357; Female 290). FA access was preceded by anatomic FA localization during Period 1 vs. additional fluoroscopic marking of femoral head during Period 2. Ultrasound guidance was not utilized during either period. VCs were defined as hematoma>3 cm, major bleeding requiring blood transfusion or hemoglobin drop >2 g, retroperitoneal bleed, pseudoaneurysm, AV fistula, arterial thrombosis, distal embolism, dissection, and transient limb ischemia. RESULTS: Rate of VCs did not differ from Periods 1 to 2 (2.44% vs. 2.32%, p = 1.0). An elevated rate of VCs experienced by women in Period 1 (Female 3.68% vs. Male 1.34%, p < 0.05) is no longer noted in Period 2(Female 2.07% vs. Male 2.52%, p = 0.79). Vascular closure device (VCD) use was protective in both Periods 1 and 2. CONCLUSIONS: The use of fluoroscopic marking of femoral head prior to access, smaller sheath size, and being a high femoral volume center may have contributed to the reduced incidence of VCs in women. VCD utilization is continuing to reduce VC rates in both men and women.

Does micropuncture technique really help reduce vascular complications?

BACKGROUND: Micropuncture technique (MPT) is being adapted nationally to reduce vascular complications (VC). We initiated a quality improvement project in our cath lab to reduce VCs utilizing MPT. METHODS: We utilized MPT on all of our non-STEMI femoral artery (FA) access cases starting September 2016. As a comparator group, we collected data from April to August 2016. Anatomic localization of FA and fluoroscopic marking of femoral head was utilized in all cases. VCs were defined by BARC definitions for bleeding/hematomas, retroperitoneal bleed, pseudoaneurysm, AV fistula, arterial thrombosis, distal embolism, dissection, and transient limb ischemia. RESULTS: A total of 647 patients (Male 357, Female 290; MPT 333) were included in the analysis. MPT as compared to regular 18-gauge needle access did not demonstrate a reduction in VCs (2.4% vs. 2.2%; p = 1.0). MPT utilization did not affect the risk of VCs on univariate (OR 1.08; 95% CI 0.38-3.01; p = 0.88) or multivariate analysis (OR 0.91, 95% CI 0.28-2.93; p + 0.87). Vascular closure device (VCD) utilization as compared to manual/fem-stop hemostasis was the only factor that demonstrated a statistically significant and lower VC rate on both univariate (OR 0.28; 95% CI: 0.08-0.89; p = 0.03), and multivariate (OR 0.24; 95% CI 0.06-0.93; p = 0.039) analysis. CONCLUSION: Utilization of MPT in conjunction with fluoroscopic marking of the femoral head and without ultrasound guidance did not contribute to statistically significant reduction in the VC rate. The only factor found to be beneficial is utilization of VCDs. Further large randomized studies are required to demonstrate benefit of routinely utilizing MPT.

Comparison of prasugrel and ticagrelor in patients with acute coronary syndrome undergoing percutaneous coronary intervention: A meta-analysis of randomized and non-randomized studies.

BACKGROUND: The newer oral P2Y12 receptor antagonists (i.e. prasugrel and ticagrelor) are recommended over clopidogrel for patients with acute coronary syndrome (ACS) going for percutaneous coronary intervention (PCI). As the superiority of one agent over the other remains unclear, we designed a systematic review and meta-analysis of these agents in patients with ACS undergoing PCI. METHODS: PUBMED, EMBASE, Cochrane CENTRAL, CINAHL and manual search were performed through 11/02/2016. Mortality, myocardial infarction (MI), stroke, repeat revascularization, stent thrombosis (ST) and BARC bleeding ≥2 were the major outcomes. RESULTS: A total of 9 studies with 21,360 total patients were included in the meta-analysis. Compared to ticagrelor, prasugrel was associated with lower rate of MI [0.8% vs. 1.9%; 0.54 (0.29-0.99); P=0.05] but no difference was noted in mortality [2.1% vs. 2.4%; 0.84 (0.64-1.09); P=0.19], repeat revascularization [1.6% vs. 2.1%; 0.82 (0.61-1.10); P=0.19] and stroke [0.2% vs. 0.3%; 0.68 (0.25-1.83); P=0.44] between two agents. In addition, prasugrel was associated with lower risk of BARC ≥2 bleeding [2.5% vs. 3.8%; 0.75 (0.59-0.95); P=0.02] and showed a trend toward a lower risk of ST [0.3% vs. 0.6%; 0.55 (0.28-1.07); P=0.08] in comparison with ticagrelor. CONCLUSIONS: Based on this meta-analysis of observational and randomized studies, prasugrel appears to be equivalent or superior to ticagrelor in patients with ACS undergoing PCI on the 30-day follow up. Larger randomized trials with longer follow-ups are needed to establish superiority of one agent over the other.

