Early Angiography Research Articles

Predictors of Obstructive Coronary Disease and Mortality in Adults Having Cardiac Arrest

Coronary angiography is a key component of systematic, multi-disciplinary post-cardiac arrest (CA) care, however, coronary angiogram is not routinely performed in the setting of CA. We sought to identify the predictors of obstructive coronary artery disease (CAD) and mortality in adults with CA undergoing coronary angiogram. The study population included 208 consecutive patients hospitalized with CA who underwent resuscitation and subsequent coronary angiogram at an academic tertiary medical center. The primary outcome of interest was presence of obstructive CAD, defined as >1 coronary artery with >70% stenosis or >1 coronary bypass graft with >70% stenosis. The secondary outcome of interest was in-hospital mortality. Of the 208 patients studied, 160 (76.9%) had obstructive CAD while 48 (23.1%) did not. In-hospital mortality occurred in 47 patients (22.6%). In multivariate analysis, ST-elevation myocardial infarction (STEMI) (OR 7.69, 95% CI 2.89 to 20.51), defibrillation (OR 4.90, 95% CI 1.19 to 20.17), vasopressors (OR 3.53, 95% CI 1.15 to 10.81), and absence of therapeutic hypothermia (OR 0.38, 95% CI 0.15 to 0.98) were independently associated with presence of obstructive CAD while STEMI (OR 3.21, 95% CI 1.01 to 10.24), vasopressors (OR 4.92, 95% CI 1.78 to 13.62), therapeutic hypothermia (OR 3.89, 95% CI 1.47 to 10.31), and admission blood urea nitrogen (OR 1.06, 95% CI 1.00 to 1.11) were independently associated with higher rates of in-hospital mortality. In this observational contemporary study, predictors of obstructive CAD and mortality exist in adults with CA undergoing coronary angiogram. Such risk models may aid in identification of CA patients who will benefit from early angiography and percutaneous coronary intervention.

Early OCT angiography changes of type 1 CNV in exudative AMD treated with anti-VEGF

AimsTo investigate, with optical coherence tomography angiography (OCTA), short-term changes of type 1 choroidal neovascularisation (CNV), secondary to exudative age-related macular degeneration, after anti-vascular endothelial growth factor (VEGF) treatment.MethodsPatients affected...

Treatment of Wide-Necked Bifurcation Aneurysms

BackgroundRecently, numerous devices dedicated to the treatment of wide-necked aneurysms have become available. We present our initial experience with the pCANvas device and present the technical success rate, clinical outcome and immediate angiographic occlusion rates.ObjectiveWe sought to determine the efficacy of flow with the pCANvas for the treatment of unruptured intracranial aneurysms.MethodsWe performed a retrospective review of our prospectively collected data to identify patients treated with the pCANvas device between February 2015 and February 2017. The patient demographics, aneurysm characteristics, immediate and delayed clinical and radiographic follow-up data were recorded.ResultsWe identified 17 patients (13 female) treated only with the pCANvas device. The average age of the patients was 60.5 ± 13.3 years (range 25–75 years). The average dome width was 7.6 ± 3.2 mm (range 3–15.8 mm), dome height 7.1 ± 3.2 mm (range 3–12.9 mm) and neck width 5.4 ± 3.2 (range 3–16.3 mm). The average aspect ratio was 1.5 ± 0.8 (range 0.6–3.7). At the end of the procedure 15 aneurysms continued complete filling of the aneurysm (Raymond Roy Classification[RRC] 3) with 2 aneurysms showing only filling of the neck of the aneurysm (RRC 2). Early follow-up angiography was available for 16 patients and at this stage 11 aneurysms showed persistent and complete filling of the aneurysm (RRC 3), 5 aneurysms showed complete occlusion of the aneurysm (RRC 1) and 7 aneurysms underwent repeat treatment with coiling.ConclusionThe early results on the use of the pCANvas are promising; however, longer term follow-up and larger studies are required.

