Complication Of PCI Research Articles

Transradial intervention in ST elevation myocardial infarction.

Primary percutaneous coronary intervention (PPCI) in ST elevation myocardial infarction (STEMI) represents the current gold standard reperfusion therapy. Recent advances in antiplatelet and anticoagulant therapy have reduced the risk of ischemic complications and mortality in PPCI although this has been at the expense of major bleeding complications. Access site-related bleeding complications account for up to 50 % of major peri-procedural bleeding complications in PCI. Increasing adoption of the radial artery as the default access site has been shown to markedly reduce such major bleeding complications and mortality in selected patient cohorts. Recent data has suggested that adoption of the transradial access site in STEMI PCI procedures is associated with significant reductions in major bleeding complications and mortality in both national registry data and randomised controlled trials. We provide an overview of this data and discuss the remaining uncertainties around the synergy between access site and contemporary antithrombotic and antiplatelet therapy in such patients. Finally, whilst adoption of the radial artery as the default access site in PPCI has yielded a similar reduction in mortality as observed in the switch from thrombolysis to PPCI in the past, its adoption as a default access site is not universal. We discuss the remaining obstacles and challenges for more widespread adoption of the radial access site as the default access site in PPCI.

Left main reconstruction as an alternative method to CABG after primary PCI complication

Left main coronary artery disease is rare, accounting for 1% of all coronary artery disease and traditionally, is treated by coronary artery bypass grafting. We report our experience and five years follow up, after a coronary osteal surgical plasty in a young man who referred to our center with an anterior myocardial infarction.

RADIAL VERSUS FEMORAL ACCESS FOR CORONARY ANGIOGRAPHY/INTERVENTION IN WOMEN WITH ACUTE CORONARY SYNDROMES: INSIGHTS FROM THE RIVAL TRIAL

To determine the efficacy and safety of radial versus femoral access for coronary angiography/intervention in women in the RIVAL trial. Radial access is more challenging in women due to smaller radial arteries, possibly resulting in reduced procedural success. In a pre-specified RIVAL subgroup analysis, we compared outcomes in patients randomized to radial versus femoral access in women (N=1861). There was no difference in the primary composite endpoint of death, myocardial infarction, stroke, and non-CABG bleeding at 30 days in women (radial 3.96%; femoral 5.04%; HR 0.78; 95%CI 0.50-1.20; p=0.250), and men (radial 3.54%; femoral 3.55%; HR 0.99; 95%CI 0.74-1.33; p=0.971; p for interaction=0.356). Major vascular complications were significantly reduced with the radial access use (in women: radial 3.2%; femoral 6.2%; HR 0.51; 95%CI 0.33-0.81; p=0.003; in men: radial 0.77%; femoral 2.81%; HR 0.27; 95%CI 0.17-0.45; p<0.0001; p for interaction=0.064). Cross-over rates were higher with radial access in both women and men (women: HR 5.49; 95% CI 3.37-8.97; p<0.0001;men: HR 3.20; 95%CI 2.36-4.38; p<0.0001; p for interaction=0.063). PCI success rates were similar irrespective of access site (women: HR 1.03; 95%CI 0.91-1.16; p=0.686;men: HR 1.00; 95%CI 0.94-1.01; p=0.948; p for interaction = 0.808), with no differences in PCI complications. In a multivariable analysis, women versus men was an independent predictor of major vascular complications (HR 2.397; 95%CI 1.76-3.250; p<0.0001) and access-site cross over (HR 1.395; 95%CI 1.04-1.85; p=0.0233). Women have a higher risk of vascular complications compared to men and radial access is an effective method to prevent these complications.