Evidence for the vitamin D hypothesis: The NHANES III extended mortality follow-up.

BACKGROUND AND AIMS: Emerging evidence suggests that low levels of vitamin D may be an important risk factor for multiple chronic diseases and mortality, but the evidence is mixed. Vitamin D levels are associated with sun exposure, diet, and metabolic status. One potential explanation for the lack of consistent findings amongst various studies is that low vitamin levels may be associated with poor diets or other risk factors that we were not adequately controlled for in different analyses. METHODS: Prospective analysis of adults over the age of 35 in NHANES III data (1988-1994) with 20 year mortality follow-up. Sequential Cox proportional hazard models quartiles of 25OH vitamin D adjusted for age, season, geography, sociodemographic (SD), CVD risk factors (CVD) and nutritional factors (NF) were performed. RESULTS: Gender, race, diabetes, anti-hypertensive meds, income, taking vitamin D supplements, physical activity, alcohol consumption, region, body mass index, blood pressure, creatinine, albumin, CRP, thyroxine, iron, RBC folate, vitamin A, E, alpha-carotene, and lycopene were all associated with different quartiles of vitamin D and as well as CHD and all-cause mortality and thus are important potential confounders of this relationship. Adjusting for the confounding factors, higher levels of vitamin D demonstrate an inverse relationship with all-cause mortality, but only the top quartile of vitamin D shows an inverse relationship with CHD mortality. CONCLUSIONS: The highest quartile compared to the lowest quartile of 25OH vitamin D levels is inversely associated with CHD and all-cause mortality adjusting for multiple confounders. Whether supplementation of individuals with low vitamin D will result in similar benefits will require a randomized clinical trial.

Atherectomy devices: technology update.

Atherectomy is a procedure which is performed to remove atherosclerotic plaque from diseased arteries. Atherosclerotic plaques are localized in either coronary or peripheral arterial vasculature and may have different characteristics depending on the texture of the plaque. Atherectomy has been used effectively in treatment of both coronary and peripheral arterial disease. Atherectomy devices are designed differently to either cut, shave, sand, or vaporize these plaques and have different indications. In this article, current atherectomy devices are reviewed.

Aspiration thrombectomy in a case of acute myocardial infarction due to coronary emboli in a patient with peripartum cardiomyopathy and mural thrombus.

Acute coronary syndrome (ACS) due to embolic phenomenon in the setting of peripartum cardiomyopathy (PPCM) and left ventricular mural thrombus is a rare occurrence. There have been two known cases described in medical literature. We present a unique case in which catheter-based aspiration thrombectomy was used to successfully treat a patient with ACS due to coronary emboli in the setting of PPCMand left ventricular mural thrombus. We believe this to be the first report of the use of aspiration thrombectomy in such a clinical case.

Using 7.5 frames per second reduces radiation exposure in lower extremity peripheral vascular interventions.