Control angiography for perioperative myocardial Ischemia after coronary surgery: meta-analysis

BackgroundPerioperative myocardial ischemia (PMI) in patients undergoing coronary artery bypass grafting (CABG) is associated with poor outcome. The aim of this study was to pool the available data on the outcome after control angiography and repeat revascularization in patients with perioperative myocardial ischemia (PMI) after coronary artery bypass grafting (CABG).MethodsA literature review was performed through PubMed, Scopus, ScienceDirect and Google Scholar to identify studies published since 1990 evaluating the outcome of PMI after CABG.ResultsNine studies included 1104 patients with PMI after CABG and 1056 of them underwent control angiography early after CABG. Pooled early mortality after reoperation for PMI without control angiography was 43.6% (95%CI 29.7-57.6%) and 79.8% of them (95%CI 64.4-95.2%) had an acute graft failure detected at reoperation. Among patients who underwent control angiography for PMI, 31.7% had a negative finding at angiography (95%CI 25.6-37.8%) and 62.1% had an acute graft failure (95%CI 56.6-67.6%). Repeat revascularization was performed after early control angiography in 46.3% of patients (95%CI 39.9-52.6%; 54.2% underwent repeat surgical revascularization; 45.8% underwent percutaneous coronary intervention). Pooled early mortality after control angiography with or without repeat revascularization was 8.9% (95%CI 6.7-11.1%). Three studies reported on early mortality rates which did not differ between repeat surgical revascularization and PCI (11.7% vs. 9.2%, respectively; risk ratio 1.45, 95%CI 0.67-3.11). In these three series, early mortality after conservative treatment was 5.9% (95%CI 3.6-8.2%).ConclusionsControl angiography seems to be a valid life-saving strategy to guide repeat revascularization in hemodynamically stable patients suffering PMI after CABG.

Coronary angiographic findings and outcomes in patients with sudden cardiac arrest without ST-elevation myocardial infarction: A SWEDEHEART study

Background/aimSudden cardiac arrest (SCA) has a substantial mortality rate and the acute coronary syndrome constitutes the major cause. Post-resuscitation electrocardiogram ST-elevation SCA (STE-SCA) is a strong indication for emergency coronary angiography, but the role of early angiography and PCI in patients without ST-elevation (NSTE-SCA) remains to be established. This paper aimed to describe this patient group and evaluate the prognostic effect of early PCI in a large nationwide cohort of NSTE-SCA patients undergoing coronary angiography. MethodsData from SCAAR (Swedish Coronary Angiography and Angioplasty Registry) and RIKS-HIA (Register of Information and Knowledge about Swedish Heart Intensive Care Admissions) on 4308 SCA patients in Sweden between 2005 and 2016 were descriptively analyzed and related to mortality within 30-days in both unadjusted and adjusted analyses using Cox proportional hazard models. ResultsNSTE-SCA patients had more often serious comorbidities than STE-SCA patients. Among NSTE-SCA patients, 36.4% had no significant coronary artery stenosis while severe coronary stenosis (≥90%) was present in 43.9% (1271/2896). In NSTE-SCA patients with significant stenosis (≥90%), PCI was performed in 59.2% (753/1271) with an increased unadjusted 30-day mortality (40.9% vs. 32.7%; p = .011). However, after adjustments for confounders, no difference in mortality was observed (hazard ratio 1.07; 95% CI 0.84–1.36; p = .57). ConclusionIn resuscitated SCA patients without ST-elevation who underwent coronary angiography, this large retrospective study found severe coronary artery stenosis in 43.9% but found no clear benefit of early PCI. Prospective randomized controlled trials are needed to accurately define the role of coronary angiography and PCI in post-resuscitation care.

Contemporary Patterns of Early Coronary Angiography Use in Patients With Non–ST-Segment Elevation Myocardial Infarction in the United States: Insights From the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry

ObjectivesThe study sought to characterize patient- and hospital-level variation in early angiography use among non–ST-segment elevation myocardial infarction (NSTEMI) patients. BackgroundContemporary implementation of guideline recommendations for early angiography use in NSTEMI patients in the United States have not been described. MethodsThe study analyzed NSTEMI patients included in ACTION (Acute Coronary Treatment and Intervention Outcomes Network) registry (2012 to 2014) who underwent in-hospital angiography. Timing of angiography was categorized as early (≤24 h) vs. delayed (>24 h). The study evaluated factors associated with early angiography, hospital-level variation in early angiography use, and the relationship with quality-of-care measures. ResultsA total of 79,760 of 138,688 (57.5%) patients underwent early angiography. Factors most strongly associated with delayed angiography included weekend or holiday presentation, lower initial troponin ratio values, higher initial creatinine values, heart failure on presentation, and older age. Median hospital-level use of early angiography was 58.5% with wide variation across hospitals (21.7% to 100.0%). Patient characteristics did not differ substantially across hospitals grouped by tertiles of early angiography use (low, middle, and high). Hospitals in the highest tertile tended to more commonly use guideline-recommended medications and had higher defect-free care quality scores. ConclusionsIn contemporary U.S. practice, high-risk clinical characteristics were associated with lower use of early angiography in NSTEMI patients; hospital-level use of early angiography varied widely despite few differences in case mix. Hospitals that most commonly utilized early angiography also had higher quality-of-care metrics, highlighting the need for improved NSTEMI guideline adherence.

Modified double patch repair with infarct exclusion technique for ventricular septal perforation: a case study

BackgroundVentricular septal perforation (VSP) after acute myocardial infarction (AMI) is accompanied by the worsening of rapid hemodynamics, resulting in a poor prognosis. In our department, infarct lesions are preoperatively detected with electrocardiogram (ECG)-synchronized contrast computed tomography, and the scope of approach and exclusion is determined. Furthermore, to effectively prevent a residual shunt, modified double patch repair and infarct exclusion techniques were used in combination to preserve left ventricular (LV) function. This method is reported because it considers both techniques as a surgical procedure that can be accomplished relatively easily and simultaneously.Case presentationWe targeted two consecutive VSP patients who underwent this procedure. It took an average of 1 day from the onset of VSP to surgery. We performed double patch and infarct exclusion for VSP using bovine pericardium via an LV incision. Two patches were marked with a skin pen to anastomose eight mattresses equally. In addition, a one piece-coupled patch was made for infarct exclusion. The two patients were extubated on the day after surgery and intra-aortic balloon pump assistance was also withdrawn. Without perioperative complications, they could leave the intensive care unit after 6.5 days on average. Early postoperative ECG and magnetic resonance angiography showed good LV wall contraction, except at the infarcted area, with no evidence of a residual shunt.ConclusionThe modified double patch repair with infarct exclusion technique is more effective for preventing a residual shunt and maintaining postoperative cardiac function than either of the techniques alone.

FAILED PREHOSPITAL FIBRINOLYSIS IN PATIENT WITH PERCUTANEOUS CORONARY INTERVENTION IN ST-ELEVATION MYOCARDIAL INFARCTION

On the example of the clinical case of newly diagnosed ST-elevation myocardial infarction combination of different reperfution strategies and their benefit was discussed. Recommendations on lifestyle modification and medicament treatment tactics are described. From one hand, in spite of side-effects of treatment as an increased risk of stroke and hemorrhagic stroke, prehospital FL is associated with a decreased risk of cardiogenic shock and its effectiveness depends on the time from symptom onset to reperfusion. From other hand, despite the fact that PPCI is the recommended default reperfusion strategy, its effectiveness depends also on time limits and absence of the majority of PPCI-facilated hospitals worldwide. Combination of prehospital single-bolus FL following after 3–24h early routine angiography and PCIcan improve post-STEMI survival and help to avoid hyperreactivity and thrombin-induced platelet activation after FL, which can be a key to success in effective treatment and rehabilitationafter STEMI in patients without high risk factors of potential bleeding or stroke.

Effects of Sublingual Glyceryl Trinitrate Administration on the Quality of Preprocedure CT Angiography Performed to Plan Prostate Artery Embolization