LEFT MAIN INTERVENTIOIN IN A STANDALONE PCI CENTRE - A RECENT 5 YEAR EXPERIENCE

LEFT MAIN INTERVENTIOIN IN A STANDALONE PCI CENTRE - A RECENT 5 YEAR EXPERIENCE

Abstract 21: Variation in Hospital Costs of Percutaneous Coronary Intervention

Introduction: A great emphasis exists on improving PCI outcomes and quality, but there are no data on the variation in hospitals' costs of PCI. As Payers move away from a fee-for-service model, most forms of bundled payments or gain-sharing, increasingly require hospitals to contain costs. Hospitals are at financial risk if costs exceed a specified budget. Our goal was to understand the variation in costs of PCI across hospitals, and the extent of the variation in PCI costs explained by hospitals, after controlling for patient characteristics. Methods: We identified 230,410 patients undergoing PCI at 258 hospitals (performing ≥100 PCIs), from 2007-2010 from the Healthcare Cost and Utilization Project state inpatient database (SID) from California, Florida and New York. The SID includes 97% of all discharges regardless of payers, from these states. Costs of PCI were determined by applying hospital- and year-specific Cost-to-Charge Ratios to the total charges. Variation in costs of PCI across hospitals were examined by a hierarchical linear regression model with PCI costs as the dependent variable and hospital site as a random effect, adjusting for differences in prevalence of patient and demographic characteristics by hospital site. Results: The mean cost of performing a PCI procedure was $17,543 ± $ 12767. We observed a large degree of variation in mean PCI costs across hospitals ranging from $5,823 to $38,532. Length of stay (LOS), was associated with incrementally higher PCI cost ($2,400, per day p&lt;0.0001). After adjusting for LOS, PCI complications, and patient comorbidities, we observed a persistent 24% variation in PCI costs across hospitals. A significant interaction between hospital cost quintile and LOS (interaction P-value &lt;0.001) was also observed, such that in the highest quintile hospital, PCI costs were higher by $1,277 per day LOS, despite adjusting for LOS and patient comorbidities and PCI complications. Conclusions: PCI costs vary tremendously across hospitals. Approximately one quarter of the variation in PCI costs is explained by hospitals, despite controlling for differences in LOS, PCI complications and patient characteristics. The same LOS costs differently across different hospitals. There is an urgent need for hospitals to examine and reduce the variation in PCI costs.

Abstract 147: Do Billing Data Accurately Describe Causes Of Readmission After PCI? An Analysis Of A Large PCI Readmission Database.

Introduction: Early readmission after PCI can be a useful performance measure, particularly if the reasons for readmission are related to patient management (e.g. angina, stent thrombosis or bleeding). Prior studies on readmission have used principal billing discharge diagnosis, but the validity of billing codes for this purpose is unclear. Methods: PCI patients readmitted within 30 days of discharge at the Massachusetts General Hospital (January 2007-December 2011) and Brigham and Women’s Hospital (June 2009-December 2011), were identified, and their medical records reviewed by a cardiologist. For each readmission, the principal billing discharge diagnosis of the readmission was compared to the primary diagnosis of the readmission as determined by the chart review. The accuracy of billing discharge diagnoses for readmissions due to chest pain or other symptoms concerning for angina and vascular access complications was assessed. Results: Of 9081 patients undergoing PCI and surviving to hospital discharge, 1011 (11.1%) were readmitted to the index hospital within 30 days. After excluding repeat readmissions, 894 readmissions were reviewed and of those, 754 (84.3%) could be matched to billing diagnoses. For each reason for readmission, corresponding billing diagnoses were diverse (Table 1). The sensitivity and specificity of billing code 414.01 for a readmission for chest pain or other symptoms concerning for angina were 0.36 and 0.85, respectively. The sensitivity and specificity of billing code 997.2 (Peripheral vascular complications, not elsewhere classified) for a bleeding or vascular complication of PCI were 0.28 and 0.997, respectively. Conclusions: The diversity of ICD-9 codes does not allow straightforward categorization of principal diagnoses of readmission from billing data. More complex algorithms need to be developed and validated to reliably derive reasons for readmission after PCI from billing data.

The Transradial Approach for Primary Percutaneous Coronary Interventions in Octagenarians: Its Safety, Feasibility and Limitations

The Transradial route (TR) has been shown less bleeding and vascular complications in primary PCI. Its technique however remains generally underutilised in the elderly (> 80 years) population because of concerns of high cross over rates, longer catheter lab to balloon and fluoroscopy times. We aim to report the safety, efficacy and limitations of performing primary PCI in octogenarians via the TR at the CK Hui Heart Centre which has been carrying out PCI via the TR route since 2001.

