Postangiography Increases in Serum Creatinine and Biomarkers of Injury and Repair.

BACKGROUND AND OBJECTIVES: It is unknown whether iodinated contrast causes kidney parenchymal damage. Biomarkers that are more specific to nephron injury than serum creatinine may provide insight into whether contrast-associated AKI reflects tubular damage. We assessed the association between biomarker changes after contrast angiography with contrast-associated AKI and 90-day major adverse kidney events and death. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a longitudinal analysis of participants from the biomarker substudy of the Prevention of Serious Adverse Events following Angiography trial. We measured injury (kidney injury molecule-1, neutrophil gelatinase-associated lipocalin, IL-18) and repair (monocyte chemoattractant protein-1, uromodulin, YKL-40) proteins from plasma and urine samples at baseline and 2-4 hours postangiography. We assessed the associations between absolute changes and relative ratios of biomarkers with contrast-associated AKI and 90-day major adverse kidney events and death. RESULTS: Participants (n=922) were predominately men (97%) with diabetes (82%). Mean age was 70±8 years, and eGFR was 48±13 ml/min per 1.73 m2; 73 (8%) and 60 (7%) participants experienced contrast-associated AKI and 90-day major adverse kidney events and death, respectively. No postangiography urine biomarkers were associated with contrast-associated AKI. Postangiography plasma kidney injury molecule-1 and IL-18 were significantly higher in participants with contrast-associated AKI compared with those who did not develop contrast-associated AKI: 428 (248, 745) versus 306 (179, 567) mg/dl; P=0.04 and 325 (247, 422) versus 280 (212, 366) mg/dl; P=0.009, respectively. The majority of patients did not experience an increase in urine or plasma biomarkers. Absolute changes in plasma IL-18 were comparable in participants with contrast-associated AKI (-30 [-71, -9] mg/dl) and those without contrast-associated AKI (-27 [-53, -10] mg/dl; P=0.62). Relative ratios of plasma IL-18 were also comparable in participants with contrast-associated AKI (0.91; 0.86, 0.97) and those without contrast-associated AKI (0.91; 0.85, 0.96; P=0.54). CONCLUSIONS: The lack of significant differences in the absolute changes and relative ratios of injury and repair biomarkers by contrast-associated AKI status suggests that the majority of mild contrast-associated AKI cases may be driven by hemodynamic changes at the kidney.

The role of angio-embolization in the acute treatment concept of severe pelvic ring injuries.

BACKGROUND: In recent years a wide variety of strategies to treat the haemodynamically unstable patient with pelvic ring fractures have been proposed. This study evaluates our institutional management of patients with severe pelvic fractures and analyses their outcomes. METHODS: Retrospective review of all severely injured trauma patients with pelvic ring injuries admitted to a level I trauma centre from 2007 to 2012. Patient records were documented prospectively in a trauma database and evaluation was performed by SPSS. RESULTS: During the study period, a total of 173 patients with pelvic ring fractures were admitted and formed the basis of this study. Overall, 46% of the patients had suffered a type A fracture, 25% a type B fracture and the remaining 29% a type C pelvic ring fracture. Surgical treatment was required in 21% of the patients (pelvic C-clamp, n = 6; supra-acetabular external fixator, n = 32; pelvic packing, n = 12; definitive plate osteosynthesis of the pubis symphysis, n = 6). Angio-embolization was performed in 16 patients (9%); in 8 patients it was the only specific treatment for the pelvic injury on day 0 and in 8 patients it was performed immediately post-operatively. The overall mortality rate was 12.7% (n = 22), with the type C pelvic fractures having the highest mortality (30.0%). Four patients died immediately after admission in the shock room. CONCLUSIONS: Angiographic embolization as a first-line treatment was only performed in haemodynamically stable patients or in patients responding to fluid resuscitation with the finding of an arterial blush in the CT scan. In haemodynamically unstable patients, pre-peritoneal pelvic packing in combination with mechanical pelvic stabilization was immediately carried out, followed by angio-embolization post-operatively if signs of persistent bleeding remained present.

Spinal cord arteriography: a safe adjunct before descending thoracic or thoracoabdominal aortic aneurysmectomy.

