Collaborative practice model between cardiologists and clinical pharmacists for management of patients with cardiovascular disease in an outpatient clinic.

The increasing prevalence of cardiovascular disease (CVD) has prompted leading cardiovascular organizations to advocate utilization of a team approach to patient care that includes nonphysician providers. In spite of that, the American College of Cardiology reported that nonphysician providers are underutilized in the management of patients with CVD. A survey of cardiologists revealed that the underutilization is a result of lack of understanding of how best to involve nonphysician providers in the health care team. Clinical pharmacists are one category of nonphysician providers that have recognized effectiveness in managing patients with CVD. No example of a comprehensive model of collaboration between cardiologists and clinical pharmacists is described in the literature that could serve to close this gap in understanding. The objective of this report is to describe a model of cardiologist-clinical pharmacist collaboration in the longitudinal management of patients with CVD that has been successfully implemented in 2 diverse settings. The implementation, evolution, scope of practice, required pharmacist training, logistical elements needed for success, and implementation barriers are reviewed. A summary of the patients referred to the clinic are examined as well.

Isolated pharmaco-mechanical thrombectomy (IPMT) for the endovascular treatment of acute axillofemoral graft occlusion.

Since the long-term patency of axillofemoral (AXF) grafts is inferior to aorto-bifemoral (ABF) grafts, limb salvage procedures are crucial in this group of patients. Emerging endovascular devices have helped in the successful restoration of flow for acute limb ischemia in both native arteries as well as bypass grafts. One such device, the Trellis thrombectomy system is being used more frequently in this setting. The device has previously been used in veins, native arteries, and rarely in aortofemoral grafts. We present its first successful use for the treatment of occluded AXF bypass graft. The use of this device helped to isolate the treatment zone in the occluded graft, which allowed the use of a lower dose of thrombolytics, less systemic release of thrombolytics, and less distal embolization. Resolution of extensive clot burden was achieved and, with subsequent stenting of the graft at the distal anastomotic site, arterial flow to the leg through the AXF graft was restored and a revision surgery was avoided.

Percutaneous isolated pharmaco-mechanical thrombolysis-thrombectomy system for the management of acute arterial limb ischemia: 30-day results from a single-center experience.

OBJECTIVE: To study the efficacy of isolated pharmaco-mechanical thrombolysis-thrombectomy (IPMT) by Trellis device (Covidien, Mansfield, MA) in managing acute limb ischemic (ALI). BACKGROUND: ALI is both life and limb threatening disease with a reported 9-15% mortality and 15-25% limb loss in the first month after presentation. Pitfalls of current endovascular techniques include major bleeding, distal embolism, and prolonged thrombolytic infusion. IPMT isolates the thrombus between two balloons and utilizes wire oscillation to increase the thombus-lytic exposure surface area followed by aspiration. It decreases systemic lytic exposure, procedure time, and distal embolism. METHODS: Technical aspects, success, and bleeding complications in 24 consecutive patients with ALI treated with IPMT between October 2009 and September 2010 were analyzed. In-hospital and 30-day mortality, amputation rates and treatment success rates were determined. RESULTS: 24 patients constituted 32 arteries; 18 (56.25%) were suprainguinal including 3 grafts (9.4%) and 14 (43.75%) were infrainguinal native arteries. Substantial or complete response was seen in >90% vessels with 87.5% patients revealing TIMI three flow while none demonstrated TIMI 2 or 3 pretreatment. Only three patients required adjunctive post-IPMT thrombolysis. In-hospital and 30-day all cause mortality was 4.16%. One patient died in-hospital and no patient underwent amputation. CONCLUSION: Besides being the largest series of ALI patients treated with IPMT, this is the first and largest series including 14 native infrainguinal arteries. These results suggest IPMT to be a promising and safer therapeutic option in ALI, likely due to its site-specific nature and limited thrombolysis exposure time.

Retrograde access via the popliteal artery to facilitate the re-entry technique for recalcitrant superficial femoral artery chronic total occlusions.