Identifying a Deadly Complication of Pci: A Case Study of Acute Stent Thrombosis

Identifying a Deadly Complication of Pci: A Case Study of Acute Stent Thrombosis

Endothelialisation of 3rd generation orsiro hybrid drug eluting stents at 6 months follow-up: analysis by optical coherence tomography

Background: Since the introduction of 2rd generation DES and dual antiplateled therapy (DAPT) stent thrombosis is a rare complication of PCI. DAPT is recommended for 6-12 months after DES implantation. Long term DAPT involves the risk of bleeding events, shorter DAPT duration would be beneficial. The Hybrid Orsiro DES presenting a new concept by combination of passive and active components. The passive coating seals the stent and minimizes tissue interaction. The active component is a bioresorbable polymer matrix combined with sirolimus. Stent thrombosis correlates to mal-apposition and incomplete stent coverage. IVUS is not able to monitor strut coverage due to lack of resolution. Intracoronary optical coherence tomography (OCT) is able to solve this shortcoming. Stent endothelialisation is associated to OCT strut coverage although not fully identical. We tested, whether the Orsiro Hybrid DES has no strut malapposition related to the polymer/drug combination as measured by OCT after 6 months. Methods: Patients (n=13, with n =21 Orsiro Hybrid-DES) were readmitted for routine coronary angiography and OCT 6 months after PCI. (Figure 1) Stent struts (n= 702) were classified according to previously described criteria (mean ± SEM): type I (embedded struts with>0.15 mm neointima): 25.5±11.2%; type II (embedded struts with< 0.15mm neointima): 49.9±21.5%; type IIIa (protruding/covered struts): 19.6±9.7%; type IIIb (protruding/ uncovered): 3.3±3.1%; type IV (malapossed/uncovered struts): 1.7±3.1%. ![Figure][1] Figure 1 Conclusion: The data support the hypothesis that Orsiro Hybrid DES achieved nearly complete strut coverage as measured by OCT at 6 months. Therefore an early termination of DAPT could be an option to prevent major bleeding events without increasing the risk of acute stent-thrombosis. [1]: pending:yes

Cangrelor reduced ischemic PCI complications more than clopidogrel without increasing severe bleeding

Source Citation Bhatt DL, Stone GW, Mahaffey KW, et al; CHAMPION PHOENIX Investigators. Effect of platelet inhibition with cangrelor during PCI on ischemic events. N Engl J Med. 2013;368:1303-13. 23473369

