Complications of carotid stenting during live transmissions

Complications of carotid stenting during live transmissions

208 Abstracts / Cardiovascular Revascularization Medicine 10 (2009) 195–212 Does intracardiac echocardiography facilitate the treatment of high-risk...

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Abstracts / Cardiovascular Revascularization Medicine 10 (2009) 195–212

Does intracardiac echocardiography facilitate the treatment of high-risk mitral stenosis patients with percutaneous balloon mitral valvuloplasty? Hosakote M Nagaraj a, Ravi Desai a, Drisana R Misra a, Santosh Koshy b, William B Hillegass a, Vijay Misra a a University of Alabama at Birmingham, Birmingham, AL b University of Memphis, Memphis, TN Introduction: Percutaneous balloon mitral valvuloplasty (PBMV) is a well-established alternative to commissurotomy and is recommended for patients with Mitral stenosis (MS) and echocardiographic (ECHO) score b8 and no calcified mitral valves. However, the question remains whether simultaneous intracardiac echocardiography (ICE) is useful to perform PBMV in suboptimal candidates without provoking excessive mitral regurgitation (MR). Materials and Methods: Fifty-seven consecutive PBMV procedures under ICE guidance were performed under local anesthesia and mild sedation between May 2004 and October 2008 at University of Alabama at Birmingham. Left femoral vein was used for ICE insertion while the right was used for transseptal access. Transthoracic echocardiography was used to assess the mitral valve pre and post PBMV. The corresponding pre- and postPBMV mitral valve areas (MVA) were calculated. Inhospital adverse clinical events were collected. Results: There were 10 (18%) men. The mean age was 53.9±14 years (range, 26–94 years). Two thirds had ECHO score N8, and 33% had moderate to severe MR before PBMV. After PBMV, MVA increased from 1.1±0.29 cm2 to 1.8±0.9 cm2 (Pb.005) by planimetry, from 1.25±0.58 cm2 to 1.97±0.57 cm2 (Pb.005) by Gorlin's formula. The mean mitral valve gradient decreased from 14±5 mm Hg to 7±3 mm Hg (Pb.005). None had cardiac tamponade or died during the procedure. Fifty-two patients (91.2%) had successful PBMV without in-hospital adverse events. Three (5.2%) required MVR. Two patients developed flail MV leaflet due to rupture of chordae. The third with Grade 3 MR prior to PBMV had progressively worsening symptoms for 7 days requiring MVR. One patient, with prePBMV valve area of 0.6 cm2 had improvement in MVA to 1.4 cm2 but developed MRSA sepsis and acute renal failure, which resolved during her hospital stay. Conclusion: MS patients with poor MV anatomy and moderate to high risk for PBMV have been traditionally relegated to medical therapy. With ICE guidance, PBMV can be extended to these patients with unsuitable MV anatomy with reasonable procedural success and safety. To our knowledge, this is the largest case series reporting the use of ICE to facilitate PBMV in such moderate to high-risk patients doi:10.1016/j.carrev.2009.04.045

Carotid Stenting The SAPPHIRE worldwide carotid artery stenting with distal embolic protection registry Christopher Metzger a, Maurice Solis b, Majdi Ashchi c, Rasesh Shah d, Ravish Sachar e, William Bachinsky f, Farrell Mendelsohn g, Robert Hibbard h, Greg Schultz i a Holston Valley Medical Center, Kingsport, TN b Medical Center of Central Georgia, Macon, GA c Memorial Medical Center, Jacksonville, FL d Sentara Norfolk General Hospital, Norfolk, VA e Wake Heart Research, Raleigh, NC f Pinnacle Health, Harrisburg, PA g Baptist Medical Center, Birmingham, AL h Bryan Heart Institute, Lincoln, NE i Sioux Valley Hospital, Sioux Falls, SD Objective: The primary objective of the SAPPHIRE Worldwide Registry is to evaluate 30-day outcomes after carotid artery stenting (CAS) performed at multiple centers by physicians with varied experience and utilizing a formal training program.

Methods: SAPPHIRE Worldwide is a multicenter, prospective, postapproval, observational study. CAS was performed using the Cordis PRECISE Stent and ANGIOGUARD Emboli Capture Guidewire. The primary end point is 30-day major adverse events (MAE), including death, stroke, and myocardial infarction. Results: To date, 2001 patients at 216 centers have been enrolled and completed 30-day follow up. Among these patients, the mean age was 72.2 years, and 27.7% of patients were symptomatic. Patients were enrolled with either anatomic (36.5%), physiological (49.4%), or both (14.2%) risk factors considered high-risk for surgery. Thirty-day MAE for the overall population was 4.4%. MAE was significantly lower in patients with asymptomatic vs. symptomatic stenosis (P=.0005), and in patients with anatomic high-risk factors compared with physiological high-risk factors (P=.0306). Conclusions: Results from SAPPHIRE Worldwide will continue to provide evidence in support of optimal patient selection, lesion criteria, and operator experience in performing CAS in patients at high surgical risk.