BACKGROUND: Peripheral vascular interventions can be associated with significant radiation exposure to the patient and the operator. OBJECTIVE: In this study, we sought to compare the radiation dose between peripheral vascular interventions using fluoroscopy frame rate of 7.5 frames per second (fps) and those performed at the standard 15 fps and procedural outcomes. METHODS: We retrospectively collected data from consecutive 87 peripheral vascular interventions performed during 2011 and 2012 from two medical centers. The patients were divided into two groups based on fluoroscopy frame rate; 7.5 fps (group A, n = 44) and 15 fps (group B, n = 43). We compared the demographic, clinical, procedural characteristics/outcomes, and radiation dose between the two groups. Radiation dose was measured as dose area product in micro Gray per meter square. RESULTS: Median dose area product was significantly lower in group A (3358, interquartile range (IQR) 2052-7394) when compared to group B (8812, IQR 4944-17,370), p < 0.001 with no change in median fluoroscopy time in minutes (18.7, IQR 11.1-31.5 vs. 15.7, IQR 10.1-24.1), p = 0.156 or success rate (93.2% vs. 95.3%), p > 0.999. CONCLUSION: Using fluoroscopy at the rate of 7.5 fps during peripheral vascular interventions is associated with lower radiation dose compared to the standard 15 fps with comparable success rate without associated increase in the fluoroscopy time or the amount of the contrast used. Therefore, using fluoroscopy at the rate of 7.5 fps should be considered in peripheral vascular interventions.

Median arcuate ligament syndrome: Use of fractional flow reserve in documentation of chronic mesenteric ischemia.

Median arcuate ligament syndrome (MALS) is a rare clinical entity. This condition typically affects women between the ages of 20 and 40 years and causes symptoms of abdominal pain, primarily post-prandial, as well as nausea, vomiting and weight loss. MALS is considered a diagnosis of exclusion. Typically, mesenteric arterial duplex ultrasonography, computed tomography (CT), and magnetic resonance (MR) are highly suggestive, and conventional contrast angiography confirmatory. We explore the role of fractional flow reserve and intravascular ultrasound in the evaluation of MALS. In order to illustrate the utility of these tools, we present the case of a 47-year-old symptomatic woman who underwent angiography, complemented by assessment of fractional flow reserve and intravascular ultrasound. These data convincingly demonstrated the dynamic nature of the obstructive characteristic of MALS.

Racial and ethnic differences in incident hospitalized heart failure in postmenopausal women: the Women's Health Initiative.

BACKGROUND: The differences in the incidence of heart failure by race/ethnicity and the potential mechanisms for these differences are largely unexplored in women. METHODS AND RESULTS: A total of 156 143 postmenopausal women free of self-reported heart failure enrolled from 1993 to 1998 at 40 clinical centers throughout the United States as part of the Women's Health Initiative and were followed up until 2005, for an average of 7.8 years, for incident hospitalized heart failure. Incident rates, hazard ratios (HRs), and 95% confidence intervals were determined by use of the Cox proportional hazard model comparing racial/ethnic groups, and population-attributable risk percentages were calculated for each racial/ethnic group. Blacks had the highest age-adjusted incidence of heart failure (380 in 100 000 person-years), followed by whites (274), Hispanics (193), and Asian/Pacific Islanders (103). The excess risk in blacks compared with whites (age-adjusted HR=1.45) was significantly attenuated by adjustment for household income (HR=0.97) and diabetes mellitus (HR=0.89), but the lower risk in Hispanics (age-adjusted HR=0.72) and Asian/Pacific Islanders (age-adjusted HR=0.44) remained despite adjustment for traditional risk factors, socioeconomic status, lifestyle, and access-to-care variables. The effect of adjustment for interim coronary heart disease on nonwhite versus white HRs for heart failure differed by race/ethnic group. CONCLUSIONS: Asian/Pacific Islander and Hispanic women have a lower incidence of heart failure and black women have higher rates of heart failure compared with white women. The excess risk of incident heart failure in black women is explained largely by adjustment for lower household incomes and diabetes mellitus in black women, whereas the lower rates of heart failure in Asian/Pacific Islanders and Hispanics are largely unexplained by the risk factors measured in this study. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000611.

Relative Merits of Single-Photon Emission Computed Tomography and PET Perfusion Imaging: A Cardiologist's View.

Evidence from the medical literature supports the use of Cardiac positron emission tomography (PET) scanning to assess myocardial viability in patients with severe Left ventricular dysfunction who are being considered for revascularization. Cardiac PET has emerged as an alternative to Single Photon Emission Computed Tomography (SPECT) imaging for assessment of Coronary Artery Disease. PET scanning is less likely than SPECT scanning to provide indeterminate results. The aim of the present paper is to review existing literature on relative merits of Cardiac PET imaging.