PurposeTo determine the effects of sublingual glyceryl trinitrate (GTN) on the quality of planning computed tomography (CT) angiography performed prior to prostate artery embolization (PAE). Materials and MethodsA retrospective cohort study was performed on patients who had previously undergone CT angiography before a procedure for PAE at our institution. Early CT angiography studies for PAE at our single center had initially been performed without GTN. These were compared to subsequent CT angiography studies that had been performed with GTN, after a previously implemented change in practice. Prostate arteries were examined by 2 blinded observers for peak enhancement (Hounsfield units [HU]) and lumen diameter. In addition, assessors’ interpretation of the prostate artery origin from CT angiography was compared with the true anatomy demonstrated at the time of procedure. ResultsA total of 16 patients, corresponding to 32 prostate arteries, were examined on CT angiography. Mean diameter of the prostate artery was found to be significantly greater in those receiving GTN (2.2 mm vs. 1.6 mm, P < .001). Peak prostate artery enhancement was also greater in the GTN group (218 HU vs 173 HU, P = 0.042). Observers correctly identified the prostate artery origin more frequently in the GTN group; however, this difference was not statistically significant (56% vs 25%, odds ratio = 3.9, P = .149). ConclusionsThe administration of sublingual GTN immediately prior to CT angiography is associated with a significant increase in prostate artery diameter and peak opacification. This was not associated with a statistically significant increase in the ability of observers to correctly identify the origin of the prostate artery.

Different Filling Patterns of the Choriocapillaris in Fluorescein and Indocyanine Green Angiography in Primate Eyes Under Elevated Intraocular Pressure.

To investigate the hemodynamics of the choriocapillaris in primate eyes under elevated intraocular pressure. Indocyanine green angiography (ICGA) and fluorescein angiography (FA) were performed in two monkeys after elevation of the intraocular pressure (IOP) to 35 and 60 mm Hg. ICGA and FA showed no perfusion delays in the choriocapillaris at 35 mm Hg. The slow dye filling at 60 mm Hg made it possible to observe the early phase angiography sequence. During ICGA, C-shaped precapillary arterioles multiplied in numbers and emerged in the posterior pole, forming the outer rim of the numerous mosaics or lobules. Dye subsequently infiltrated into the lobules. During FA, after numerous hyperfluorescent spots emerged in the posterior pole, each of the spots enlarged and became numerous mosaics with a dark outer rim. When the FA and ICGA images were superimposed, the C-shaped arterioles observed during the ICGA were shown to correspond to the outer dark rim of the mosaics seen during the FA. The earliest dye emergence was delayed during FA compared to ICGA, with 13 seconds elapsing in monkey 1 and 4 seconds in monkey 2. The horizontal diameter of the optic disc contained three to four mosaics in both monkeys. The choriocapillaris lobules appear to be supplied from peripheral arterioles, not central. After blood perfuses the lobules, it drains into the venules at the center. Mosaic or lobular patterns during FA may reflect extravasated fluorescein from the fenestrated choriocapillaris.

Early coronary angiography in patients resuscitated from out of hospital cardiac arrest without ST-segment elevation: A systematic review and meta-analysis

ObjectiveA meta-analysis of published studies was performed to determine the impact of performing early versus delayed or no coronary angiography in patients without ST-segment elevation myocardial infarction following out of hospital cardiac arrest. MethodsA structured search was conducted using Medline, Embase and Ovid by two independent investigators using a variety of keywords. The primary outcome was short term (at discharge) and long term (at 6–14 months follow-up) mortality whereas the secondary end-point was good neurological outcome (defined as a Cerebral Performance Category Score of 1 or 2), at discharge and follow up. Random-effects model was utilized to pool the data, whilst publication bias was assessed using funnel plot. ResultsA total of 8 studies (7 observational studies and 1 randomized control trial) were identified and incorporated into the meta-analysis. The use of early angiography was associated with decreased short term (OR=0.46, 95% CI=0.36–0.56, P<0.001) and long term (OR=0.59, 95%CI=0.44–0.74, P<0.001) mortality. Early angiography was also shown to be associated with improved neurological outcomes on discharge (OR=2.00, 95% CI=1.50–2.49, P<0.001) as well as on follow-up (OR=1.48, 95% CI=1.06–1.90, P<0.001). ConclusionThe results of our meta-analysis support the use of early coronary angiography in out of hospital cardiac-arrest patients presenting without ST-segment elevation on the post-resuscitation electrocardiogram. However, given the low level of evidence of available studies, future guideline changes should be directed by the results of large-scale randomized clinical trials on the subject matter.

