A Concurrent Pseudoaneurysm and an Arteriovenous Fistula Following Percutaneous Radial Artery Access.

The incidence of radial artery cannulation resulting in the concurrent development of a pseudoaneurysm and an arteriovenous fistula is not well defined. Here, we present the case of a 42-year-old man who developed an iatrogenic pseudoaneurysm (PSA) and a concurrent arteriovenous fistula (AVF) following multiple right radial artery cannulations. Access was obtained for a preoperative diagnostic cardiac catheterization and again for hemodynamic monitoring intraoperatively during a surgical aortic valve replacement. A palpable thrill over the right radial artery developed and persisted for nine months, leading to anxiety and mental fixation on the thrill. There were no other symptoms. Given a failed resolution with conservative care for the same duration, the patient elected to proceed with surgical resection. Following resection, the patient reported resolution of his symptoms and decreased anxiety. A follow-up targeted arterial ultrasound demonstrated no residual PSA or AVF.

Surgical Versus Transcatheter Aortic Valve Replacement in Patients With Malignancy.

BACKGROUND: Patients with aortic stenosis (AS) and malignancy experience poor clinical outcomes with challenging decisions regarding aortic valve replacement (AVR). We sought to compare the outcomes of transcatheter (TAVR) versus surgical (SAVR) AVR in patients with AS and malignancy. METHODS: Based on the Nationwide Readmission Database, we compared all patients with malignancy who underwent isolated SAVR vs. TAVR in 2016 for severe AS. We performed univariate and multivariate analyses for baseline characteristics and clinical outcomes. A total of 2566 patients were included, 1952 (76%) had TAVR and the remaining 614 (24%) had isolated SAVR. Patients who underwent TAVR were older (82 vs 72 years, p < .001), had more metastasis (19 vs 14%, p = .004), heart failure (72% vs 34%, p < .001), coronary artery disease (72% vs 52%, p < .001), anemia (28% vs 22%, p = .006), chronic lung (30% vs 22%, p < .001) and renal disease (35% vs 14%, p < .001), and shorter length of stay (3 vs 7 days, p < .001). RESULTS: In multivariate regression, TAVR and SAVR had similar in-patient mortality (HR = 1.08; 95%CI 0.61 ̶ 1.94) and 30-day readmission (HR = 1.26; 95%CI 0.95 ̶ 1.67). TAVR was associated with lower vascular complications (HR = 0.59; 95%CI 0.41 ̶ 0.86), acute deep venous thrombosis (HR = 0.25, 95%CI 0.1 ̶ 0.59), acute kidney injury (HR = 0.24, 95%CI 0.17 ̶ 0.33), blood transfusion (HR = 0.22, 95%CI 0.16 ̶ 0.3), cardiogenic shock (HR = 0.48, 95%CI 0.26 ̶ 0.89), and respiratory complications (HR = 0.26, 95%CI 0.2 ̶ 0.35). CONCLUSIONS: In patients with malignancy, TAVR is a viable and safe option compared to SAVR with better clinical outcomes, especially thromboembolic events.

National Trends of Tobacco, Alcohol, and Drug Use in Patients Admitted With Acute Myocardial Infarction.

BACKGROUND: Acute myocardial infarction (AMI) is a significant health and economic burden in the US. Tobacco, alcohol, and drug use are established risk factors. We sought to evaluate the national trend of use of each substance in patients admitted with AMI. METHODS: We used the National Inpatient Sample between 2005 and 2017. We included adult patients hospitalized with AMI. International Classification of Diseases, Ninth and Tenth Revisions codes were used to define tobacco, alcohol, cocaine, opioid, cannabis and other drug use. Trends of each substance use were assessed using multivariable Poisson regression, and were expressed as annual percent change (APC) with their 95% confidence intervals (CIs). RESULTS: A total of 10,796,844 hospitalizations with AMI were included. Among all substances used, tobacco was the most common (32.7%), followed by alcohol (3.2%). Between 2005 and 2017, the prevalence ratio of tobacco use increased from 21.5% to 44.5% with an APC +6.2% (95%CI 6.2%-6.2%). Tobacco users had more percutaneous coronary intervention (41%vs25%) and coronary artery bypass surgery (6.9%vs4.9%), p < 0.001. Further, there were positive trends in alcohol (APC +3.1%; 95%CI 3.0%-3.2%), opioid (APC +9.0%; 95%CI 8.7%-9.2%), cannabis (APC + 7.2; 95% CI 7%-7.4%), and combined all drug use (+7.1%; 95%CI 7%-7.2%). Meanwhile, there was a slight negative trend in cocaine use. CONCLUSIONS: This analysis outlines the national trends of substance use in patients admitted with AMI and reveals an increasing prevalence of tobacco use, alcohol and drug use. More effective cessation measures are necessary to reduce the risk for AMI and its burden on the healthcare system and economy.

