Efficacy and Safety of Subcutaneous Fellow's Stitch Using "Fisherman's Knot" Technique to Achieve Large Caliber (> 10 French) Venous Hemostasis.

BACKGROUND: Among patients undergoing intervention involving venous access, various techniques have been implemented to achieve hemostasis in order to reduce local access site complications, to decrease length of stay and to facilitate early ambulation. We aimed to assess the efficacy and safety of fellow's stitch using "fisherman's knot" (figure of Z (FoZ)) technique when compared with conventional manual compression for immediate closure of large venous sheath (> 10 French (Fr)). METHODS: Between November 2012 and March 2019, 949 patients underwent various interventions which involved venous access requiring hemostasis. All the patients were anticoagulated with heparin during the procedure. In a sequential allocation, fellow's stitch using "fisherman's knot" (group I: n = 384) and conventional manual compression (group II: n = 365) were used in achieving hemostasis at right/left femoral venous access site following sheath removal (> 12 Fr). A 0-Vicryl suture was used to make one deep stitch just distal to entry of sheath and one superficial stitch just proximal to entry site, thereby creating an FoZ. A fisherman's knot was then tied, and knot was pushed down while sheath was removed. In cases where immediate hemostasis was not achieved, it was compressed for 2 min to achieve it. RESULTS: The mean age of 949 patients was 13.1 ± 8.2 years where male (n = 574; 65%) outnumbered female (n = 375; 35%). In group I, hemostasis was achieved immediately after tying the knot in 343 (89.3%) patients, while within ≤ 2 min of light pressure in 41 (10.7%) patients. Five (1.3%) patients had failure of stitch as suture snapped during knotting, and hemostasis was achieved by manual compression as per protocol in group I. The median time to hemostasis (1.1 vs. 14.3 min, P < 0.001), ambulation (3.3 vs. 18.9 h, P < 0.01) and hospital stay (24.6 vs. 36.8 h, P < 0.001) was significantly shorter in group I compared to group II. The minor vascular access site complications in form of hematoma (n = 6 (1.6%) vs. n = 1 (0.2%); P < 0.001), and thrombosis at femoral vein (n = 4 (1.1%) vs. n = 0 (0%); P < 0.001) were significantly higher in group II when compared to group I. The differences regarding re-bleeding and formation of arterio-venous fistula between both the groups were statistically insignificant. CONCLUSION: The fellow's stitch using "fisherman's knot" or "FoZ" suture is a simple, efficacious and safe technique to achieve an immediate hemostasis after removal of larger venous sheath (> 10 Fr).

Unduly long left main (79 mm) coronary artery arising from right coronary sinus in a 64-year-old diabetic man.

Coronary artery anomalies are usually an incidental finding on coronary angiogram. Most of them are benign, although few of them are malignant which may cause sudden cardiac death. A 64-year-old diabetic, hypertensive man underwent coronary angiography for evaluation of exertional dyspnoea, and angina which revealed an anomalous left main coronary artery (LMCA) arising from right coronary sinus which was unduly long (79 mm) but free from any disease. To the best of our knowledge after extensive search in literature, this is the longest LMCA to be ever reported. The patient was managed conservatively.

Permanent Pacemaker Implantation in Patients With Isolated Persistent Left Superior Vena Cava From a Right-Sided Approach: Technical Considerations and Follow-Up Outcome.

BACKGROUND: Positioning a permanent pacing wire in patients with persistent left superior vena cava (PLSVC) to right ventricle often comes as on-table surprise. It is technically demanding and therefore most of operators prefer left-sided approach. We assessed technical challenges during pacemaker implantation, and their short- and long-term outcomes among patients with isolated PLSVC from a right-sided approach. METHODS: Thirty-one consecutive patients with isolated PLSVC and 93 patients with right superior vena cava (RSVC) were enrolled with syncope with sinus node dysfunction (SND) and atrioventricular (AV) block. Study was designed on the basis of nested case-control method, and therefore 1:3 proportions was the enrolment criteria to detect any difference as statistically significant as incidence of isolated PLSVC is low. RESULTS: Mean age of patients was 64.8 ± 10.5 years. SND was the most common indication (n = 55; 44%) followed by AV block (n = 47; 37%). Nineteen (20%) patients received tined pacing lead, while 105 (85%) had screwing lead. There was no significant difference in mean procedural time (25 ± 11 min vs. 23 ± 12 min; P = 0.24), mean fluoroscopic time (3.1 ± 2.2 min vs. 2.7 ± 2.1 min; P = 0.54), pacing parameters for atrial and ventricular leads, dislodgement rate (3.2% vs. 4.8%; P = 0.32) and follow-up duration (6.9 ± 1.3 years vs. 7.2 ± 1.1 years; P = 0.18) between two groups. Compared to patients with RSVC, those with PLSVC had alpha loop configuration for ventricular lead which was statistically significant (31 vs. 00; P = 0.002). CONCLUSIONS: Patients with PLSVC had alpha loop configuration for ventricular lead because of circuitous course via left mediastinum. Although pacemaker implantation through coronary sinus via isolated PLSVC from right sided-approach is technically challenging, it obtains good long-term results but needs frequent follow-up during the initial period.

Anomalous Coronary Artery From the Opposite Sinus (ACAOS): Technical Challenges During Percutaneous Coronary Intervention.

Anomalies of the coronary arteries are reported in 1-2% of patients among diagnostic angiogram. Ectopic origin of right coronary artery (RCA) from opposite sinus is one of the most common and they are mainly benign, but at times may be malignant. We report a case of a 69-year-old male who underwent early invasive percutaneous coronary intervention for non-ST-segment elevation myocardial infarction (NSTEMI) where RCA arising from left sinus at the root of left main artery was culprit and various technical challenges were encountered while intervening in form of cannulation to tracking of hardwares. RCA was cannulated with floating wire technique using hockey stick guide catheter and revascularized by deployment of 3.5 × 38 mm Promus Premier Everolimus eluting stent (Boston Scientific, USA). To the best of our knowledge, this is the first ever report of ectopic RCA being revascularized by using hockey stick catheter.

Acute Stent Loss and Its Retrieval of a Long, Tapering Morph Stent in a Tortuous, Calcified Lesion.

A 72-year-old male with diabetes and smoking as coronary risk factors was evaluated for chronic stable angina - Canadian Cardiovascular Society III - despite guideline directed medical treatment which revealed a diffuse, tortuous, calcified narrowing (90% stenosis) in left circumflex (LCx) coronary artery. After predilatation, a 3.0 - 2.5 × 60 mm BioMime Morph stent - long tapering stent (Sirolimus eluting stent, Meril life Sciences, India) - was tracked which failed and dislodged to right deep femoral artery during its pullback. It was successfully retrieved by EN snare: 6 - 10 mm (Merit Medical, USA) by contralateral femoral approach. Lesion was further dilated and successfully stented with another 3.0 - 2.5 × 60 mm BioMime Morph stent at 10 atm pressure showing proper stents expansion with TIMI-3 coronary flow. Our case highlights trackibility issues and importance of adequate lesion preparation before stent deployment in a tortuous and calcified vessel especially with very long stent. To the best of our knowledge, this is the first such case report demonstrating dislodgement and successful retrieval of long, tapered Morph stent.