Delayed Yet Successful Mechanical Thrombectomy for Phlegmasia Cerulea Dolens in a Limb with Severe Arterial Disease and May-Thurner Syndrome.

Phlegmasia cerulea dolens (PCD) is a rare but life-threatening complication of acute deep venous thrombosis that lacks consensus regarding the approach to management. We present a case of PCD developing shortly after a spinal surgery and manifesting as acute swelling and discoloration in a leg with existing severe atherosclerotic arterial disease. The patient's critical limb ischemia was completely and rapidly reversed by percutaneous mechanical thrombectomy using the ClotTriever device despite a delay in treatment. An underlying iliac vein compression "May-Thurner" syndrome was discovered using intravascular ultrasound and treated with angioplasty. This case identifies mechanical thrombectomy using the ClotTriever system as a possible effective and safe treatment for PCD.

Emergency physician discretion to activate the cardiac catheterization team decreases door-to-balloon time for acute ST-elevation myocardial infarction.

STUDY OBJECTIVE: The national standard for door-to-balloon time is 90 minutes, as recommended by the American Heart Association/American College of Cardiology guidelines for ST-elevation myocardial infarction (STEMI). Percutaneous coronary intervention for STEMI was initiated at our institution in June 2004. Review of our door-to-balloon times revealed that we were not meeting this recommendation. We determine whether concurrent rather than serial activation of the cardiac catheterization personnel and interventional cardiologist by the emergency physician would improve door-to-balloon times in the community hospital setting. METHODS: We conducted a retrospective before-and-after study from June 2004 to June 2005 to evaluate this protocol change. In November 2004, a revised STEMI protocol went into effect at our community hospital that called for concurrent activation of the cardiac catheterization personnel and the interventional cardiologist by the emergency physician. No other changes were made to our protocol or personnel during this time. The mean door-to-balloon time for the 6 months before our intervention was then compared to the mean door-to-balloon time for the following 6 months. RESULTS: During the 6-month period before protocol revision, the average door-to-balloon time for the 37 STEMI patients was 147 minutes. After the protocol was revised, the average door-to-balloon time for the 51 patients in the concurrent activation group was 106 minutes, a decrease of 41 minutes (95% confidence interval 21 to 61 minutes). CONCLUSION: At our community hospital, concurrent activation of the cardiac catheterization team and the interventional cardiologist by the emergency physician significantly decreases door-to-balloon time for acute STEMI.

Outcome of contemporary percutaneous coronary intervention in the elderly and the very elderly: insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium.

BACKGROUND: There is a paucity of data on the outcome of contemporary percutaneous coronary intervention (PCI) in the elderly. Accordingly, we assessed the impact of age on outcome of a large cohort of patients undergoing PCI in a regional collaborative registry. HYPOTHESIS: Increasing age is associated with a higher incidence of procedural-related complications. METHODS: We evaluated the outcome of 152,373 patients who underwent PCI from 2003 to 2008 in the 31 hospitals participating in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. The procedural outcomes of the cohort were compared by dividing patients into < 70 years of age, 70 to 79 years, 80 to 84 years, 85 to 89 years, and ≥ 90 years. RESULTS: Of the cohort, 64.64% were <70 years of age, 23.83% were 70 to 79 years, 7.85% were 80 to 84 years, 3.09% were 85 to 89 years, and 0.58% were 90 years or older. Increasing age was associated with an increase in all-cause in-hospital mortality, contrast-induced nephropathy, transfusion, stroke/transient ischemic attack, and vascular complications. The overall in-hospital mortality rate was 1.09% and increased from 0.67% in those younger than 70 years up to 5.44% in those 90 years old or greater. The mortality rate in patients over 80 years approached 12% to 15% for those with ST-segment myocardial infarction and 39% in cardiogenic shock patients. CONCLUSIONS: The proportion of elderly patients referred for PCI is increasing. Procedural complications increase with age, and patients presenting with unstable symptoms are at the highest risk.

The Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) collaborative quality improvement initiative in percutaneous coronary interventions.

The past decade has been characterized by increased scrutiny of outcomes of surgical and percutaneous coronary interventions (PCIs). This increased scrutiny has led to the development of regional, state, and national databases for outcome assessment and for public reporting. This report describes the initial development of a regional, collaborative, cardiovascular consortium and the progress made so far by this collaborative group. In 1997, a group of hospitals in the state Michigan agreed to create a regional collaborative consortium for the development of a quality improvement program in interventional cardiology. The project included the creation of a comprehensive database of PCIs to be used for risk assessment, feedback on absolute and risk-adjusted outcomes, and sharing of information. To date, information from nearly 20,000 PCIs have been collected. A risk prediction tool for death in the hospital and additional risk prediction tools for other outcomes have been developed from the data collected, and are currently used by the participating centers for risk assessment and for quality improvement. As the project enters into year 5, the participating centers are deeply engaged in the quality improvement phase, and expansion to a total of 17 hospitals with active PCI programs is in process. In conclusion, the Blue Cross Blue Shield of Michigan Cardiovascular Consortium is an example of a regional collaborative effort to assess and improve quality of care and outcomes that overcome the barriers of traditional market and academic competition.