TCT-2 Coronary angiographic findings and outcomes in patients with sudden cardiac arrest without ST-elevation myocardial infarction: a SWEDEHEART study

Sudden cardiac arrest (SCA) has a substantial mortality rate and the acute coronary syndrome constitute the major cause. Post-resuscitation electrocardiogram ST-elevation SCA (STE-SCA) constitute a strong indication for emergency coronary angiography, but the role of early angiography and PCI in

CORONARY ANGIOGRAPHY IN OUT OF HOSPITAL CARDIAC ARREST (OHCA): A PRACTICAL GUIDE TO DECISION MAKING

Early coronary angiography remains controversial in patients without ST-segment elevation following OHCA. Observational studies have demonstrated a potential survival benefit, but are potentially confounded by selection bias. Physician decision making is further complicated by the lower incidence of culprit lesions in patients without ST-elevation; and, the difficulty in determination of neurological prognosis at the time of presentation. The Cardiac Arrest Hospital Prognosticator (CAHP) score utilizes seven variables (age, non-shockable rhythm, time from collapse to basic life support, time from basic life support to return of spontaneous circulation, location of cardiac arrest, epinephrine dose, and arterial pH) and has been shown to be a reliable predictor of neurologic outcomes (Maupain et al. 2016). ST-segment deviation and prior history of CAD have been proposed to help identify OHCA survivors without ST-elevation who might benefit from angioplasty in deciding to pursue early angiography (Wong et al. CJC 2017). The aim of this study was to evaluate the ability of the CAHP score to help guide decision making regarding the need for urgent coronary angiography in survivors of OHCA; and, to determine the association between dynamic ST-segment changes, or a history of angina or CAD with the presence of a culprit coronary artery lesion in those patients without ST elevation. Based on these findings, we have developed a decision pathway for the use of angiography in survivors of OHCA. A retrospective chart review of 336 OHCA patients admitted to the Foothills Medical Center Cardiac Intensive Care Unit (CICU) between 2009 and 2016 was conducted. Chi-squared and t-tests were used to assess differences in categorical and continuous variables respectively. Associations were assessed using odds ratios. A CAHP score of >200 demonstrated a specificity for in-hospital death of 93.94% (89.9-96.74%), and was inversely associated with the decision to pursue angiography in patients with and without ST-elevation, but not with early angiography. ST deviation but not prior CAD/angina was predictive of a culprit lesion in patients without ST-elevation (Figure 1). These factors were not found to be associated with the decision to pursue early coronary angiography. Given the paucity of data supporting the benefit of early angiography in patients without ST-elevation, an elevated CAHP score (≥ 200) conferring poor prognosis is a reasonable indication for deferring angiography. We propose that CAHP scores and predictive factors for culprit coronary disease (ST-deviation and prior CAD/angina) be used to guide timing of coronary angiography.

Significant arterial complications after pancreas transplantation-A single-center experience and review of literature.

Arterial fistulas and pseudoaneurysms are rarely described significant arterial complications associated with pancreas transplantation that sometimes present with herald or catastrophic bleeding. We herein describe our institutional case series with a focus on management and outcomes. Of 2256 pancreas transplants, 24 arterial complications were identified in 23 recipients. Chart review was performed to describe the clinical characteristics, treatments, and outcomes of the complications (pseudoaneurysm, arterial enteric/cystic/ureteric fistula, or arteriovenous fistula). Of these 23 patients, 57% had a failed allograft at the time of the complication. Nine patients underwent primary surgical repair of 10 complications, 13 were treated by endovascular methods, and one patient by medical management. In total, 3 embolized patients rebled, 2 of which had failed allografts prior to treatment. Of those with graft function that were treated by embolization alone, all retained graft function. Diagnosis of arterial complications requires a high degree of suspicion and should involve early systemic angiography to evaluate the pancreatic vasculature. Management can be endovascular or surgical and should be individualized. We report our center's evolution from a predominantly surgical to endovascular approach as a definitive vs stabilizing therapy, with selective coiling mostly reserved for well-defined peripheral lesions in patients with a functioning allograft.