Subintimal recanalization is beneficial in selected patients with peripheral chronic total occlusions (CTO). However, in complex cases, re-entry into the true arterial lumen may prove to be unsuccessful with a conventional guidewire or a re-entry catheter when using standard femoral artery access. Our case series describes these technical dilemmas along with strategies that can be utilized to overcome these challenges.

Drug eluting versus bare metal stents in cardiac allograft vasculopathy: a systematic review of literature.

BACKGROUND: Cardiac allograft vasculopathy (CAV) is a distinct pathological condition characterized by diffuse and progressive arteriopathy and it is an important determinant of long-term graft survival. Definitive CAV treatment is retransplantation but palliation with stenting might temporarily alleviate it. The benefit of drug eluting stents (DES) over bare metal stents (BMS) in the treatment of such lesions is debatable. We therefore sought to do a literature search to review the available evidence comparing DES to BMS. METHODS: We conducted Pub Med, EMBASE, Cochrane database review, Web of Science search of studies comparing DES with BMS in CAV. Available studies were retrospective in nature with either direct comparison groups (n = 5) or historical controls (n = 1). The main outcomes analyzed were in stent restenosis (ISR) during follow-up and clinical outcomes. RESULTS: A total of 312 patients from six studies were included in the review (1995-2007). Most commonly used DES were sirolimus eluting stent. DES appeared to reduce the long-term risk of ISR compared with BMS. Three of the five studies showed a statistically significant reduction in ISR at 12 months while the one study assessing ISR at 6 months showed no significant difference. Clinical endpoints such as death and major adverse cardiac events were not statistically different. CONCLUSION: DES appear to reduce the incidence of ISR in CAV as compared with BMS. Prospective randomized clinical trials are needed to determine the clinical benefit of DES beyond a reduction in ISR.

Endovascular treatment of mesenteric ischemia.

OBJECTIVES: Our goal was to describe a single-center's experience in managing acute and chronic mesenteric ischemia with endovascular therapies. BACKGROUND: Open surgical revascularization has been considered the historical gold standard treatment for mesenteric ischemia though it poses considerable morbidity and mortality risk. An aging population with increased comorbidities makes endovascular treatment a more attractive treatment option. METHODS: Consecutive subjects receiving percutaneous mesenteric interventions for acute and chronic mesenteric ischemia from 2004 to 2010 were identified retrospectively. Information on comorbidities, symptoms, screening tests, procedural outcomes, and follow up was obtained. RESULTS: Thirty-one patients received percutaneous mesenteric interventions during this period. The mean age of the population was 65.0 years with roughly equal proportions of males (48.4%) and females (51.6%). Traditional cardiovascular risk factors were highly prevalent (hypertension 45.2%, diabetes 25.8%, dyslipidemia 38.7%, nicotine use 45.2%). Procedural success was 93.5%; no periprocedural complications were reported. During a mean follow up of 13 months, 16.1% required repeat revascularization and 22.6% died. Endovascular treatment of acute mesenteric ischemia was successful (n = 8) and no patient required open surgical revascularization acutely or during follow-up. CONCLUSIONS: Endovascular treatment of mesenteric ischemia is a safe and effective therapy with acceptable long-term results. Our experience with acute mesenteric ischemia suggests that percutaneous treatment may be an effective alternative to surgical revascularization in appropriately selected patients.

Isolated pharmacomechanical thrombectomy for the management of chronic DVT.

Thrombo-reduction in the setting of deep vein thrombosis (DVT) to prevent the postthrombotic syndrome has not been traditionally managed by interventional cardiologists. We report a case series of successful chronic DVT management with pharmacomechanical thrombectomy utilizing the Trellis device.

Use of Trellis thrombectomy system in acute aortofemoral graft occlusion.

