Covered stents: A 25-year odyssey.

The concept of the PTFE-covered stent was introduced 25 years ago in the treatment of an aneurysmal vein graft. The study by Pavani et al. represents the largest cohort of patients treated with covered stents for Ellis type 3 perforations. Covered stents are effective in treating coronary perforations and remain an invaluable tool in the cardiac catheterization lab.

PCI on a tear: Not all perforations need coverage.

Coronary perforations are a potentially lethal complication of PCI requiring prompt treatment. The study by Rosseel et al demonstrates no difference in 5-year outcomes in patients with large coronary perforations treated with and without covered stents. Covered stents are effective in treating coronary perforations and are invaluable in the cardiac catheterization lab.

Which embolic protection device is ideal during carotid artery stenting?

Embolic stroke is one of the main risks of carotid artery stenting. The EMBOLDEN trial demonstrates the safety and efficacy of the Gore® embolic filter. There is no clear evidence for the benefit of one filter-type over another. It is important to choose the device with which the interventionalist has significant familiarity.

Is the S.M.A.R.T® stent the smart option to treat femoropopliteal disease?

The femoropopliteal (FP) artery is a common site for endovascular interventions. S.M.A.R.T.® stent is effective in treating FP lesions with results comparable to other treatment options. Without head-to-head randomized controlled trials, the ideal treatment strategy for FP lesions remains unknown.

Physician alert: the legal risks associated with 'on-call' duties in the USA.

On-call physicians encounter a diverse aggregate of interfaces with sundry persons concerning patient care that may surface potential legal peril. The duties and obligations of an on-call physician, who must act as a fiduciary to all patients, create a myriad of circumstances where there is a risk of falling prey to legal ambiguities. The understanding of the doctor-patient relationship, the obligations of physicians under the Emergency Medical Treatment and Labor Act, the meaning of medical informed consent and the elements of negligence will help physicians avoid the legal risk associated with the various encounters of being on call. After introducing the legal concepts, we will explore the interactions that may put physicians at legal risk and outline how to mitigate that risk. Being on call is time consuming and arduous. While on call, physicians have a duty to act morally and ethically in the best interest of the patients.

Unintended consequences of the electronic medical record on physicians in training and their mentors.

For physicians in training and their mentors, the process of learning and teaching clinical medicine has become challenging in the electronic medical record (EMR) era. Trainees and their mentors exist in a milieu of incessant box checking and laborious documentation that has no clinical educational value, limits the time for teaching and curtails clinical cognitive skill development. These unintended consequences of the EMR are juxtaposed against the EMR's intended benefits of improved patient care and safety with reduced medical errors, improved clinical support systems, reduced potential for negligence with clinical data and metadata data supporting compliance with the standard of care. Although the mindset was technology would be the solution to many healthcare issues, there was not an appreciation of the cumulative impact of the non-educational workload on physician time and education. The EMR was intended to improve the efficiency of medical care and time management. It appears that the unintended consequences of the EMR with numerous checkboxes, automatic filling of computer screens, pre-worded templates, and automatic history and physical examination functions with detailed administrative oversight and compliance monitoring were not appreciated, and many believe that burden has overwhelmed the intended benefits of the EMR. This juxtaposition of the intended and unintended consequences of the EMR has left trainees and mentors struggling to optimise medical education and development of clinical skills while providing high-quality patient medical care. Physician educators must identify how to use the benefits of the EMR and overcome the unintended consequences. A major unintended consequence of the EMR is time dedicated to automate functions that detract from the time spent with mentors and patients. This time loss has the potential to restrict the physician from meeting the essential canons of medical informed consent and interfere with a physician meeting her fiduciary duties to the patient. To raise awareness and stimulate a search for solutions that benefit medical education and patient care, we will explore the intended and unintended consequences of the EMR and potential solutions using the intelligent systems of the EMR.

Entrapped Coronary Arteries in Constrictive Pericarditis.

Pericardial constriction can be present without pericardial calcium and often without pericardial thickening. This epicardial coronary artery motion abnormality due to entrapment in a thickened, fibrotic pericardium, is characteristic of constrictive pericarditis, and differentiates this entity from other close differential diagnoses, such as restrictive and dilated cardiomyopathy.

Percutaneous Biventricular Mechanical Circulatory Support With Impella CP and Protek Duo Plus TandemHeart.

This is the first reported case of full biventricular mechanical circulatory support with the combination of Impella and Protek Duo, which is a dual-lumen cannula inserted via the right internal jugular vein, with its proximal inflow lumen positioned in the right atrium and distal lumen positioned in the main pulmonary artery. These lumens are connected with the paracorporeal TandemHeart pump allowing flows up to 5 L/min. The alternative percutaneous option for right ventricular support is the Impella RP (Abiomed), which has to be placed in the femoral vein, preventing ambulation. The axillary and internal jugular vein positions for devices are probably less prone to infection compared to the femoral area. The combination of an Impella inserted via the axillary artery with the Protek Duo is a viable option, allowing ambulation while providing biventricular support.