Neutrophil-to-Lymphocyte Ratio May Predict Contrast-Induced Nephropathy

We read with interest the article ‘‘Neutrophil-to-lymphocyte ratio predicts contrast-induced nephropathy in patients undergoing primary percutaneous coronary intervention’’ by Kaya et al. They investigated the relationship between neutrophilto-lymphocyte (N/L) ratio and contrast-induced nephropathy (CIN) in patients with ST-segment elevation myocardial infarction (STEMI). They demonstrated a relationship between N/L ratio and CIN development in patients with STEMI undergoing primary percutaneous coronary intervention. They also demonstrated an independent association between N/L ratio and CIN development in patients with STEMI undergoing coronary angiography. A full blood count is a cheap method that provides information about red and white cells, platelets, count and dimensions of subgroups of cells, and parameters like red cell distribution width, platelet cell distribution width, and mean platelet volume. Routine peripheral blood counts may be useful in risk stratification of patients with CIN. The white blood cell (WBC) count is one of the inflammatory biomarkers. Although the WBC may be within the normal range, subtypes of WBC, as expressed by the N/L ratio, may predict all-cause mortality. The N/L ratio is an easy, cheap, noninvasive, and widely available laboratory marker used to evaluate systemic inflammation. The N/L ratio has received increased attention due to its role as an independent prognostic factor for coronary artery disease (CAD), hypertension, chronic kidney disease, diabetes, heart failure, cerebrovascular disease, peripheral arterial disease, and malignancy. It can also be affected by atherosclerotic risk factors such as smoking, alcohol consumption, hypercholesterolemia, metabolic syndrome, nonalcoholic liver disease, abnormal thyroid function tests, and older age. Furthermore, acute bacterial and viral infections may change the N/L ratio. Additionally, medications such as antihypertensive therapy including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, b-blockers, and statins may influence the N/L ratio. It would be useful and the results might be different, if the authors described these factors. The CIN is a serious complication of PCI. The CIN is one of the most important reasons of hospital-acquired renal failure. The CIN can cause prolonged hospitalization, increased cost and incidence of renal and cardiovascular events, and mortality. Elderly patients are at greater risk of CIN because of decreased renal reserve. In addition, some factors like glomerular filtration rate (GFR) 200 mL were identified as risk factors for CIN after PCI. Alcohol consumption and arterial blood pressure before contrast exposure may be associated with increased risk of CIN in patients. Hypertriglyceridemia, metabolic syndrome, impaired fasting glucose, and multivessel disease may also be associated with the higher incidence of CIN. Also, some medications including a renin–angiotensin–aldosterone system medications may be related to CIN. Finally, they used the Cockcroft-Gault equation to calculate the GFR. The modification of diet in renal disease (MDRD) is another method for calculating the GFR. However, the Cockcroft-Gault equation may estimate lower GFR in younger age groups compared with the MDRD formula, but it can measure higher GFR in older individuals compared with the MDRD formula. The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) recently published an equation for GFR using the same variables (serum creatinine level, age, sex, and race) as the MDRD formula. However, the CKD-EPI equation more accurately categorized individuals with respect to longterm clinical risk of incident end-stage renal disease, all-cause mortality, coronary heart disease, and stroke compared with the MDRD formula. In addition, even mild chronic kidney dysfunction such as a GFR <90 mL/min and dehydration was also a risk factor for CIN. In conclusion, these findings will enlighten further studies about N/L ratio as a surrogate marker of risk stratification in

Incidence and predictors of stent thrombosis: a single-centre study of 5,833 consecutive patients undergoing coronary artery stenting

Stent thrombosis (ST) is an infrequent but potentially fatal complication of PCI. The reported incidence of ST varies from 0-5%, due to differences in definition of ST, inclusion/exclusion criteria, and the type of stent and dual antiplatelet therapy used. We aimed to examine the incidence of ST and associated risk factors in this "real-world, all-comers" study. All patients undergoing PCI at South Yorkshire Cardiothoracic Centre (UK) between 2007 and 2010 were included, with no exclusion criteria. ST cases were divided into definite and probable ST, according to the ARC criteria. Univariate predictors were identified using Student's t-test and chi-square test, and entered into a Cox proportional hazards model to identify factors independently associated with ST. For 5,833 PCI patients followed up for two years, the incidence of definite and probable ST together was 1.9% (n=109); of these 73% were early, 11% late and 16% very late ST. Cardiogenic shock, ST-elevation myocardial infarction (STEMI), lack of dual antiplatelet treatment, diabetes mellitus, stent length and stent diameter were the independent predictors of ST. The incidence of definite/probable ST in this "real-world" registry is 1.9%. Cardiogenic shock, often excluded in clinical trials, is the strongest independent predictor of ST.

TCT-534 Longitudinal Stent Deformation: Insights On Mechanisms, Treatments and Outcomes From The Food And Drug Administration Manufacturer And User Facility Device Experience Database

Longitudinal stent deformation (LSD) is a recently described complication of PCI but mechanisms contributing to its occurrence and associated clinical outcomes remain unclear. The FDA Manufacturer and User Facility Device Experience (MAUDE) database is a voluntary international electronic reporting

THE CLINICAL EFFICACY AND SAFETY STUDY OF PCI REMEDIAL TREATMENT AFTER THE

ObjectivesTo evaluate the efficacy and safety of PCI remedial treatment after the failure of intravenous thrombolytic therapy in the aged patients with acute myocardial infarction (AMI).Methods59 patients with acute ST-segment...