Acute aortofemoral graft occlusion is often effectively treated with endovascular therapy but a substantial proportion of patients experience failure or complications of this therapy, and most of them require definitive surgery for the underlying inflow, outflow, or graft disease. We describe a case of an aortofemoral graft occlusion that was successfully treated with the Trellis thrombectomy-thrombolysis system (Covidien, Dublin, Ireland). Subsequent stenting of the graft obviated the need for a definitive graft revision surgery. The Trellis system combines mechanical and local pharmacologic lysis of the thrombus, with more rapid and more effective thrombus dissolution and theoretically less risk of systemic dispersion of the thrombolytic agent and less bleeding.

Giant splenic artery aneurysm: managed in the cardiovascular catheterization laboratory using the modified neck remodeling technique.

We report the first case of coil embolization using the "modified neck remodeling technique" in the management of a splenic artery aneurysm. This technique was feasible due to the unique and complex anatomy of the aneurysm. This condition has been largely treated by vascular surgeons and interventional radiologists; however, this patient was referred to the interventional cardiologists for endovascular coiling.

Bifurcated aortic endograft limb occlusion managed with a novel method of isolated pharmacomechanical thrombectomy.

Limb occlusion of an aortic endograft is uncommon, however, it can result in permanent sequelae if management is delayed. We report the first case utilizing the Trellis device to achieve localized and prompt isolated pharmacomechanical thrombectomy (PMT) for the treatment of acute limb thrombosis of a bifurcated aortic endograft.

Fluoroscopy vs. traditional guided femoral arterial access and the use of closure devices: a randomized controlled trial.

OBJECTIVE: To compare the effectiveness of accessing the common femoral artery (CFA) using fluoroscopic guidance (FG) versus traditional anatomic landmark guidance (TALG) during cardiac catheterization and to determine the effect of the two modalities on the appropriateness for use of vascular closure devices (VCDs). BACKGROUND: Previous studies have shown a consistent relationship between the head of the femur and the CFA, yet there is no prospective data validating the superiority of fluoroscopy-assisted CFA access. METHODS: A total of 972 patients were randomized to either FG or TALG access. The primary endpoint of the study was the angiographic suitability of the puncture site for VCD use. Secondary endpoints included arteriotomy location, time and number of attempts needed to obtain access, and the incidence of vascular complications. RESULTS: Of these, 474 patients were randomized into the FG arm and 498 patients into the TALG arm. A total of 79.5% of patients in the fluoroscopy arm and 80.7% in the traditional arm (P = 0.7) were deemed angiographically suitable for VCD based on the arteriotomy. The fluoroscopy group had significantly less arteriotomies below the inferior border of the head of the femur (P = 0.03). Total time for sheath insertion (105.7 +/- 130.7 vs. 106.5 +/- 152.6 sec) and number of arterial punctures (1.1 +/- 0.4 vs. 1.1 +/- 0.5) did not differ among the FG and TALG, respectively. The rates of vascular complications were not different. CONCLUSION: The angiographic suitability for VCD was not different between FG and TALG groups. Fluoroscopy decreased the number of low arteriotomies. The time to sheath insertion, number of arterial punctures needed to obtain access, and the incidence of complications were also similar.

Side balloon stenting of the left main bifurcation: a three-year angiographic follow-up.

None of the currently used interventional techniques yield durable results for coronary bifurcation lesions. We successfully treated a patient with unprotected left main bifurcation disease using a side balloon stent technique with a drug-eluting stent (DES). This technique produced excellent immediate and long-term results.

Use of simultaneous angioplasty and in situ thrombolysis with a specialized balloon catheter for peripheral interventions.

The treatment of acute limb ischemia is always challenging. Various techniques including balloon angioplasty, rheolytic thrombectomy, and prolonged localized infusion of thrombolytics are often used to achieve revascularization. However, some patients with suboptimal angiographic results may benefit from novel alternatives such as the Clearway irrigation balloon (Atrium, Hudson, NH, USA). This device allows simultaneous low-pressure balloon angioplasty and delivery of thrombolytics in situ in patients with arterial or venous thrombosis. This strategy may improve the acute angiographic results in complex acute limb ischemia cases.