The evolution of the Helsinki frostbite management protocol

BackgroundSevere frostbite can result in devastating injuries leading to significant morbidity and loss of function from distal extremity amputation. The modern day management approach to frostbite injuries is evolving from a historically very conservative approach to the increasingly reported use of early interventional angiography and fibrinolysis with tPA. The aim of this study was to evaluate the results of our frostbite treatment protocol introduced 3 years ago. MethodsAll frostbite patients underwent first clinical and then Doppler ultrasound examination. Angiography was conducted if certain clinical criteria indicated a severe frostbite injury and if there were no contraindications to fibrinolysis. Intra-arterial tissue plasminogen activator (tPA) was then administered at 0.5–1mg/h proximal to the antecubital fossa (brachial artery) or popliteal fossa (femoral artery) if angiography confirmed thrombosis, as well as unfractionated intravenous heparin at 500 units/h. The vasodilator iloprost was administered intravenously (0.5–2.0ng/kg/min) in selected cases. Results20 patients with frostbite were diagnosed between 2013–2016. Fourteen patients had a severe injury and angiography was performed in 10 cases. The total number of digits at risk was 111. Nine patients underwent fibrinolytic treatment with tPA (including one patient who received iloprost after initial non response to tPA), 3 patients were treated with iloprost alone and 2 patients received neither treatment modality (due to contraindications). The overall digital salvage rate was 74.8% and the Hennepin tissue salvage rate was 81.1%. One patient developed a catheter-site pseudoaneurysm that resolved after conservative treatment. ConclusionsPrompt referral to a facility where interventional radiology and 24/7 laboratory services are available, and the combined use of tPA and iloprost, may improve outcome after severe frostbite.

Preinfarct Health Status and the Use of Early Invasive Versus Ischemia-Guided Management in Non–ST-Elevation Acute Coronary Syndrome

Early invasive management improves outcomes in non-ST-elevation myocardial infarction (NSTEMI). The association between preinfarct health status and the selecting patients for early invasive management is unknown. The Prospective Registry Evaluating outcomes after Myocardial Infarctions: Events and Recovery and Translational Research Investigating Underlying disparities in acute Myocardial infarction Patients' Health status are consecutive US multicenter registries, in which the associations between preinfarct angina frequency and quality of life (both assessed by the Seattle Angina Questionnaire on admission) and the Global Registry of Acute Coronary Events (GRACE) risk score and referral to early invasive management (coronary angiography within 48 hours) were evaluated using Poisson regression, after adjusting for site, demographics, and clinical and psychosocial variables. Of 3,768 patients with NSTEMI, 2,182 (57.9%) patients were referred for early invasive treatment. Patients with excellent, good, or very good baseline angina-specific quality of life, respectively, were more likely to receive early angiography, even after adjustment, as compared with patients reporting poor baseline quality of life because of angina (62.1.0%, 60.9%, 59.6%, vs 51.2%; adjusted relative risk [RR] = 1.09, 95% confidence interval [CI] 1.04 to 1.16; RR = 1.13, 95% CI 1.01 to 1.27; RR 1.14, 95% CI 0.99 to 1.31, respectively). Finally, patients with a GRACE score in the highest risk decile (199.5 to <321.4) had significantly lower rates of early invasive treatment (42.7%) than patients in the lowest decile of risk (67.6%; adjusted RR for continuous GRACE score per SD [1 SD = 40 points], 0.96, 95% CI 0.92 to 0.99, p = 0.019). In conclusion, in this real-world NSTEMI cohort, patients with the highest mortality risk and worst health status were less likely to be referred for early invasive management. Further work is needed to understand the role of preinfarct health status and in-hospital treatment strategy.

Endovascular management of iatrogenic renal vascular injuries complicating percutaneous nephrolithotomy: Role of renal angiography and embolization; an analysis of 159 cases.

Objective:To describe the use of renal angiography in the detection of renal vascular injuries following percutaneous nephrolithotomy and to assess the efficacy of endovascular management of these complications.Materials and Methods:This was a retrospective review of 159 consecutive patients over a period of 12 years from 2005 to 2016 who presented with significant post nephrolithotomy hemorrhage and who were evaluated by renal angiography as a first-line diagnostic study, followed by embolization of identified renal vascular injuries in the same session. The parameters assessed for each patient included type of renal vascular injury identified, type of embolic material and therapeutic outcome.Results:Renal vascular lesions identified in 119 patients were treated with embolization with complete resolution of hemorrhage, no further clinical deterioration and preservation of renal function.Conclusions:Renal vascular injury is a rare complication of percutaneous nephrolithotomy. Early renal angiography and selective embolization can play an integral diagnostic and therapeutic role.