Longitudinal stent deformation: insights on mechanisms, treatments and outcomes from the Food and Drug Administration Manufacturer and User Facility Device Experience database

Longitudinal stent deformation (LSD) is a recently described complication of PCI, but mechanisms contributing to its occurrence and associated clinical outcomes remain unclear. The FDA Manufacturer and User Facility Device Experience (MAUDE) database was searched to identify cases of LSD to gain insight into procedural and anatomical factors that predispose to this complication and associated clinical outcomes. The MAUDE database is a voluntary international electronic reporting system whose aim is to capture major adverse events involving medical devices. Using defined search terms, we identified 57 unique cases of LSD ranging from 2004-2011. A significant increase in the reporting of LSD in the last two years was observed with most reported cases in stents based on the Element platform (90%). The lesions in which LSD was reported were complex (vessel calcification 26%; tortuosity 25%; long 28%; ostial disease 21%) and most frequently occurred following attempts to pass or withdraw secondary devices through a previously deployed stent (89% cases where mechanism identified). Adverse clinical outcomes including emergent cardiac surgery and acute and sub-acute stent thrombosis occurred in eight cases. LSD can occur secondary to a variety of mechanisms; identification and treatment is important since adverse incidents such as emergent CABG and stent thrombosis may occur. A novel classification system is proposed to facilitate future reporting of this complication.

Coronary stent longitudinal deformation by compression: is this a new global stent failure, a specific failure of a particular stent design or simply an angiographic detection of an exceptional PCI complication?

Coronary stent longitudinal deformation by compression: is this a new global stent failure, a specific failure of a particular stent design or simply an angiographic detection of an exceptional PCI complication?

Age-related differences in treatment strategies and clinical outcomes in unselected cohort of patients with ST-segment elevation myocardial infarction transferred for primary angioplasty

Data concerning the benefits and risks of primary PCI in the elderly patients presenting with ST-segment elevation myocardial infarction (STEMI) are limited. Thus, the objective of the study was to assess age-dependent differences in the treatment and outcomes of STEMI patients transferred for primary PCI. Data were gathered on 1,650 consecutive STEMI patients from hospital networks in seven countries of Europe from November 2005 to January 2007 (the EUROTRANSFER Registry population). Patients <65, 65 to 74, 75 to 84, and ≥85 years of age comprised 49.3, 27.5, 20.2, and 3 % of the registry population, respectively. Elderly patients were higher risk individuals and have experienced longer delays to reperfusion than their younger counterparts and were more likely to be treated conservatively after coronary angiography. Despite similar frequency of TIMI 3 flow before PCI, elderly patients were less likely to achieve TIMI 3 flow and ST-segment resolution >50 % after PCI, and were more likely to have PCI complications. The rates of death at 30 days, as well as at 1 year were increased with age. In the Cox regression analysis model age was an independent predictor of 30-day mortality. A trend toward higher risk of major bleeding requiring transfusion was observed. Age was an important determinant of treatment strategies selection and clinical outcomes in the group of consecutive STEMI patients transferred for primary PCI. Further efforts should be made to reduce delays and to optimize treatment of STEMI, regardless of patients’ age.

How should I treat an iatrogenic aortic dissection as a complication of complex PCI?

Background: A 61-year-old woman presented with one week of shortness of breath and was found to have occluded proximal right coronary artery with left to right collaterals. After predilation optical coherence tomography (OCT) imaging and power contrast injection was done to guide stenting therapy. Investigation: Diagnostic angiography with bilateral injection of contrast injection, OCT, intravascular ultrasound of the aorta and MSCT. Diagnosis: Iatrogenic right coronary artery and aortic dissection. Treatment: Stenting of the right coronary artery and its ostium with covered stent and drug eluting stents; imaging with OCT post stenting; imaging of the aorta with peripheral IVUS and MSCT.