OBJECTIVE: Spinal cord arteriography (SCA) often has been considered difficult, hazardous, and unreliable. In this report, we question these assumptions. PATIENTS: From August 1985 to June 2000, a total of 480 patients underwent 487 SCA procedures during diagnostic examination for 498 aneurysms, which included 159 that involved the descending thoracic aorta and 339 that involved the thoracoabdominal aorta. The underlying cause was degenerative disease in 288 cases, chronic dissection in 132 cases, and other causes in 78 cases. RESULTS: Major procedure-related complications occurred in six patients (1.2%) and included spinal cord complications in two patients, renal complications in two patients, and stroke in two patients. Puncture-site complications occurred in three patients (0.6%). Rupture of the aneurysm occurred within 3 days after SCA in two patients (0.4%). Two deaths (0.4%) were directly imputable to SCA. In 476 patients (97.7%), SCA was devoid of major complications. The Adamkiewicz's artery was successfully located in 419 patients (86.0%) and arose from a left intercostal or lumbar artery in 323 patients (77.1%) and from between T8 and L1 levels in 361 patients (86.2%). On the basis of the extent of identification of spinal cord vasculature, the procedure was considered as a complete success in 321 patients (65.9%), as a partial success in 112 patients (23.0%), and as a failure in 54 patients (11.1%). Although the failure rates were comparable, the complete success rate was significantly higher in patients with degenerative rather than dissecting aneurysms (P <.001) and in patients with limited aneurysms (ie, types 1, 2, and 3 versus type 4 descending thoracic aneurysms, P <.05; and types 3 and 4 versus types 1 and 2 thoracoabdominal aneurysms, P <.001). CONCLUSION: SCA is a safe adjunct that warrants more widespread use in the management of descending thoracic or thoracoabdominal aortic aneurysms.

[Reserve concerning pulmonary angiography in pulmonary embolism is not justified]. / Terughoudendheid ten aanzien van pulmonalisangiografie bij longembolie niet terecht.

OBJECTIVE: Evaluation of the safety of pulmonary angiography in patients with clinically suspected pulmonary embolism. DESIGN: Retrospective cohort study. SETTING: Academic Hospital, Rotterdam, the Netherlands. METHOD: The data on complications of pulmonary angiography were collected from four Dutch hospitals over a period of about five years (Academic Medical Centre and Slotervaart Hospital, Amsterdam; St. Elisabeth Hospital, Tilburg and Dr. Daniel den Hoed Cancer Centre/University Hospital Rotterdam). RESULTS: Pulmonary angiography was performed in 697 patients. No fatal complications were noted (mortality: 0%; 95% confidence interval (95% CI); 0.00-0.53). Complications were seen in 3 patients; dissection of the pulmonary artery in I patient and contrast extravasation in 2 patients (morbidity: 0.4%; 95% CI: 0.09-1.25). CONCLUSION: In patients with clinically suspected pulmonary embolism, pulmonary angiography is a safe diagnostic modality. It is recommended that, in patients in whom the diagnosis of pulmonary embolism cannot be confirmed or excluded by noninvasive diagnostic methods, pulmonary angiography should be performed (according to the Dutch consensus "Diagnostic pulmonary embolism').

A comparison of heparinized low osmolality ionic and nonionic contrast media in 500 patients undergoing cardiac angiography.

Low osmolar contrast media (CM) cause less hemodynamic and electrical changes than conventional CM, and many cardiologist have switched to the newer agents. Recently, concerns about a possible increased frequency of thromboembolic complications with low osmolar CM have been raised. This study compared two low osmolar heparinized CM, one ionic (Hexabrix) and the other nonionic (Isovue), in 500 consecutive patients undergoing either diagnostic catheterization (417) or coronary angioplasty (83). Adverse effects were uncommon (37 patients), but were more frequent with Hexabrix (12%) than Isovue (3%); p less than 0.05. The most common adverse effects were nausea or vomiting. Death, related to abrupt occlusion of a severe left main stenosis occurred in one patient who received Hexabrix, and acute pulmonary edema occurred in one patient who received Isovue. No apparent thromboembolic complication occurred. In conclusion, both low osmolar CM were well tolerated, but Hexabrix caused more transient nausea or vomiting. Both CM were safe and the incidence of thromboembolic complications when prospectively looked for was very low.

Anatomic and clinical factors associated with complications of transfemoral arteriography.

Complications of transfemoral arteriography requiring surgery are rare but carry significant morbidity. To evaluate clinical factors that might relate to such complications, we retrospectively reviewed our experience from January 1, 1985, to December 31, 1988 (four years). Forty-seven complications requiring surgery occurred among 10,589 cases. The risk was higher after cardiac catheterization than after peripheral arteriography (0.55% versus 0.17%, p less than 0.025). In nearly 40% of these cases, arterial puncture was not in the common femoral artery. Acute bleeding complications were more likely among patients with puncture outside the common femoral artery (p less than 0.001). Older patients and women were at slightly higher risk for complications requiring surgery, but this difference was not statistically significant. The frequency of bleeding complications was not significantly higher among patients who were anticoagulated following the procedure. The distribution of puncture sites was identical in obese and nonobese patients. Three patients died (two from myocardial infarction, one from multisystem organ failure). Two limbs did not improve; one required major amputation. Four limbs had persistent paresthesia and two had persistent weakness. We conclude that complications of transfemoral arteriography requiring surgery occur more frequently among patients who are undergoing cardiac catheterization and who suffer aberrant punctures. Age, sex, body habitus, and anticoagulation have less impact on patient risk.