Successful revascularization of re-stenosis of lower extremity arteries with localized delivery of paclitaxel.

Restenosis after percutaneous revascularization techniques is a challenging issue in patients with severe peripheral arterial disease. We report two cases where multiple revascularization techniques had been used previously, but restenosis occurred. We used an irrigation balloon to deliver paclitaxel locally into the tissues to obtain better results.

The use of tapered self-expanding stents and embolic protection devices in the treatment of stenotic ectatic coronary arteries: a report of two cases.

OBJECTIVE: The usage of tapered self-expanding stents and embolic protection devices in the treatment of stenotic ectatic coronary arteries. BACKGROUND: Coronary artery ectasia (CAE) is an uncommon disease that is occasionally found during cardiac catheterization. A high incidence of artherosclerotic disease is associated with CAE. Currently, there is no evidence-based approach for the management of stenotic ectatic coronary arteries (SEC). METHODS: Percutaneous intervention with carotid stenting system and embolic protection system to recanalize SEC. RESULTS: We describe two patients who presented with acute coronary syndrome and were found to have CAE with significant stenosis. Both patients underwent percutaneous intervention with RX ACCULINK Carotid stenting system and ACCUNET embolic protection system (Abbott Laboratories, Abbott Park, IL), successfully. This carotid stenting system is approved by FDA for stenting of extracranial carotid artery stenosis. CONCLUSION: To the best of our knowledge, this is the first case report illustrating the usage of these devices as an alternative for the treatment of SEC.

Coronary slow flow phenomenon and risk for sudden cardiac death due to ventricular arrhythmias: a case report and review of literature.

We report a case of coronary slow flow phenomenon (CSFP) in a patient who underwent coronary angiography due to anginal chest pain and recurrent syncope with complete normalization of flow after intracoronary adenosine. He was noted to have multiple episodes of nonsustained ventricular tachycardia on holter monitor and increased QTc dispersion on surface electrocardiogram (EKG). He responded very well to oral dipyridamole therapy with complete resolution of his symptoms and no episodes of ventricular tachycardia on the event recorder at 3 months. We review the diagnosis and clinical features of CSFP and its association with increased QTc dispersion and the role of oral dipyridamole therapy in this condition.

Hypoxia-inducible factor 1alpha polymorphism and coronary collaterals in patients with ischemic heart disease.

STUDY OBJECTIVES: Marked variability exists in coronary artery collaterals in patients with ischemic heart disease. Although multiple factors are thought to play a role in collateral development, the contribution of genetic factors is largely unknown. Hypoxia inducible factor 1 (HIF-1), a transcriptional activator that functions as a master regulator of oxygen homeostasis, is one possible genetic factor that could play an important role in modulating collateral development. DESIGN, SETTING, AND PARTICIPANTS: Collateral vessels were determined in 100 patients with > or = 70% narrowing of at least one coronary artery without acute myocardial infarction or prior revascularization. DNA was genotyped for the presence of a single nucleotide (C to T) polymorphism that changes residue 582 of HIF-1alpha from proline to serine. MEASUREMENTS AND RESULTS: The frequency of the T allele was significantly higher among patients without collaterals compared to patients with collaterals (0.188 vs 0.037, p < 0.001). In multivariate analyses, two variables affecting collateral formation were detected: two- or three-vessel coronary artery disease was a significant positive predictor (odds ratio [OR], 4.17; 95% confidence interval [CI], 1.61 to 10.8; p = 0.001), whereas the presence of HIF-1alpha genotype CT or TT was a negative predictor (OR, 0.19; 95% CI, 0.04 to 0.84; p = 0.03). CONCLUSIONS: These data suggest that variations in HIF-1alpha genotype may influence development of coronary artery collaterals in patients with significant coronary artery disease.

Successful interventional treatment of an octogenarian presenting with syncope and Ebstein's anomaly of the tricuspid valve.