A retrospective single center registry and long term follow-up of patients undergoing elective percutaneous coronary intervention. Egyptian Critical Care Department Angioplasty Registry (ECDAR)

The field of interventional cardiology continues to rapidly evolve as a result of many advances in devices as well as adjunctive medications which have been paralleled by a concomitant improvement in the safety and efficacy of PCI. We aimed at registering our elective PCI procedures with respect to their procedure details, outcome, in hospital complications and long term follow up. We tried to determine our performance in comparison to other registries and to find out risk factors associated with poor outcome. The material of this study included 1897 patients (1564 males and 333 females) who underwent PCI at the Critical Care Department, Cairo University between January 2003 to December 2007 with a follow up of 1–5 years. Retrospective analysis of those data had been done including clinical events such as death, MI, target vessel revascularization (TVR) and major adverse cardiac events (MACE). The cohort was predominantly male (82.2%) with a mean age of 55 ± 9 years. We had wide variety of PCI procedures, BMS stenting shared up 75.1% of our patients, DES 9.8%, PTCA 4.1%, failed PCI 4.4%, combined stents 1.2% and stenting with PTCA contributed 5.4% of the total patients. During hospital study clinical success was achieved in 92.8% of cases with low rate of clinical events; mortality (0.3%), MI (0.5%) with no reported cases of TVR. Angiographic success was achieved in 95.5% of treated segments with 6.7% angiographic complications. During follow up, death, MI, TVR and MACE rates increased from (3.2%, 2.1%, 8.5% and 10.2%) at first year to (24.2%, 17.2%, 35.9% and 57.2%), respectively, after 5 years follow up duration. There was a significant relationship between renal impairment, chronic total occlusion (CTO), bifurcation lesion, long lesion (>20 mm), number of stents implanted and occurence of PCI complications. Our experience is comparable to other registries. We differed in our demographic features which affected our patient’s characteristics. However, we need to establish our own registries based on our real life scenarios in the developing countries.

Prospektivní sledování periprocedurálních komplikací u pacientů podstupujících elektivní koronarografii a/nebo PCI

Cil: Cilem naseho sledovani bylo urcit výskyt a zastoupeni veskerých komplikaci, se kterými se pacient podstupujici tento diagnosticko-terapeutický výkon může setkat. Podrobně jsme se věnovali srovnani dvou dominantnich cevnich přistupů - femoralniho a radialniho.Metodika: V obdobi leden až cerven 2008 jsme prospektivně sledovali konsekutivně u vsech pacientů podstupujicich na nasem pracovisti elektivni koronarografii výskyt veskerých udalosti, ktere komplikovaly výkon ci naslednou hospitalizaci. Během sledovaneho obdobi jsme prospektivně zaznamenavali komplikace, ktere jsme statisticky vyhodnotili.Výsledky: Z 1 132 konsekutivnich nemocných přijatých v obdobi leden až cerven 2008 k elektivni koronarografii se u 84 pacientů (7,4 %) vyskytla některa z komplikaci, u osmi pacientů (0,7 %) slo o komplikaci zavažnou.Statisticky významně vyssi výskyt vsech komplikaci jsme prokazali u starsich pacientů a pacientek ženskeho pohlavi.Výskyt vsech komplikaci byl významně nižsi u radialniho než u femoralniho přistupu: 17 z 370 (4,6 %) oproti 66 ze 753 (8,8 %) výkonů (OR 0,50; 95% CI 0,29-0,87; p=0,011), v připadě zavažných komplikaci rozdily nedosahly statisticke významnosti: 2 z 370 (0,5 %) oproti 6 ze 753 (0,8 %) výkonů (OR 0,68, 95% CI 0,14-3,38; p=0,64).Zavěr: Nase prospektivni sledovani ukazuje výskyt veskerých a zvlastě pak zavažných komplikaci elektivni koronarografie v realne populaci. Nase zjistěni vcetně frekvence zavažných komplikaci odpovidaji starsim literarnim udajům, potvrdili jsme některe zname rizikove faktory komplikaci. Zejmena jsme pak prokazali významně nižsi výskyt komplikaci při použiti radialniho přistupu.