Relative efficacy and safety of ticagelor vs clopidogrel as a function of time to invasive management in non-ST-segment elevation acute coronary syndrome in the PLATO trial.

Guidelines suggest that "upstream" P2Y12 receptor antagonists should be considered in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS). Early use of ticagrelor in patients managed with an invasive strategy would be more effective than clopidogrel because of its more rapid onset of action and greater potency. In the PLATO trial, 6792 NSTE-ACS patients were randomized to ticagrelor or clopidogrel (started prior to angiography) and underwent angiography within 72 hours of randomization. We compared efficacy and safety outcomes of ticagrelor vs clopidogrel as a function of "early" (<3h) vs "late" (≥3h) time to angiography. Adjusted Cox proportional hazards models evaluated interaction between randomized treatment and time from randomization to angiography on subsequent outcomes. Overall, a benefit of ticagrelor vs clopidogrel for cardiovascular death/myocardial infarction/stroke was seen at day 7 (hazard ratio [HR]: 0.67, P = 0.002), day 30 (HR: 0.81, P = 0.042), and 1 year (HR: 0.80, P = 0.0045). There were no significant interactions in the <3h vs ≥3h groups at any timepoint. For major bleeding, overall there was no significant increase (HR: 1.04, 95% confidence interval: 0.85-1.27); but there was a significant interaction with no difference between ticagrelor and clopidogrel in the early group (HR: 0.79), but higher bleeding risk with ticagrelor in the late angiography group, at 7 days (HR: 1.51, Pint = 0.002). Patterns were similar at 30 days and 1 year. The benefit of ticagrelor over clopidogrel was consistent in those undergoing early and late angiography, supporting upstream use of ticagrelor.

Management of CAD in Patients with Active Cancer: the Interventional Cardiologists' Perspective.

Coronary artery disease in patients with active cancer presents particular challenges for clinicians, as optimum management is required in order to treat the underlying malignancy and to reduce morbidity and mortality associated with cardiovascular diseases. Special considerations must be made in respect to either primary or secondary thrombocytopenia, the presence of coagulopathies and the propensity of bleeding, vascular access complications, and increased risk of stent thrombosis. In presence of acute coronary symptoms, the cardio-oncology team has to make a complex decision between conservative medical management or early angiography (within 24h) and revascularization. There is a lack of reliable data on the outcomes of patients with active cancer who undergo invasive procedures for the diagnostic and treatment of coronary artery disease. Cardiac catheterization recommendations in cancer patients are being currently elaborated by cardio-oncologists in order to improve the overall survival in cancer patients with coronary artery disease.

Management of splenic artery aneurysm rupture following central pancreatectomy and ROUX-EN-Y pancreaticojejunostomy reconstruction

Objective: Hemorrhage from pseudoaneurysms following pancreatic surgery is a rare life-threatening and challenging complication. We present our experience management for this rare condition. Methods: 62 years old female found to have 2.7 cm pancreatic neck mass on imaging for vague abdominal pain associated with unintentional weight loss. EUS and FNA revealed non-functional low grade neuroendocrine tumor. Patient opted for central pancreatectomy with roux-en-y pancreaticojejunostomy. Procedure was uneventful. Drain fluids were negative for pancreatic fistula, and patient discharged on POD#10. The patient returned to the emergency department on POD#24 with diffuse abdominal pain, Nausea, vomiting, and hematochezia. CT imaging was read as negative, as well as colonoscopy. EGD noted duodenal ulcer with clean base. The Roux limb was not assessed. Patient discharged on HD#3. Patient returned to the ED on POD#33, with complaints of hematochezia and hematemesis, and syncopized during blood draw. NGT lavage removed 2 liters of blood from stomach, and patient diagnosed with hemorrhagic shock. Patient intubated for airway protection, and EGD performed failed to elicitate source. Patient underwent CTA, noting active extravasation from splenic artery pseudoaneurysm, and the splenic artery was coiled by interventional radiology. Results: Following massive transfusion protocol patient recovered, and discharged on HD#9. Conclusion: Delayed bleeding after pancreatic surgery is suspicious for a pseudoaneurysm. Contrast-enhanced CT followed by early angiography provides accurate diagnosis and treatment. Interventional radiological treatment should be preferred over primary surgery because it is currently the most life-saving approach.