Fatal thrombo-embolic complications at aorto-femoral angiography.

Fatal complications due to angiographic procedures are rare. An awareness of these complications is, however, mandatory in order to be able to prevent them. This report concerns three fatal cases with a deleterious complication of distal macro- and microembolization in connection with the angiographic procedure. In all cases the local circulation was surgically restored. The microcirculation was 'out of reach' and all three patients succumbed with profound tissue ischemia.

Invasive evaluation (coronary arteriography) of the coronary artery disease patient: clinical, economic and social issues.

Radionuclide techniques have greatly enhanced noninvasive evaluation in the patient with suspected coronary artery disease (CAD). Although these techniques have high sensitivity and specificity, the published data contain significant inconsistencies and inaccuracies. Coronary arteriography remains the definitive method of determining the presence, site, severity and operability of CAD. Although the procedure is invasive, recent studies have shown that complication rates have been reduced to an acceptably low level, particularly in laboratories with extensive experience. The economic aspects of coronary arteriography are complex. Survey data acquired in early 1981 from 54 active cardiac catheterization laboratories around the country showed that the mean technical charge billed by the hospital for coronary angiographic procedures was $760 (range $307-1470). Analysis of the actual costs of the procedure to the hospital indicates that in most cases, these costs far exceed $760. Hospital budgeting practices in many states fail to create any incentive to match charges with costs. The mean professional fee billed by physicians for coronary arteriography was $640 (range $200-1200). An estimated 275,000 coronary arteriograms are performed annually in the United States, yielding a total cost of $577,500,000. Opportunities for significant cost cutting are limited, and seem to lie primarily in improving the utilization of existing laboratories that are underutilized. Unresolved economic, ethical and social issues pertaining to coronary arteriography include: centralizing the procedure in a smaller number of centers around the country; self-referral of patients for coronary arteriography; establishing training standards for coronary angiographers and performance standards for angiographic equipment; acceptable levels of sensitivity in noninvasive screening for suspected CAD; and utilization of coronary arteriography throughout the country.

Fatal atheromatous embolization during coronary angiography.

Multiple fatal embolism following left heart catheterization is described in two patients. Postmortem examination showed friable atheromatous aortic plaques as the likely source of emboli that clinically involved the heart, peripheral blood vessels, brain, gastrointestinal system and solid organs. Histologic examination showed widespread arterial embolism by atheromatous material.

How safe is the coronary angiogram?

The pertinent literature on complications of selective coronary angiography has been reviewed. Three reports that describe the incidence of major complications in large patient groups are presented for comparative analysis of their results and used as a baseline for consideration of factors that may affect variations between the actual and reported rate of complications. It is recommended that agreement be reached on formulating national standards for the performance of the examination, taking into account the best data available.

The risk and cost of coronary angiography. II. The risk of coronary angiography in Washington State.

The risk of coronary angiography has been decreasing since development of the procedure 19 years ago. Deaths resulting from angiography now occur only in high-risk clinical circumstances. Whether a certain case load per angiographer or laboratory is necessary for adequate safety is still a question. Even though little available data exist on the relationship of case loads to risk, the National Guidelines for Health Planning now require 300 cardiac catheterizations per laboratory per year and forbid development of new laboratories in hospitals without heart surgery programs. Data collected from all 16 laboratories in Washington showed 26 deaths (0.19%) during 14,050 coronary angiograms. Eighteen of those who died had a severe left main coronary obstruction, and three had severe triple-vessel disease. There were 18 myocardial infarctions (0.13%) and nine strokes (0.06%). The risks in hospitals without cardiac surgery programs and in hospitals performing fewer than 200 cases per year were no higher than in the other hospitals studied. The National Guidelines should be reevaluated before they are used to change the existing pattern of health care.

Clinical indicators of left main coronary artery disease in unstable angina.

Two hundred consecutive catheterized patients with unstable angina pectoris were reviewed to find clinical and noninvasive indicators of left main coronary artery disease (greater than or equal to 50% lesion). Thirty-five patients (17.5% of total) had left main coronary artery disease. There were no differences between patients with and without left main coronary artery disease in age, sex, results of resting electrocardiogram, congestive heart failure, dyspnea during pain, duration of longest pain, arrhythmias, response to medical therapy, or other risk factors. Crescendo angina pectoris (worsening of pre-existing angina), transient ST-segment depression with pain, simultaneous anterior and inferior ST changes during pain, and fluoroscopic calcification of the left main coronary artery were all significantly more common in patients with left main coronary artery disease. However, low sensitivity or low predictive value, or both, limit the usefulness of these clinical predictors. Left main coronary artery disease cannot be reliably predicted in patients with unstable angina pectoris before coronary arteriography.