Syncope is a frequent occurrence in the elderly and cardiac causes are common. Therefore, accurate diagnosis is essential since specific treatments are often required. We present an 85-year-old woman with recurrent syncope secondary to sinus node reentrant tachycardia (SNRT), which was successfully treated by radiofrequency ablation. This is the first reported description of SNRT and its successful treatment in Ebstein's anomaly. Atrial arrhythmias and accessory atrioventricular bypass pathways are common in Ebstein's anomaly and are briefly discussed. Our patient is alive at age 87, which is exceptional for Ebstein's anomaly.

Use of the trellis device in the management of deep vein thrombosis: a retrospective single-center experience.

OBJECTIVES: The Trellis thrombectomy system (Covidien) is one of the newer devices that incorporates isolated pharmacomechanical thrombectomy and thrombolysis (PMT) for treatment of deep venous thrombosis (DVT). We conducted a retrospective review of patients with upper- and lower-extremity DVT managed with the Trellis thrombectomy system at our center. METHODS: All patients with symptomatic DVT who presented to our center between April 2010 and April 2011 who underwent PMT by the Trellis device were included in this retrospective review. RESULTS: Twenty-eight patients (mean age, 46.4 ± 21.2 years) presented with symptoms with a mean duration of 1.3 ± 1.8 months. Eighty-six percent had 100% occlusion on admission, while 14.3% had 70%-90% stenosis. The mean lytic dose used was tPA 20.7 ± 12 mg. The mean Trellis treatment time was 25.1 ± 11.5 minutes. Grade 3 lysis was achieved in 23 of 28 patients (85.8%), while grade 2 lysis was achieved in 14.2%. Mean total hospital stay was 2.6 ± 2.7 days. Postprocedure symptom resolution was 100%, and there was no reocclusion in 78.6% of patients at 1 year. At 12 months, the patency rate (primary or secondary) was 80% as determined by Doppler ultrasound. CONCLUSIONS: In patients with DVT involving the ilio-femoral and the upper-extremity vessels, the use of the Trellis device was associated with a high technical success rate as well as a satisfactory 12-month patency rate. Moreover, this strategy was associated with reduced lytic dose, shorter treatment time and hospital stay, and no bleeding complications.

Hemorrhagic and ischemic outcomes after bivalirudin versus unfractionated heparin during carotid artery stenting: a propensity score analysis from the NCDR.

BACKGROUND: The direct thrombin inhibitor, bivalirudin, is associated with similar efficacy and superior safety in patients undergoing percutaneous coronary intervention. However, the role of direct thrombin inhibitors in carotid artery stenting is not well defined. The objective of this study was to compare the safety and effectiveness of bivalirudin and unfractionated heparin (UFH) for carotid artery stenting. We hypothesized that bivalirudin would be associated with less in-hospital postprocedure bleeding than UFH but similar rates of in-hospital and 30-day ischemic outcomes. METHODS AND RESULTS: We compared the incidence of in-hospital hemorrhagic and in-hospital/30-day ischemic outcomes among patients in the CARE Registry who underwent carotid artery stenting between May 2005 and March 2012 using bivalirudin or UFH. Propensity score matching was used to obtain a balanced cohort of 3555 patients in each treatment group. Patients treated with bivalirudin had a significantly lower incidence of bleeding or hematoma requiring red blood cell transfusions (0.9% versus 1.5%; odds ratio, 0.57 [0.36-0.89]; P=0.01) when compared with UFH-treated patients. The incidence of in-hospital and 30-day ischemic outcomes, including death, myocardial infarction, stroke, transient ischemic attack, and the composite outcome, death/myocardial infarction/stroke, did not differ significantly between groups. CONCLUSIONS: Bivalirudin was associated with lower rates of hemorrhagic outcomes compared with UFH during the index hospitalization for carotid artery stenting. In-hospital and 30-day ischemic events were similar between the 2 groups. Randomized comparisons of these agents are needed to confirm these findings.