Safety measures to 30 days

All Patients (n=2001)

Asymptomatic (n=1446)

Symptomatic (n=555)

Anatomic (n=716)

Physiologic (n=918)

MAE Any death or stroke Any death MI Any stroke

4.4% 4.0%

3.3% 2.9%

7.0% 6.7%

2.8% 2.5%

4.9% 4.5%

1.1% 0.7% 3.2%

0.8% 0.6% 2.4%

2.0% 0.9% 5.4%

0.6% 0.4% 2.2%

1.4% 0.9% 3.5%


Complications of carotid stenting during live transmissions Jennifer Franke a, Bernhard Reimers b, Marta Scarpa b, Marcus Thieme c, Nina Wunderlich a, Dierk Scheinert c, Horst Sievert a a CardioVascular Center Frankfurt, Frankfurt, Germany b Ospedale di Mirano, Mirano, Italy c Department of Angiology, Heart Center Leipzig, Leipzig, Germany Introduction: Teaching courses focusing on live demonstrations of carotid interventions have been the key educational facility for physicians interested in learning state-of-the-art interventional techniques of carotid stenosis treatment. However, starting with the very first live demonstration of interventional procedures, there has been an ongoing discussion whether patients treated during live transmissions are at higher risk. The purpose of this registry is to report the acute in-hospital results of carotid stenting performed during live transmissions. Methods and Patients: Between March 1, 2001, and June 30, 2008, 186 high-grade lesions of the internal carotid artery in 186 patients have been treated by stent implantation during live transmissions to 22 interventional conferences. Postinterventional neurological assessment according to National Institutes of Health stroke scale and clinical examinations were performed before discharge. Technical success was defined as the ability to perform carotid stent implantation with the adjunctive use of an embolic protection device. The combined end point of death, major stroke, minor stroke, or myocardial infarction was defined as primary end point. Results: The procedure was technically successful in 185/186 (99.5%) interventions. In one patient (0.5%), the procedure was complicated due to a broken tip of a filter device. The patient suffered a major hemorrhagic stroke during recovery of the filter tip. Seventeen patients had one of the following acute inhospital complications: death in 0, major stroke in two (1.1%), minor stroke in three (1.6%), transient ischemic attack in 11 (5.9%), amaurosis of the ipsilateral eye due to an occlusion of the retinal artery in 1 (0.5%), and myocardial infarction in 0 patients. The composite primary end point occurred in six patients (3.2%).

Abstracts / Cardiovascular Revascularization Medicine 10 (2009) 195–212 Conclusion: The patients and lesions selected for live transmissions represent the real-world scenario in these centers. The results of this study show that the results of carotid stenting procedures performed during live interventional courses are not inferior to those found in publications of major carotid stenting trials. doi:10.1016/j.carrev.2009.04.047

Cardiac CTA Noninvasive assessment of coronary artery bypass graft with 64-slice CT: comparison with invasive coronary angiography Pedro L Urdiales, Alejandro de la Vega Fundacion Medica de Rio negro y Neuquen, Cipolletti, Argentina Background: To evaluate the usefulness of 64-slice multidetector computed tomography (MDCT) in assessing the patency of CABG and to compare MDCT with conventional selective bypass graft angiography (SGA), the gold standard for such assessment. Methods: A total of 131 bypass graft (80 left internal mammary artery grafts, 42 great saphenous vein grafts, two right internal mammary artery grafts, and seven radials artery grafts) in 47 patients (41 men, six women; mean age, 64.1 years; range, 39–85 years; mean heart rate, 67.3 bpm, range 46–98 bpm) were studied with MDCT and SGA, 5 days to 20.3 years (average 364.1 days, median 15.0 days) after CABG procedures. In these grafts, 172 sites of graft anastomosis were evaluated by both MDCT and SGA. Electrocardiogram-gated MDCT was performed with a Somatom Sensation 64 scanner (Siemiens) with a slices of 0.6-mm width at a pitch of 0.2 and gantry rotation of 330 ms. Based on volume-rendered 3D and multiplanar reformation images, anastomoses or bypass grafts were evaluated for patency, high-grade stenosis (≥50% diameter reduction), and occlusion. Results of MDCT and SGA were compared. Results: Of 172 anastomoses, SGA showed that 161 were patent, three were high-grade stenotic, and eight were occluded. Of these, MDCT demonstrated correctly 136 of 161 patent, two of three high-grade stenotic, and eight of eight occluded anastomoses. MDCT demonstrated one stenotic anastomosis to be occluded. According to these results, the overall sensitivity, specificity, and accuracy of the patency of graft anastomoses were 84.5% (136/161), 100% (11/11), and 85.5% (147/172), respectively. Of the 161 patent anastomoses, MCDT was unable to identify 13 because of metallic clip and misdiagnosed one as high-grade stenosis and eleven as occlusion. The major causes of the misdiagnosis on MDCT were competing flow from and the small diameter of the native coronary arteries at the sites of anastomosis. Conclusions: Sixty four-slice MDCT is useful in assessing the patency of CABG and its use can obviate the use of conventional angiography if the technique demonstrates patency of graft anastomosis. doi:10.1016/j.carrev.2009.04.048

