Pitfalls associated with the use of current recommendations for fluoroscopy-guided common femoral artery access.

BACKGROUND: Vascular access complications remain the leading cause of morbidity after cardiac catheterization procedures. Fluoroscopy-guided vascular access has been recommended to reduce these complications. However, the use of current recommendations still results in arterial access above the inferior epigastric artery (IEA) (high stick) or below the common femoral artery (CFA) bifurcation (low stick). OBJECTIVES: The goal of our study was to evaluate the influence of patient characteristics like age, body mass index, and pelvic anatomy on current recommendations. METHODS: We prospectively collected clinical, anatomic, and angiographic data on 631 consecutive patients who underwent coronary and noncoronary procedures via CFA access. Anatomic location of IEA loop, CFA bifurcation, public tubercle (PT), and anterior superior iliac spine were identified in relationship to the femoral head Location of IEA loop was used as a surrogate for inguinal ligament (IL). RESULTS: Approximately 12% of patients had a low-lying IEA loop (group B). These patients had a significantly higher BMI compared with patients with IEA loop above the centerline of femoral head (group A) (P = 0.018). The anatomic location of PT was below the lower border of femoral head significantly more frequently in group B compared to group A (P < 0.0001). Fifteen percent of patients had a high CFA bifurcation. On clinical follow-up during index hospitalization, there was no significant difference between the two groups, in terms of complications including retroperitoneal hemorrhage, access site hematoma >5 cm, bleeding requiring transfusion or pseudoaneurysm. CONCLUSIONS: Anatomic location of PT on fluoroscopy can be used as an additional surrogate to predict the location of IL. Patients with high BMI have a low lying IL, which may predispose them to "high sticks." The location of IEA cannot be used as a surrogate for IL in all patients.

Feasibility of the 3D RCA catheter to engage the brachiocephalic vessels during carotid angiography and stenting.

BACKGROUND: Engagement of the brachiocephalic vessels during carotid angiography is performed using a JR-4, Vitek, or other catheters with variable success. These catheters require additional training for safe manipulation. In this study, we evaluated the feasibility of using the 3D RCA catheter which requires less manipulation in the aorta, and less training, to engage the brachiocephalic vessels. METHODS: We prospectively studied consecutive high-risk patients undergoing carotid angiography and stenting from August 2005 to March 2009 at our institution. A baseline aortogram was performed to define the arch type in all patients. Engagement of the brachiocephalic vessels was initially attempted using the 3D RCA catheter using the following approach: The 3D RCA catheter is positioned in the ascending aorta beyond the brachiocephalic vessels take off. The natural curve of the catheter usually makes it point cephalad spontaneously in most patients and as it is gently withdrawn it engages the aortic arch vessels without much manipulation. Clinical follow-up with a neurological exam was performed at one month and six months. RESULTS: A total of 52 patients were enrolled in this study. Baseline demographics and aortic arch types encountered are listed in Table I. The 3D RCA catheter readily engaged the brachiocephalic vessels in 50/52 patients (96.0 %) in our cohort of patients undergoing carotid angiography. Of the 52 patients, 43 subsequently underwent carotid stenting and shuttle sheath placement was facilitated by initial engagement of the relevant common carotid artery with the 3D RCA catheter. There was one transient neurologic complication that resolved by 5 days in a patient that underwent carotid stenting. CONCLUSIONS: The 3D RCA catheter can be used with a high success rate to engage the brachiocephalic vessels in all 3 arch types, including a bovine arch during carotid angiography and facilitates shuttle sheath placement for carotid stenting. It requires less manipulation and therefore may be a more operator friendly approach. © 2010 Wiley-Liss, Inc.

Use of gadolinium for carotid artery angiography and stenting in patients with renal insufficiency.

Use of iodinated contrast media (ICM) for angiography can result in contrast-induced nephropathy (CIN). Gadolinium-based contrast media (GCM) have been used in angiography with a goal to reduce the incidence of CIN. We performed a retrospective analysis involving 85 patients with renal insufficiency who underwent 97 carotid artery angiography and stenting (CAAS) procedures with a combination of GCM and ICM. The incidence of peri-procedural death, Q wave myocardial infarction (QWMI), stroke and CIN were recorded. Patients in GCM group had worse preprocedure renal function compared to ICM group. There were no peri-procedural deaths or QWMI in both groups. The incidence of stroke was 2.2% in GCM group and 0% in ICM group. The incidence of CIN were similar in GCM and ICM groups (8.5% vs. 10%, respectively, p NS). However, the predicted risk of CIN was 18.5% for GCM group and 10.4% for ICM group. Use of GCM and ICM combination for CAAS resulted in a 50% reduction in the incidence of predicted CIN risk compared to ICM.

Cavernous hemangioma of the mitral valve: a case report and review of literature.

Cardiac hemangiomas are rare cardiac tumors with fewer than 50 surgically treated cases reported in the literature. Incidence of valvular hemangiomas is extremely low, as cardiac valves are predominantly avascular structures. In this case report, we describe a 33-year-old woman who presented with progressively worsening cardiovascular symptoms. Echocardiography revealed a mitral valve mass for which she underwent surgical resection and mitral valve replacement. Histological examination of the mass revealed cavernous hemangioma of the mitral valve. Postoperative course was uncomplicated, and the patient's symptoms improved after surgery. Surgical excision of valvular hemangiomas appears to be curative in most cases and is the treatment of choice. Periodic echocardiographic follow-up is advised for early detection of tumor recurrence.

A one-carbon modification of protein lysine associated with elevated oxidative stress in human substantia nigra.

We describe for the first time a naturally occurring lysine modification that is converted to methyllysine by reduction with sodium borohydride. This modification is approximately 1.7 times as abundant in soluble proteins from human substantia nigra pars compacta as in proteins from other brain regions, possibly as a result of elevated oxidative stress in the nigra. Proteins from cultured PC12 cells exposed to oxidative stress conditions also contain elevated levels of this lysine modification. The abundance of the naturally occurring modification is roughly 0.08 nmoles/mg protein in either unstressed brain or PC12 cells. Modification levels remain stable in isolated proteins incubated for 2 h at 37 degrees C in pH 7 buffer. We propose that the endogenous modification is the lysine Schiff base, epsilon-N-methylenelysine, and that lysine modifications may result from a reaction with formaldehyde in vivo. Rat brain contains approximately 60 nmoles/g wet weight of formaldehyde, which probably includes both free and reversibly bound forms. Adding approximately 35 microm HCHO to PC12 cell growth medium introduces methylenelysine modifications in cell proteins and impairs cell viability. The existence of this post-translational modification suggests new mechanisms of oxidative stress that may contribute to tissue degeneration, including loss of nigral dopamine neurons during normal aging and in Parkinson's disease.