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.

Aldosterone Antagonist Therapy and Mortality in Patients With ST-Segment Elevation Myocardial Infarction Without Heart Failure: A Systematic Review and Meta-analysis.

Importance: Treatment with aldosterone antagonists is recommended and has been shown to have beneficial effects in patients with ST-segment elevation myocardial infarction (STEMI) and left ventricular ejection fraction (LVEF) less than 40%. However, the role of aldosterone antagonists in patients with ejection fraction greater than 40% or without congestive heart failure is not well known. Objectives: To perform a systematic review and meta-analysis using standard techniques to determine the role of therapy with aldosterone antagonists in this patient population. Data Sources: PubMed, Embase, CINAHL, and Cochrane Central databases were searched and a manual search for relevant references from the selected articles and published reviews was performed from database inception through June 2017. Study Selection: Randomized clinical trials that evaluated treatment with aldosterone antagonists in patients with STEMI without clinical heart failure or LVEF greater than 40% were included. Data Extraction and Synthesis: Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used to conduct and report the meta-analysis, which used a random-effects model. Two investigators independently performed the database search and agreed on the final study selection. A manual search was performed for relevant references from the selected articles and published reviews. Main Outcomes and Measures: The outcomes analyzed were mortality, new congestive heart failure, recurrent myocardial infarction, ventricular arrhythmia, and changes in LVEF, serum potassium level, and creatinine level at follow-up. Results: In all, 10 randomized clinical trials with a total of 4147 unique patients were included in the meta-analysis. In patients who presented with STEMI without heart failure, treatment with aldosterone antagonists compared with control was associated with lower risk of mortality (2.4% vs 3.9%; odds ratio [OR], 0.62; 95% CI, 0.42-0.91; P = .01) and similar risks of myocardial infarction (1.6% vs 1.5%; OR, 1.03; 95% CI, 0.57-1.86; P = .91), new congestive heart failure (4.3% vs 5.4%; OR, 0.82; 95% CI, 0.56-1.20; P = .31), and ventricular arrhythmia (4.1% vs 5.1%; OR, 0.76; 95% CI, 0.45-1.31; P = .33). Similarly, treatment with aldosterone antagonists compared with control was associated with a small yet significant increase in LVEF (mean difference, 1.58%; 95% CI, 0.18%-2.97%; P = .03), a small increase in serum potassium level (mean difference, 0.07 mEq/L; 95% CI, 0.01-0.13 mEq/L; P = .02), and no change in serum creatinine level (standardized mean difference, 1.4; 95% CI, -0.43 to 3.24; P = .13). Conclusions and Relevance: Treatment with aldosterone antagonists is associated with a mortality benefit in patients with STEMI with LVEF greater than 40% or without heart failure.

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.