The "bladder sign"--an important early marker of retroperitoneal hemorrhage.

Retroperitoneal hemorrhage remains one of the major complications of cardiac and peripheral vascular catheterization. Its high associated morbidity and mortality require vigilance and early intervention. We report six cases of retroperitoneal hemorrhage featuring a "bladder sign." The compression of the bladder described in this series can be visualized on the incidental cystogram that results from contrast given during catheterization. Its significance as a highly specific marker of retroperitoneal hemorrhage should be appreciated.

Reducing costs and improving outcomes of percutaneous coronary interventions.

OBJECTIVE: To describe cost reduction and quality improvement efforts in our percutaneous coronary intervention (PCI) program and how risk adjustment was used to assess the effects of these changes. STUDY DESIGN: Single center registry analysis. PATIENTS AND METHODS: Data were collected on 2158 PCIs performed between July 1, 1994, and June 30, 1997. Of these, 1126 PCIs reflected care provided after implementation of competitive bidding for catheterization lab supplies, and efforts to reduce the use of postprocedure heparin and to implement early arterial sheaths removal (postbidding period). Hospital costs were estimated using a microcost accounting method. In-hospital mortality rates during the 2 time periods were compared using standardized mortality ratio estimated with a previously validated risk adjustment model for in-hospital mortality. RESULTS: Compared with the prebidding period, the postbidding period was characterized by a significantly higher utilization of new technology (coronary stents and atherectomy devices 46% vs 25%; abciximab 19.1% vs 3.7, P<.01), and an overall increase in case complexity. Despite these changes, the average and median postbidding cost per case was dollars 1223 and dollars 1444 lower, respectively, than in the prebidding period. After adjustment for comorbidities, procedure variables, complications, and length of hospital stay, multivariate regression modeling identified the postbidding period as an independent predictor of lower hospital costs (P<.001) with an estimated adjusted cost savings of dollars 460. These cost savings were associated with trends toward a lower observed mortality rate, a higher predicted mortality rate, and a significantly lower standardized mortality ratio (SMR .71; 95% CI 0.48-0.9; P<.05). CONCLUSION: Despite an increase in case complexity and utilization of new technology, cost reductions can be achieved through competitive bidding for supplies and modifications of periprocedure care. Risk adjustment appears to be a valid tool for assessing the effectiveness of these efforts independently from changes in case mix.

Competitive bidding for interventional cardiology supplies: lessons learned during round 2.

OBJECTIVE: To assess the magnitude of savings and develop concepts for "best strategies" in reducing costs in the purchasing of high-technology, high-cost materials used in coronary interventions and electrophysiologic treatments. STUDY DESIGN: Observational experience in competitive bidding for defibrillators, pacemakers, coronary stents, and coronary balloon catheters at a large, midwestern, publicly owned, academic cardiovascular center. METHODS: Iterative negotiation following a broad request for proposal sent to a diverse group of vending organizations in high-technology areas of cardiology. Product costs and volume usage were assessed before and after the process to estimate annualized cost reduction achieved. RESULTS: Using a combination of identification of preferred vendors; consignment of supplies; and collaborative consensus among physicians, administration, materials management, purchasing, and vendors, an annualized savings of more than $1.3 million was achieved. CONCLUSIONS: Aggressive, collaborative, fair, and competitive bidding for high-cost products used for coronary interventions and electrophysiologic treatments leads to substantial cost savings and can promote provider-industry partnerships that further enhance product use, provision, and tracking.