Determinants of coronary artery bypass graft patency: 64 multidetector computed tomography versus coronary angiography Eman M ElSharkawy, Fatma AboEl-Enein, Amr Zaki, Mohamed Loutfy, Magdy Rashwan Faculty of Medicine Alexandria University, Alexandria, Egypt Background: Multidetector computed tomography (MDCT) of the coronary arteries is currently considered as a promising alternative to conventional coronary angiography (CA) in both native coronary arteries and coronary artery bypass grafts.


Objectives: The purpose of this study was to compare the diagnostic accuracy of 64-slice MDCT with that of invasive angiography in the detection of graft disease, and to investigate the clinical value of 64 MDCT determining the factors affecting graft patency. Methods: Fifty symptomatic patients, 7.2±5.1 years after bypass surgery, were referred for 64-slice MDCT coronary angiography and standard invasive coronary angiography. Two independent, blinded observers assessed separately the results of both. Results: The study included 174 grafts, 65 arterial grafts (37.4%) and 109 venous grafts (62.6%), 50 left internal mammary arteries (LIMA), three right internal mammary arteries, and 12 radial artery grafts (RA). Four hundred ninety-six segments were analyzed and yielded: per-segment detection of graft disease, a 99% sensitivity (89/90), and 100% specificity (379/379). Patients with diseased grafts had older surgery (8.68±4.32 vs. 4.79±3.98 year, Pb.001). There were more patent arterial than venous grafts (54/65 vs. 66/109, Pb.01) and more patent LIMA than RA grafts (44/50 vs. 7/12, Pb.05). The target vessels included 63 SVG to right coronary artery and branches, 21 SVG to left circumflex (LCX)-marginal, 25 SVG to left anterior descending (LAD)-diagonals, six arterial grafts to LCX-marginal, and 59 to LAD-diagonals. There were more patent grafts targeting LAD-diagonals than others [73/174 (42%) vs. 47/174 (27%), Pb.001]. The target vessels size was larger in patent than diseased grafts in both arterial (2.74±0.44 vs. 2.0±0.63 mm, Pb.01) and venous (2.05±0.6 vs. 1.55±0.7 mm, Pb.001) grafts. The target vessel lesions were tighter in patent than diseased grafts in both arterial (95.76±4.38% vs. 89.91±4.25%, Pb.001) and venous (92.21±5.98% vs. 79.28±16.4%, Pb.001). Conclusions: Sixty-four-slice MDCT can accurately delineate the patency and disease of bypass coronary grafts. LIMA to LAD remains the best optional graft. Large caliber target vessels with tight lesions are major determinant of grafts patency. doi:10.1016/j.carrev.2009.04.049

Analyzing the predictive value of coronary artery calcium score to assess coronary artery disease events Bassel Artin a, Amol Bahekar a, Ahmad Khraisat a, Rohit Bhuriya a, Sarabjeet Singh a, Rohit Arora b, Sandeep Khosla a a Mount Sinai Hospital, Chicago, IL b Rosalind Franklin University and Chicago Medical School, North Chicago, IL Background: Studies have shown that coronary artery calcium (CAC) score may be a marker for an increased risk of coronary artery disease (CAD). The aim of our study is to evaluate the predictive value of various grades of CAC score on occurrence of CAD events. Methods: A systematic review of the literature was performed using PubMed, Medline, Cochrane database, CINAHL, and EMBASE search engines using relevant search words. Data abstraction was performed by two separate authors. Mantel–Haenszel fixed-effect model was used to calculate combined relative risks (RR) when studies were homogenous and the random effect model was used when the studies were heterogenic. Results were considered statistically significant if P value was b.05. Results: Total 10 prospective studies were eligible for meta-analysis (N=35,058 and follow-up 3 to 7 years). The RR for death and myocardial infarction (MI) were 3.5 (1.7–7.1) (Pb.001), 5.2 (1.8–14.5) Pb.005 and 9.6 (4.7–19.6) Pb.001 when very low CAC score was compared with low CAC score, intermediate CAC score, and high CAC score respectively. Similarly the RR of revascularization with CABG or PCI were 3.8 (1.8–7.9) (Pb.001), 10.8 (5.7–20.6) (Pb.001) and 43.8 (23.8–80.5) (Pb.001) when very low CAC score was compared with low CAC score, intermediate CAC score, and high CAC score, respectively. Conclusion: The CAC score can be utilized to predict CAD events independently. Predictive value for occurrence of CAD events increases significantly with higher CAC score.